Quarterly of the European Observatory on Health Systems and Policies EUROHEALTH RESEARCH • DEBATE • POLICY • NEWS

• Putting big data to work • What does Brexit mean

› Harnessing Big for health systems for health in the UK? 2017

| Data for Health • Big data for better health outcomes • Health policy in the United States under Trump • Health priorities of the

Maltese EU Presidency • Reforms to inpatient care Number 1

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in Slovakia • Health care reform in Kosovo Volume 23 1356 ISSN Still Steve Production: and Design permission. prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of 2017. part No Policies and Systems Health on Observatory European of behalf on © WHO Medicine. &Tropical Hygiene of School London the and Science Political and Economics of School London Funds), Insurance Health of Union National (French UNCAM Bank, World the Commission, European the Italy, of Region Veneto the and Kingdom United the Switzerland, Sweden, Slovenia, Norway, Ireland, Finland, Belgium, Austria, of Governments the Europe, for Office Regional Organization Health World the between apartnership is Policies and Systems Health on Observatory European The consideration. for authors by submitted or editors the by commissioned independently are Articles sponsors. or partners its of any or Policies and Systems Health on Observatory European the of those necessarily not and alone authors in expressed views The beyond. and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for Eurohealth at: Available Guidelines Submission Article White: Caroline MANAGER SUBSCRIPTIONS North: Jonathan MANAGER PRODUCTION Still: Steve EDITOR DESIGN B. Richard Mossialos, Elias McKee, Martin Lessof, Suszy Palm, Willy Grand, Le Julian Holland, Walter Figueras, Josep Busse, Reinhard Belcher, Paul BOARD ADVISORY EDITORIAL aboutUs/LSEHealth/home.aspx http://www2.lse.ac.uk/LSEHealthAndSocialCare/ 6803 7955 20 +44 F: 6840 7955 20 T: +44 Kingdom United 2AE, WC2A London Street, Houghton Science Political and Economics of School London Health, LSE Mossialos: Elias EDITOR FOUNDING Palm: Willy ADVISOR EDITORIAL 6381 7955 20 +44 McDaid: David Maresso: Anna 6194 7955 20 +44 Merkur: Sherry TEAM EDITORIAL SENIOR http://www.healthobservatory.eu Email: 0936 2525 +32 F: 9240 2524 T: +32 Belgium Brussels, 1060 Horta Victor Place 07C020) (Office Eurostation Policies and Systems Health on Observatory European the of Quarterly EUROHEALTH info@obs.euro.who.int is a quarterly publication that provides a forum aforum provides that publication aquarterly is Saltman, Sarah Thomson Thomson Sarah Saltman, – [email protected] [email protected] 1030 http://tinyurl.com/eurohealth [email protected] [email protected] [email protected] [email protected] / 40 Hortaplein, Victor Eurohealth

Eur opean [email protected] are those of the the of those are [email protected] on Healt

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oli cies Back issuesof To subscribeto receivehardcopiesof http://www.euro.who.int/en/home/projects/observatory/publications/e-bulletins in hard-copyformat.Ifyouwanttobealertedwhen anewpublicationgoesonline,pleasesignuptothe Eurohealth Prague, Czech Republic Czech Prague, Pažitný Peter Slovakia of Palušková Monika Kosovo Prishtina, Muharremi Robert Mifsud Stephen MarušiˇcDorjan Laktišová Michaela Republic Czech Prague, Kandilaki Daniela USA Law, of Jost Timothy Kingdom United London, Science, Political and Economics of Jayawardana Sahan Kingdom United Hervey Tamara Kingdom United London, Industry, Pharmaceutical Hanif Shahid Kosovo Prishtina, Health, of Halimi Ramadan Gauci Charmaine Fahy Nick Calleja Antoinette Malta of University Management, Services Health of Department and Azzopardi-Muscat Natasha Agius-Muscat Hugo Kosovo Prishtina, Cooperation, Development Osmani Ademi Aferdita List of isavailableonlineat: Eurohealth

w Contributors University of Oxford, United Kingdom United Oxford, of University

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Chief General Practitioner Practitioner General Chief w Rochester Institute of Technology, Technology, of Institute Rochester w http://www.euro.who.int/en/about-us/partners/observatory/publications/eurohealth Ministry for Health, Malta Health, for Ministry Ministry of Health, Slovakia Health, of Ministry LSE Health, London School School London Health, LSE

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Ewout van Ginneken van Ewout Hungary Budapest, University, Semmelweis Centre, Szócska Miklós Germany Berlin, Technology of University Management, Care Health of Department and Policies, and Systems Spranger Anne Slovakia Health, of Ministry Smatana Martin Netherlands The Hague, The Smand Carin Sedláková Darina Switzerland Basel, Salimullah Tayyab Kingdom United Science, Political and Economics of School London Salcher Maximilian Kingdom United Windlesham, Ltd, Company and Lilly Eli Evidence, World Real Reed Catherine Slovenia Ljubljana, Research, Rupel Prevolnik Valentina of Technology Berlin, Germany Berlin, Technology of University Policies, and Systems Health on

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CONTENTS EUROHEALTH Quarterly of the European Observatory on Health Systems and Policies and Systems Health on Observatory European the of Quarterly Data for Health › Harnessing Big • Health priorities of the • Big fordata health outcomes better •big Putting todata work Maltese Maltese EU Presidency for health systems • care Health reform in Kosovo • Reforms to inpatient care • policyHealth in the United • What does Brexit mean in Slovakia underStates Trump for health in the UK? RESEARCH • DEBATE • POLICY • NEWS • POLICY • DEBATE • RESEARCH

Volume 23 | Number 1 | 2017 Shutterstock © McIek CONTENTS 17 13 10 3 2 27 24 20 28 7

THE TRUM THE Muscat, Antoinette Calleja, Charmaine Gauci, Hugo Agius-Muscat Agius-Muscat Hugo Gauci, Charmaine Calleja, Antoinette Muscat, Eurohealth Reed Catherine TayyabSalimullah, TRANSFORMATION OUTCOMES: DATA BIG BETTER FOR – CONNECTING Eurohealth EDITORS’ NEW PUBLICATIONS NEW Eurohealth – THE UK? IN HEALTH FOR MEAN BREXIT WHATDOES Ramadan IN KOSOVO REFORM CARE HEALTH HEAVY SEAS INTO CHANGES Darina Palušková, Monika Laktišová, Michaela Kandilaki, Daniela Pažitný, Peter IN SLOVAKIA CARE INPATIENT TO REFORMS Eurohealth NEWS HEALTH PRIORITI HEALTH

Maximilian Salcher Maximilian Nick Fahy Fahy Nick

Sedláková Sedláková

COMMENT

Halimi, Robert Muharremi Muharremi Robert Halimi, P ADMINISTRATION LAUNCHES AMERICAN HEALTH LAW LAW HEALTH AMERICAN LAUNCHES ADMINISTRATION P and

THE Tamara Hervey Tamara

and

DOTS: International Observer Monitor Systems IN ES OF THE 2017 MALTESE EU PRESIDENCY EU MALTESE 2017 THE OF ES

EUROPE

Ewout van Ginneken van Ewout

PUTTING BIG DATA HEALTH SYSTEMS BIG FOR WORK TO PUTTING

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Miklós Szócska, Sahan Jayawardana, Carin Smand, Smand, Carin Jayawardana, Sahan Szócska, Miklós

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and Timothy Jost Timothy and and Shahid Hanif Shahid

– SUPPORTING Valentina Prevolnik Rupel Prevolnik Valentina

Aferdita Ademi, Dorjan Maruš Dorjan Ademi, Aferdita Policies Eurohealth

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Anne Spranger, Martin Spranger, Anne

Observer Euro incorporating

HEALTH

CARE

and

– SYSTEM

Natasha Azzopardi- Natasha Stephen Mifsud Stephen i c, c, — ˇ

Smatana, Smatana, Vol.23 |

No.1

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2017 1 1 2

There is a growing awareness that harnessing ‘big data’, if done properly, could transform both the quality of health care for patients and how health systems perform. However, processes that can link the content of large and diverse health-related datasets from multiple sources in ways that achieve these goals without compromising privacy or other ethical concerns are only in their infancy.

In this Spring issue, the Observer section opens President Obama’s legacy. As the author points out, with an article that gives a panoramic view of the the process will be far from straightforward, with benefits of unlocking the potential of big data in significant hurdles already presenting themselves. health care – for patients, providers, policy-makers and researchers. Despite his optimistic view, the We are also very pleased to feature Kosovo in this author does not shy away from the challenges, issue. Discussing Kosovo’s ambitious health care including technical hurdles to achieve compatibility, reform, divided into four pillars, Ademi et al. give a safeguarding personal data and the need for strong balanced and forthright appraisal of the progress governance frameworks. Building on this overview, achieved so far and the remaining challenges Szócska et al. share some initial results from the IMI2 for successful implementation. Rounding off,

COMMENT BD4BO programme which explores the opportunities Fahy and Hervey discuss the consequences of offered by big data in representative disease areas. Brexit for health in the UK by focusing on the six

In this article they discuss three disease-specific areas identified in the Parliamentary inquiry. projects on Alzheimer’s disease, haematologal malignancies and cardiovascular diseases. Our Monitor section features two new Policy Briefs on structured cooperation related to workforce In our International section, Azzopardi- challenges in highly specialised health care and Muscat et al. discuss the health priorities of to voluntary cross-border collaboration in public the 2017 Maltese Presidency of the EU, which procurement of health technologies, both written to endeavour to tackle childhood obesity and inform discussions under the Maltese Presidency emphasise structured cooperation between of the EU. We also have our usual roundup of health systems. They also identify many other health policy news from around Europe. important areas that will also be on the agenda. We hope you enjoy the Spring issue! This issue’s Systems and Policies section features very divergent countries and some highly uncertain Sherry Merkur, Editor policy arenas. An article on Slovakia presents reforms Anna Maresso, Editor to the acute inpatient sector since 2010. Spranger David McDaid, Editor and colleagues analyse efforts which have targeted changes in payment mechanisms and strategic hospital planning as well as reducing bed capacity. Cite this as: Eurohealth 2017; 23(1).

Moving to the US and Donald Trump’s election pledge to dismantle ‘Obamacare’, Timothy Jost’s article outlines the current attempts (in a fast-moving policy context) to repeal and replace the Affordable Care Act, which many see as the cornerstone of former EDITORS’

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CONNECTING THE DOTS: PUTTING BIG DATA TO WORK FOR HEALTH SYSTEMS

By: Maximilian Salcher

Summary: Linking existing databases is seen as key to unlocking the potential of big data to revolutionise health care. Shared electronic health records and provider benchmarking can improve the quality of care, while linked databases are deemed enablers to support the transformation towards value-based health care. The wealth of collected data allows researchers to answer questions that are of high relevance for policy-makers, patients and providers. However, data privacy concerns pose a challenge to the integration of data sources. Effective use of big data to transform health care systems requires substantial commitment from all stakeholders and a strong governance framework.

Keywords: Big Data, Governance, Data Privacy, Data Linkage, Value-based Health Care

Acknowledgement: This article partially builds on a mini-brief written by the author on behalf Introduction contain information in various formats of the European Observatory on and which require novel methods to Health Systems and Policies. Health care systems around the world be processed. 3 Independently of this, the author routinely generate a wealth of data on would also like to acknowledge every patient, providing a comprehensive that this work has received funding In theory, access to detailed data about picture of health care pathways and from the Innovative Medicines individual patients supports patient- Initiative 2 Joint Undertaking outcomes. Enhanced by data from centred and outcomes-focused care under grant agreement No 116055. non-health care system sources, such This Joint Undertaking receives through individualised treatment as geographic location, socio-economic support from the European decisions, which take into account clinical, Union’s Horizon 2020 research status, lifestyle and social networks, a genetic, lifestyle and other information. and innovation programme near-complete picture of the individual and the European Federation of However, most of the data are contained can be created. The increased supply of Pharmaceutical Industries and in silos, and even for health care-related Associations (EFPIA). health-related data from multiple sources data there is no or limited linkage between (“big data”) has the potential to change existing databases. Missing information the face of health care and provide about a patient’s background, history and added value for all health care system Maximilian Salcher is Research outcomes poses a problem for a range of stakeholders. 1 2 While no single definition Officer at LSE Health and Social health care systems stakeholders, including Care, London School of Economics for big data is universally accepted, all care providers, who are interested in and Political Science, London, describe a similar concept: large, diverse, United Kingdom. providing better quality care for their and rapidly increasing datasets that Email: [email protected] patients; policy-makers and regulators,

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who aim to ensure effective and efficient of health care quality and system In the United States, the Centers for services for the population; as well as performance; coordination and outcomes Medicare and Medicaid Services (CMS) researchers, who need comprehensive data of care pathways; quality of care through aim to use big data to drive health care to investigate risk factors and remedies in compliance rates with national guidelines; systems change and are planning to link order to inform clinical practice and the resource use and costs; disease prevalence; two thirds of payments to value, including development of new therapies. Linking and the analysis of relationships between through initiatives such as Accountable existing databases is therefore seen as key socio-economic status, health and health Care Organizations and Coordinated Care to unlocking the potential of data-driven care. 4 However, many countries miss Organizations. Data-driven health care health care system change. Opportunities out on opportunities to improve clinical system change is also on the agenda of from using big data to improve quality practice using linked data. 5 An example the European Union (EU). The recently of care, increase health care system for putting data linkage to action is the launched “Big Data for Better Outcomes” efficiency, and conduct high-quality National Board of Health and Welfare in programme (Innovative Medicines research are now presented, alongside Sweden, which monitors compliance of Initiative) creates research platforms and considerations regarding the ethical and providers with national clinical guidelines big data networks for various disease technical challenges associated with the in various disease areas using data from areas (currently including Alzheimer’s use of large and linked databases. its patient registries network (the National disease, haematological malignancies, Quality Registries) that are linked to and cardiovascular diseases) with the mortality and prescriptions databases. aim of accelerating the transition towards Performance across providers can be value-based health care systems in Europe compared and reasons for shortcomings (see the article by Szócska et al. in this investigated, which in turn informs action issue). In line with recommendations Meaningful use plans for clinical practice improvement. from a recent European Commission report on big data in health care, 1 this of big data could Improving the efficiency of health research programme leverages expertise care systems from the public and private sectors in a contribute to public-private partnership to combine The existence of substantial waste in and expand existing data sources, waste reduction health care systems, stemming from build analytic capacities, and establish underuse of effective treatments, common standards. Improving the quality of care overuse of ineffective treatments, failure to coordinate and execute care Data linkage can also create efficiency At the individual level, the integration and other sources, 6 has given rise to gains in the collection and use of of clinically relevant‘‘ data can lead to the promotion of value-based health data. At the heart of the Belgian significant improvements in clinical care as a priority for policy-makers: healthdata.be initiative is the recognition practice with tangible benefits for patients, improving patient outcomes in a cost- that the analysis of health care data can including individualised treatment plans effective way. Meaningful use of big be improved significantly by linking and and fewer duplicate diagnostic tests. data could contribute to waste reduction making better use of existing, rather than Increasingly, lack of linkage between by identifying the most cost-effective collecting additional, data. Integrating existing databases is recognised as a treatments, enable care coordination data from various sources is a particular barrier to coordinated provision of health (see shared EHR above), and accelerate challenge in decentralised health care care services and shared electronic health the development of innovative and systems and can require substantial records (EHR) are introduced as a counter highly effective medicines. For example, investments in technical solutions and measure in many health care systems. linked data on long-term and real world political will to overcome long-standing Projects such as the Catalonian “HC3” outcomes can be used to assess the fragmentation. In the Belgian example, a shared EHR and the Danish sundhed. efficacy, (comparative) effectiveness and new centre for the integration of existing dk online portal act as information cost-effectiveness of new medicines, databases was established as part of a sharing platforms for all health care leading to more informed decisions about national eHealth action plan that was professionals involved in the care of an market access and availability of these agreed by a few hundred stakeholders. individual patient. drugs. However, the trade-off between rigorous evidence standards for market Research opportunities At the aggregate level, big data provides approval of new drugs and faster access to an opportunity to monitor provider innovative medicines for patients needs to For researchers, linked databases provide performance and ensure high quality of be carefully considered, and evidence on opportunities to analyse disease patterns, care. In a survey of OECD countries, big data-induced efficiency gains in health detect associations between exposures the measurement of various elements care systems through value-based health (such as behaviour or health care services of the health care system was given care or other mechanisms is yet to emerge. received) and outcomes (e.g., acute events as a key reason for enabling linkage such as heart attacks or onset of chronic between datasets, including measurement diseases such as Alzheimer’s), and

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potentially identify causal relationships our understanding of chronic and multiple between consent to using data for service that can serve as starting points for chronic diseases. Linkage of data from provision (coordination and continuation the development of new therapies. As separate sources, such as administrative of care) and for research purposes. While value-based health care gains traction, data from different payers, providers research plays an important role in interest and investments in comparative (in- and out-patient care, social care), improving quality of care, the benefits of effectiveness research have increased, diagnostic tests, laboratory results and using integrated data for research purposes with the wealth of collected data enabling prescriptions, can help to understand are less tangible for the individual patient, researchers to answer questions that are of disease patterns. While public health requiring additional information to be high relevance for policy-makers, patients monitoring is the most common use of made available to obtain consent. and providers. Data linkage further EHRs in OECD countries, 5 fragmentation widens the realm of possible research of the health care system with isolated The legal framework for allowing questions, adding outcome as well as points of care hinders records linkage. researchers to use existing data varies by prediction variables to the dataset at the Research initiatives, such as the Austrian country and disease area. The EU Data researcher’s disposal. DEXHELPP project, which aims to Protection Regulation allows the use of combine data sources and develop personal data for research of significant methods to support decision-making at public interest. While data collection the population level, require substantial may be mandatory without an opt-out investments, technical expertise, and option in some areas (e.g. registries stakeholder buy-in to overcome these of infectious diseases), others require Effective use difficulties and play a role in informing explicit consent from the patient. Either health care planning. way, researchers and those managing of big data to the data have a responsibility to ensure Technical and ethical challenges: can trust in their handling of the data. Good transform health data be linked? practice measures make inappropriate use of sensitive data less likely, including systems requires Simultaneously with the formulation of the establishing steering committees with promises of big data, technical and ethical patient representatives; using trusted third substantial challenges for realising this potential have parties for data linkage; clear rules for been identified. 3 7 Different standards requesting access to data and tracking commitment in databases might prevent data from data use; and safe data environments to ‘‘ being used together or require significant conduct research. from all resources to be made compatible. Unique patient identifiers, which allow Big data governance stakeholders deterministic linkage of records, are not available in all countries. Projects While some countries lead the way For example, the CALIBER project in addressing these challenges develop novel in allowing data to be shared among the United Kingdom integrates data from methods, such as statistical models and government and health systems entities, different sources to depict the journey algorithms to match data from separate as well as data to be made available for of patients with myocardial infarction sources based on the probability of research (including the United Kingdom, through the health care system. Relevant common features (probabilistic matching). Sweden and New Zealand), others remain data of events leading up to and after the much more restrictive and do not allow infarct are collected in different electronic Data privacy concerns arguably pose an data custodians and researchers access to databases, including a database on primary even greater challenge to the integration datasets they do not own. The different care, hospitalisation with interventions and of data sources. Careful consideration speeds at which countries are developing associated resource use, a disease registry, needs to be given to the delicate trade- governance frameworks that maximise and the death certificate. Integration of off between access to more personal benefits while minimising risks showcase the data contained in separate datasets information and associated potential the complexity of integrating legal, ethical, provides researchers with a powerful individual and societal benefits in health technical, and political considerations tool to analyse the factors leading to care service provision, policy making into a common framework. Enabling heart attacks, as well as the relative and research on one side, and the need governance mechanisms that reconcile effectiveness of different interventions to for data privacy on the other side. The data use with data protection include, reduce the morbidity and mortality burden English Department of Health is currently among others, accessible and well- of these events. evaluating models to inform the public designed health information systems and about usage of data in health and social a legal framework for processing sensitive Knowledge about prevalence of diseases care, including different options for information. 4 and their patterns are important opting out of information sharing between determinants of national and regional different service providers. 8 Some of As mentioned above, the European Data health care planning, yet gaps remain in the proposed opt-out models distinguish Protection Regulation provides for the

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latter in the European context, although and by whom linked datasets will be 3 Salas-Vega S, Haimann A, Mossialos E. Big Data it leaves room for interpretation and used. Some of these questions cannot and Health Care: Challenges and Opportunities for requires countries to develop their own be answered globally, as fundamental Coordinated Policy Development in the EU. Health Systems & Reform 2015;1(4):285 – 300. doi:10.1080/ frameworks. The development of health differences exist in approaches to using 23288604.2015.1091538. information systems and investment in data in health system planning and 4 infrastructure is reflected in some national policy development, and in citizens’ OECD. Health Data Governance. Paris: Organisation for Economic Co-operation and health strategies, including in France, attitudes towards the trade-off between Development; 2015. Available at: http://www.oecd- where the recent health system reform privacy and promised benefits from ilibrary.org/content/book/9789264244566-en foresees linkage of data from social granting access to sensitive personal 5 OECD. Strenghtening Health Information health insurance with private insurance, data. Trust, as an integral element of the Infrastructure for Health Care Quality Governance: social care and mortality records. Despite patient-provider relationship, extends Good Practices, New Opportunities and Data Privacy these developments, implementation of to using personal data for research, Protection Challenges. Paris: Organisation for governance frameworks and associated health system planning and monitoring Economic Co-operation and Development, 2013. investments can lag behind and delay the and has to be won through open 6 Berwick DM, Hackbarth AD. Eliminating waste meaningful use of big data for quality communication and the implementation in US health care. JAMA 2012;307(14):1513 – 16. of care improvement, efficiency gains, of measures that demonstrate attention Available at: doi:10.1001/jama.2012.362. and research. to citizens’ concerns. 7 Weber GM, Mandl KD, Kohane IS. Finding the Missing Link for Big Biomedical Data. JAMA 2014;311(24):2479 – 80. Available at: doi:10.1001/ Conclusion References jama.2014.4228.

1 Effective use of big data to transform Habl C, Renner A-T, Bobek J, Laschkolnig A. Study 8 National Data Guardian for Health and Care. health care systems requires substantial on Big Data in Public Health, Telemedicine and Health Review of Data Security, Consent and Opt-Outs. care. Brussels, Belgium: European Commission, commitment from all stakeholders and a National Data Guardian for Health and Care, 2016. 2016:117. Available at: https://ec.europa.eu/health/ Available at: https://www.gov.uk/government/ solid governance framework. Linkage of sites/health/files/ehealth/docs/bigdata_report_ uploads/system/uploads/attachment_data/ datasets is more than a technical exercise en.pdf file/535024/data-security-review.PDF and requires reflection on data privacy 2 Roski J, Bo-Linn GW, Andrews TA. Creating value and security, incorporation of data use in health care through big data: opportunities and into health system planning, and how policy implications. Health Affairs 2014; 33(7):1115 – 22. doi:10.1377/hlthaff.2014.0147.

Malta: Health system review The main outstanding challenges include: adapting the health system to an increasingly diverse population; increasing capacity to cope By: Natasha Azzopardi-Muscat, Stefan Buttigieg, with a growing population; Neville Calleja, Sherry Merkur Health Systems in Transition Vol. 19 No. 1 2017 redistributing resources and Copenhagen: World Health Organization 2017 activity from hospitals to (on behalf of the Observatory) primary care and Malta Health system review strengthening primary care; Number of pages: 137 pages; ISSN: 1817-6127 strengthening the mental Freely available to download at: http://www.euro.who. health sector; building the int/__data/assets/pdf_file/0009/332883/Malta-Hit.pdf?ua=1 health information system to support improved

Natasha Azzopardi-Muscat • Neville Calleja The health care system in Malta offers universal coverage Stefan Buttigieg monitoring and evaluation; to a comprehensive set of services that are free at the point Sherry Merkur ensuring access of use for people entitled to statutory provision although to expensive new patients often choose to visit private primary care providers. medicines whilst still The historical pattern of integrated financing and provision is making efficiency shifting towards a more pluralist approach and in 2016 a new improvements; and public-private partnership contract for three existing hospitals addressing medium-term financial was agreed. Overall, the Maltese health system has been sustainability and ageing. making remarkable progress, with improvements in avoidable Contents: Preface, Acknowledgements, Abstract, Executive mortality and low levels of unmet need. Maltese life expectancy summary, Introduction, Organisation and governance, continues to be high, and Maltese people spend on average Financing, Physical and human resources, Provision of close to 90% of their lifespan in good health. Malta has recently services, Principal health reforms, Assessment of the health increased the proportion of Gross Domestic Product spent on system, Conclusions, Appendices. health to above the EU average, though the private share of expenditure is still higher than in many EU countries.

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BIG DATA FOR BETTER OUTCOMES: SUPPORTING HEALTH CARE SYSTEM TRANSFORMATION IN EUROPE

By: Miklós Szócska, Sahan Jayawardana, Carin Smand, Tayyab Salimullah, Catherine Reed and Shahid Hanif

Summary: Large amounts of data from multiple sources have led to the opportunity of deriving health benefits through using sophisticated technologies. Regardless of the frequently cited revolution of data- driven health care, promises remain to be fulfilled. The IMI2 BD4BO programme recognises this in representative disease areas, providing a framework to guide research and invite stakeholders to discuss the Acknowledgement: This work has received funding from future of health systems shaped by big data. The projects will impact the Innovative Medicines Initiative 2 Joint Undertaking the research environment through shared definitions and methods under grant agreement No 116055. This Joint Undertaking receives to avoid duplication of work, while transforming health care systems support from the European in terms of clinical operations, research and development, evidence- Union’s Horizon 2020 research and innovation programme based personalised medicine and public health. and European Federation of Pharmaceutical Industries and Associations ( EFPIA). Keywords: Innovative Medicines Initiative, Big Data, Health Outcomes, Knowledge Integration, Data Privacy

Miklós Szócska is Director, Health Services Management Training Centre, Semmelweis University, Introduction standardised collection of data, delaying or Budapest, Hungary; Sahan even diverting the implementation of data Jayawardana is Research Officer, The computer age has brought about the sharing agreements. LSE Health, London School of rapid generation of large amounts of easily Economics and Political Science, accessible data from variable, quickly London, United Kingdom; Carin In the European Union (EU), the developing, digital and non-digital sources, Smand is Managing Director, key health policy objectives are European Hematology Association, often referred to as “big data”. Big data the strengthening of health system The Hague, The Netherlands; has immense, yet so far hardly utilised Tayyab Salimullah is Global effectiveness, accessibility, resilience, potential to improve almost all areas of Pricing and Market Access quality and performance. 1 However, Director, Novartis Oncology, Basel, human life, including health. Whether this health care systems in Europe face Switzerland; Catherine Reed is potential can be exploited depends on the Principal Research Scientist, Global significant challenges due to the high sophistication of methods and technologies Patient Outcomes and Real World incidence of chronic diseases, ageing Evidence, Eli Lilly and Company available to process and use (make sense populations, rising cost of new drugs and Ltd, Windlesham, United Kingdom; of) big data. Regardless of the frequently Shahid Hanif is Head of Health Data widely varying health outcomes across cited revolution of data-driven health care & Outcomes, the Association of the the region. 2 Amid these challenges, the British Pharmaceutical Industry, decision-making, there are still promises focused application of big data has the London, United Kingdom. to be fulfilled. This is also true for Europe, Email: [email protected] where the fragmented legal landscape, and inconsistent public opinion inhibits the

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potential to enable health care systems to outcomes. The perception of health care and integration of AD-relevant real world effectively transform towards value-based stakeholders on outcomes are different, datasets that are suitable for answering health care. 3 an issue that can only be tackled with a questions about the natural history, cost- holistic approach by including as many effectiveness, and clinical utility of new The Innovative Medicines Initiative 2 perspectives as possible, continuously and innovative treatment interventions (IMI2), Europe’s largest public-private being adapted to the context of the disease, across the entire spectrum of the disease. initiative (a joint undertaking between patient population or therapeutic field. The proposed pilot project under this the EU and the European Federation The programme addresses the following topic (titled “ROADMAP”) will align of Pharmaceutical Industries and key enablers: definition of outcome outcomes and methods to develop an Associations [EFPIA]), recognised metrics; protocols, processes and tools to approach within existing data systems to this phenomenon through the recently access high quality data; methodologies efficiently enable initiation, maintenance, launched Big Data for Better Outcomes and analytics to drive improvements; and evaluation of the right treatment (BD4BO) programme, which aims to digital and other solutions that increase to the right patient at the right time in catalyse and support the evolution towards patient engagement in the efforts for health care systems. Engagement with outcomes-focused, sustainable health care better outcomes. Each project launched health technology assessment (HTA)/ systems in Europe. In order to reach its under the BD4BO programme will make national health care bodies, regulators, goal, it seeks to exploit the opportunities concentrated efforts to advance common and patient advocacy groups will ensure offered by big and deep data sources in outcomes definitions, use of more reliable that proposals for future prospective data a few representative disease areas, to put data and related analytical methods with collection efforts are relevant to access together a methodological framework increased patient involvement. and reimbursement questions. The initial to guide big data research and to invite results produced by ROADMAP will be a wide range of stakeholders to discuss With the BD4BO programme focusing on critical to ensure that the work proposed in the future of health systems shaped by filling the gaps in availability of standard the second phase of the project is realistic big data. sets of outcomes, combining different in scope, relevant to stakeholder needs, data sources, identifying best practices, and complementary to ongoing IMI2 and The programme explicitly differentiates and increasing patients’ engagement in other EU collaborations for better patient itself from previous initiatives through their care, project deliverables will allow outcomes from pre-clinical/early stages of the high level of stakeholder engagement stakeholders to gain more powerful AD through all dementia stages. in leveraging existing databases and insights to improve health care. These collaborations to reach its aim. It brings features of the programme and the HARMONY together the key stakeholders, including cooperation framework of IMI seek to The second BD4BO topic is titled patients, payers, providers, regulators, promote an efficient dialogue between “Development of an outcomes-focused academic researchers and health care projects and with other similar non- data platform to empower policy makers policy makers that are required to IMI initiatives. Upon completion of the and clinicians to optimise care for patients create the synergies in big data policies programme, the realisation of each disease with haematological malignancies”. The needed to shift to value-based health project’s aims will contribute to an organic proposed project (titled “HARMONY”) care. The effective use of big data transformation of research and clinical aims to deliver a series of benefits for resulting from such synergies and the practice in health care systems. patients, health care providers and insights gained from projects launched manufacturers within this disease area. under the BD4BO programme has Focusing on disease, population and Due to the rarity of the conditions and the the potential to transform health care therapeutic area diverse health care practice across the EU, systems in terms of clinical operations, current health care systems are challenged research and development, evidence- Currently, three disease specific BD4BO with several issues. There is limited data based personalised medicine and public projects have been launched within on haematological malignancies that health. For example, better access to data IMI2, focusing on Alzheimer’s disease are comparable, making it difficult for may improve comparative effectiveness (AD), haematological malignancies and policy makers to establish benchmarks research, allowing providers to make more cardiovascular diseases. All of these such as risk/benefit ratios and payers to clinically relevant decisions and identify projects attempt to use the toolbox of accurately make reimbursement decisions cost-effective ways to diagnose and treat big data, but with a focus on somewhat on life prolonging treatment options. patients. 4 Such improvements may enable different aspects of the selected diseases in In addition, the lack of data is forcing health care systems to derive value by relation to health outcomes. clinicians to make decisions based on lowering expenditure and improving short-term surrogate data that is often not patient outcomes. ROADMAP comparable, which may result in patients The first BD4BO disease specific topic is not getting the right treatment at the right In more operative terms, the BD4BO titled “Real World Outcomes Across the time. Further, there is a lack of definition programme provides a platform and AD Spectrum (ROADS) to Better Care”. and alignment on outcomes that is relevant resources for defining and developing The first phase of this topic provides an to all stakeholders within this disease area. enablers to enhance the transparency of important initial step for identification

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HARMONY aims to use ‘big data’ to of adherence to treatment, the role of care stakeholders, lead communication deliver information that will help to risk factors, comorbidities, genetics and engagement, and address data privacy improve the care of patients with certain and lifestyles; improving awareness of issues in the development of informed haematological malignancies. Specifically, quality of life aspects that are important consent forms for use within clinical, the project will collect, integrate and for patients; evaluation and testing of non-clinical and biobanking research. analyse anonymous patient data from tools that may be useful for predictive As a European-wide project, the value of a number of high quality sources. This analytics and surrogate markers for the CSA project is that it will harmonise will help to define clinical endpoints cardiovascular outcomes; developing activities and the acceptability of outcome and outcomes for these diseases that strategies to use these predictive analytic measures, and leverage the breadth are recognised by all key stakeholders. tools and surrogate markers to improve of experience in member states from Meanwhile the project’s data sharing clinical care pathways and support different stakeholders towards sustainable platform will facilitate and improve innovative drug development that provide health care systems and patient access to decision-making for policy makers and relevant improvement of outcomes that are innovative and safer medicines. clinicians alike to help them to give the important for patients. right treatment to the right patient at the References right time. Key to this is the collaboration Prostate cancer and firm commitment of industry, HTA, 1 Salas-Vega S, Haimann A, Mossialos E. Big data Another further topic on prostate cancer, payers and other stakeholder experts plus and healthcare: Challenges and opportunities for with the primary objective of increasing coordinated policy development in the EU. Health the input of patients. Harmonising data the body of evidence to improve prostate Systems & Reform 2015;1(4):285 – 300. collection and subsequent data flows cancer outcomes, will aim to identify and 2 will rely on the collaboration between OECD. Fiscal Sustainability of Health Systems: broaden the relevant outcome measures: Bridging Health and Finance Perspectives. Paris: researchers, pharmaceutical companies, epidemiological, clinical, economic, and OECD Publishing, 2015. and academics, in order to advance patient reported outcomes. This includes 3 structures that already exist and which The Economist Intelligence Unit. Value-based screening, diagnosis and predictive factors healthcare in Europe: Laying the foundation, 2016. include expert, pan-European groups. that may have an impact on these measures Available at: https://www.eiuperspectives.economist. Sources certainly need to be of the (including complications and adverse com/healthcare/value-based-healthcare-europe- highest quality throughout and thorough laying-foundation effects) across all stages of disease through assessment to identify and utilise optimum 4 collection and analysis of available data. Raghupathi W, Raghupathi V. Big data analytics in data is key if the knowledge currently healthcare: promise and potential. Health Information being gathered is to be put to the best Science and Systems 2014;2:3. possible use. The project will be supported Impact on research environment by a robust communication strategy to for big data inform all stakeholders in and outside the The BD4BO programme ambition project about developments and results, is to invest in four key enablers that as well as issues that need to be addressed will support the evolution towards in order to achieve the project’s goals. outcomes-focused and sustainable health care systems. In addition, the BD4BO BigData@Heart programme will endeavour to impact The most recent BD4BO topic is titled on the use of big data in the research “Increase access and use of high quality environment. Researchers will have the data to improve clinical outcomes in opportunity to benefit from the improved heart failure (HF), atrial fibrillation quality of data sets in these specific (AF), and acute coronary syndrome disease areas, stakeholder agreement (ACS) patients”. The expected impact of of clinical outcomes and endpoints the proposed project (titled “BigData@ to improve health care services and Heart”) is better and safer treatment accelerate the development and availability paradigms for patients with AF, HF, and of innovative medicines, and a wealth of ACS. In more direct terms, the project is patient reported outcome measures from expected to improve understanding of the digital solutions for data mining to develop risks of serious outcomes in these patients preventative and personalised approaches compared to the general population. The to patient care. existing knowledge should be further improved on how these patients are The BD4BO has a coordination and treated in the real world and what affects support action (CSA) project (titled outcomes with more efficient surveillance DO ➔IT) that will facilitate programme of safety and effectiveness in real world coordination of current and future settings. Further expectations include: projects, develop a repository for sharing improving information on the importance knowledge and insight for use by health

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HEALTH PRIORITIES OF THE 2017 MALTESE EU PRESIDENCY

By: Natasha Azzopardi-Muscat, Antoinette Calleja, Charmaine Gauci, Hugo Agius-Muscat and Stephen Mifsud

Summary: Malta is at the helm of the EU between January and June 2017. The Maltese Presidency intends to continue to build on the work of previous Presidencies to tackle important priorities for which there is clear added value for action at EU level. To this end Malta has identified childhood obesity and structured cooperation between health systems as its two main thematic priorities. HIV, eHealth, Rare Diseases, medicines, cancer and antimicrobial resistance will also be on the agenda. Through a series of expert and political meetings, the Maltese Presidency aims to bring forward specific actions on the identified health priorities.

Keywords: Maltese EU Presidency, health systems, childhood obesity, eHealth, HIV

Introduction response to be mounted by Member States. The approach taken is one where needs In January 2017, Malta assumed the should be identified by evidence and Presidency of the Council of the driven through a bottom up cooperation European Union (EU) for the first time process between Member States, with the since it acceded to the EU in 2004. This support of the European institutions. The Presidency comes at a delicate moment Maltese Presidency is emphasising the Natasha Azzopardi-Muscat in the history of the EU since it will have need for the EU to prioritise social aspects is Consultant in Public Health to tackle key issues that have developed Medicine, Ministry for Health and and the pursuit of health and well-being at a European level, including Brexit. a Resident Academic, Department for European citizens is an important of Health Services Management, Nonetheless, the Maltese Presidency has component of this objective. University of Malta; Antoinette identified six main priorities which it aims Calleja, Chairperson, 2017 Maltese EU Presidency and Director, to push forward during its Presidency. Department for Policy in Health, These are: migration, the single market, Legislative agenda International Affairs and Policy security, social inclusion, Europe’s The Maltese Presidency will continue Development, Ministry for Health, neighbourhood and the maritime sector. 1 2 Malta; Charmaine Gauci is to work on the Proposals put forward Superintendent of Public Health and by the Commission, namely to amend Director General Health Regulation, Although health policy does not feature Regulation (EC) No.726/2004 laying Department for Health Regulation, as one of these major themes, the health Ministry for Health, Malta; Hugo down Community procedures for the and well-being of European citizens can Agius-Muscat is Consultant authorisation and supervision of medicinal in Public Health Medicine, also be positively impacted through the products for human and veterinary use Information Management Unit, adoption of strategies in some of these Ministry for Health, Malta; Stephen and establishing a European Medicines key priority areas. More specifically, the Mifsud, Health and Consumer Agency. Protection Attaché, 2017 Maltese Maltese Presidency has put together an EU Presidency. Email: natasha. ambitious programme of events for the Besides convening the regular meetings [email protected] health sector. The overall goal is that of in Brussels and in Malta, a programme of highlighting issues that need cooperation specific themed events has been developed across health systems for an effective

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around the main priorities identified. These events are expected to inform the development of Council Conclusions on childhood obesity and structured cooperation between health systems.

The Presidency health priorities In the field of health, the Maltese Presidency will continue to build on the work carried out by the Netherlands and Slovakia as part of the Trio Presidency. It will also, however, seek to forge links with the upcoming Trio Presidency and therefore contribute to identifying the health priorities for the EU in the coming years. The main thematic priorities which will link up with planned Council Conclusions are, childhood obesity Launch of the new HiT health system review on Malta on 28 February: (left to right) Josep Figueras and structured cooperation between and Elias Mossialos (European Observatory), Maltese Health Minister Chris Fearne, HiT author Natasha Azzopardi-Muscat and Martin Seychell (EU Commission). health systems. In addition, the Maltese Presidency will focus on several other entities are obliged to go for the lowest and provide tangible benefits for health topics through the organisation of specific priced contractor; however, this may professionals and patients. The Maltese Malta based events. These include HIV, give rise to children being provided with EU Presidency has chosen to focus on the eHealth, Rare Diseases and Cancer. unhealthy meals. For this reason, the scope of voluntary structured cross-border Furthermore, the Maltese Presidency Maltese Presidency, in collaboration with cooperation between Member States to will follow up on the work carried out the European Commission and Member ensure access to innovative medicines by previous Presidencies on the issues of States though members of the High Level and technologies as well as access to antimicrobial resistance (AMR) and access Group on Diet and Physical Activity, the highly specialised health services. The to medicines. Joint Research Centre and the Regional needs of small populations, referring both Office for Europe of the World Health to populations of smaller countries, as Childhood obesity Organization, have developed evidence- well as patients with Rare Diseases, are Childhood obesity has reached epidemic based guidelines for procurement of highlighted. proportions across the globe. The negative school food that is healthy and suitable impacts that childhood obesity bears for children. Structured cooperation between Member on health, productivity, quality of life, States can enhance capacity, increase longevity and the significant related social equity and also improve quality and and economic costs are well known. Malta efficiency of health system interventions. has one of the highest rates of childhood Policy briefs synthesising the evidence obesity in the world. 3 The key objective is on collaboration in the procurement to halt the rise in overweight and obesity an ambitious of health technologies and health in children and young people (0 – 18 years) workforce challenges related to highly by 2020. The Maltese Presidency aims programme of specialised health care have been prepared to tackle the rise in childhood obesity by in collaboration with the European taking a strategic approach to support events for the Observatory on Health Systems and Member States in identifying good Policies. 4 5 Access to medicines and other practices and key areas where further health sector medical technologies is still a problem action is required. Malta aims to highlight in Europe, especially for small, lower the findings of the mid-term evaluation Structured cooperation between health income countries and or products with a of the EU Action Plan on Childhood systems small demand. These challenges are partly Obesity 2014 – 2020 and to identify key related to the manner in which pricing and The health systems of Member States areas that call for further actions. procurement are being organised. In this face common challenges‘‘ which can area, the Maltese Presidency will seek be mitigated when Member States Since children spend a large proportion to follow up on the Council Conclusions work together in synergy. The Maltese of their time in schools, this presents an adopted under the Netherlands Presidency is working to identify opportunity to alter their eating habits by Presidency in 2016 by seeking to identify mechanisms of voluntary structured exposing them to healthy and nutritious the mechanisms which will promote cooperation between health systems to food. In the absence of procurement sustainable cooperation in the processes support Member State health systems guidelines, many public bodies and Eurohealth incorporating Euro Observer — Vol.23 | No.1 | 2017 12 Eurohealth INTERNATIONAL

of procurement of innovative medicines support for reform of health care systems; ways to address the issue of high prices and technologies with a view to improving and new roles and shifting balances in for innovative medicines in view of the access and affordability. health care. High-level delegates will also changing nature of the industry and the discuss the health-related objectives of the need to ensure that European citizens can The launch of the European Reference Digital Single Market. gain access to important medicines in a Networks (see news section of this issue) timely and affordable manner. The Maltese provides an opportunity to build strong HIV/AIDS Presidency will also continue to follow up cross-border professional networks to on the work carried out on the important Although there have been impressive gains support the provision of highly specialised topic of AMR in order to ensure that the in reducing the number of AIDS diagnoses services and interventions for patients follow up actions envisaged are being duly during the last decade, the burden of HIV with Rare Diseases. Patient mobility can implemented. infection remains unacceptably high in be completed by structured mobility of Europe. Each year about 30,000 people health professionals. The development of are newly diagnosed with HIV in the EU/ The future opportunities for structured cross-border EEA, and almost another 110,000 people medical specialist training may assist to Throughout the dialogues on the are known to be infected in the broader overcome various challenges being faced respective priorities being discussed European Region. Europe is the region by Member States in ensuring retention during the Maltese Presidency, the with the fastest growing rate of infection and development of their specialised health importance of determining the role that in the world. 7 There is good evidence workforce. Ensuring good quality training Member States would like the EU to on what works to effectively prevent and opportunities across the EU will also play, both in taking forward work in the control HIV. In order to reverse the HIV indirectly improve access and continuity area of public health concerns, as well epidemic in the EU/EEA, countries need of care for European citizens. as supporting Member States to address to scale up: HIV prevention, both in terms common health system challenges, will of coverage and uptake, especially those These themes will be discussed by be a key underlying consideration. The targeting men who have sex with men, experts and recommendations for priority Maltese Presidency has the ambition of migrants and people who inject drugs; areas in which structured cooperation leaving a robust legacy in the area of HIV testing to reduce the undiagnosed can support Member States’ health health at EU level, mirroring the value and fraction and ensure early linkage to care systems, underpinned by the appropriate importance that health and health systems for people living with HIV (PLHIV) and ​ mechanisms that respect health system are given at a national level. HIV treatment and to ensure that the diversity, will be put forward in Council proportion of PLHIV with an undetectable Conclusions. viral load is increased, both for their References

personal benefit as well as to reduce future 1 eHealth 2017 Maltese Presidency of the Council of the HIV transmission. European Union [web site]. Available at: https:// Data for Health: the key to personalised www.eu2017.mt/en/Pages/home.aspx

sustainable care is the central The Maltese Presidency recently 2 The Maltese Priorities [web page]. Available at: theme underpinning eHealth Week, brought together leading experts on HIV http://www.eu2017.mt/en/Pages/Maltese-Priorities. 10 – 12 May 2017 6 organised by the prevention and control from across the aspx

Maltese Presidency, the European EU to discuss how Europe can improve 3 Azzopardi-Muscat N, Buttigieg S, Calleja N, Commission and HIMSS–Europe, in its response to HIV and these ideas were Merkur S. Malta: Health system review. Health collaboration with the World Health summarised in a technical declaration. Systems in Transition 2017;19(1):1–137.

Organization. eHealth Week 2017 will 4 Espín J, Rovira J, Calleja A, et al. How can gather more than 1,300 stakeholders Other health priorities voluntary cross-border collaboration in public from around the globe to address current procurement improve access to health technologies in international topics related to health A series of meetings being held in Malta Europe? Policy Brief 21. Copenhagen: WHO/European care IT. will focus on a number of other priority Observatory on Health Systems and Policies, 2017. areas. Foremost amongst these is the 5 Kroezen M, Buchan J, Dussault G, et al. How can The following issues have been earmarked event on Rare Diseases co-organised structured cooperation between countries address for discussion during eHealth Week: with EURORODIS and the research and health workforce challenges related to highly specialized health care? Improving access to services patient access to and sharing of health development aspects associated with through voluntary cooperation in the EU. Policy data; security and privacy of health orphan medicines. The closing meeting Brief 20. Copenhagen: WHO/European Observatory care data; sharing personal health data of the CANCON project brings together on Health Systems and Policies, 2017.

across country borders; IT support for years of important work carried out in 6 eHealth Week 2017 [web page]. Available at: European Reference Networks; improving the area of cancer at EU level. The need www.ehealthweek.org the effectiveness, safety and privacy of to sustain such valuable initiatives is 7 Key facts on HIV epidemic and progress in regions mHealth applications; scaling up digital highlighted within the overall thematic and countries in 2010 [web page]. Available at: innovation for health and care; smart priority on structured cooperation. The http://www.who.int/hiv/pub/progress_report2011/ environments and integrated care; data Maltese Presidency has also placed regional_facts/en/index2.html management analytics for personalised medicines as a key focus area. Here medicine and public health policy; IT meetings will discuss the need to find

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REFORMS TO INPATIENT CARE IN SLOVAKIA

By: Anne Spranger, Martin Smatana, Peter Pažitný, Daniela Kandilaki, Michaela Laktišová, Monika Palušková, Darina Sedláková and Ewout van Ginneken

Summary: The Slovak health system has undergone several episodes of ambitious reforms over the last 15 years. One important area of reform has been the inpatient sector. Acute care beds have been decreased by roughly 30% since the 1990s and are to be decreased further until 2030 as outlined in the Strategic Framework. A Slovenian Diagnosis Related Group (DRG-) based hospital payment is expected to become fully operational by 2022. These reforms also targeted the financial stability of the Slovak inpatient sector that has been characterised by underfunding, recurrent hospital debts and ageing infrastructure.

Keywords: Hospital Reforms, Inpatient Care, Hospital Payment, DRGs, Slovakia

Introduction as recurrent allegations that hospital managers were engaging in corruption, In the early 1990s, Slovakia re-introduced the Slovak health system underwent a a statutory health insurance system, in major reform between 2002 and 2004. which nearly all hospitals were in state The reform installed market principles for ownership and established as budgetary health insurance and health provision and contributory organisations (a Slovak form as a result, responsibility for contracting Anne Spranger is a research of not-for-profit legal entities established health service provision was moved away fellow at the Department of by the central government, regional Health Care Management, from the state towards health insurance government or municipality in order to University of Technology Berlin, companies (HICs). Other major aims Germany; Martin Smatana is perform tasks in the public interest). The were to improve efficiency in acute Director of the Institute for Health Soviet legacy of oversupply of acute beds Policies, Ministry of Health, inpatient care and achieve a more effective and lack of chronic care beds, medical Slovakia; Peter Pažitný and utilisation of resources. 1 Daniela Kandilaki are lecturers technology and inefficient coordination at the University of Economics proved difficult to change. Any attempts This article describes the most important in Prague, Czech Republic; to reduce the number of hospital beds were Michaela Laktišová is the chief reforms targeting acute inpatient care in opposed by the hospitals, as well as by analyst at the Ministry of Health Slovakia since 2010. These reforms did in Slovakia; Monika Palušková local authorities. 1 The financial situation not merely aim to reduce bed capacity, but is the chief general practitioner of hospitals (and their poor financial of Slovakia, Darina Sedláková is also targeted the efficiency and financial management) further deteriorated as some Head of WHO Country Office of sustainability of inpatient care through Slovakia and Ewout van Ginneken privately-owned hospitals entered the changes in payment mechanisms and is hub coordinator of the European market with protests by health workers Observatory on Health Systems strategic hospital planning. and Policies at the University of for higher wages in 2001. Confronted Technology Berlin, Germany. Email: with highly indebted hospitals, as well [email protected]

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Figure 1: Reducing the density of acute hospitals beds but not closing the gap €3.9 billion by the Ministry of Health 4 up with the EU average to €8.3 billion in the worst case scenario of an independent think-tank. 5 beds per 100 000 population

675 Reining in hospital debt To remedy the situation, in 2017, the 625 Ministry of Health announced plans to improve hospital governance by 575 introducing higher compliance standards to non-debts. 6 Furthermore, Slovakia

525 opted for a DRG-based payment mechanism for inpatient care. Since 2010, Poland Slovakia the implementation process has been 475 governed by the HCSA using the German DRG-system as a base. The SK-DRG Hungary 425 Czech Republic system is expected to become fully operational by 2022. Members of 375 the EU Since 2016, hospitals have been informed 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 of the respective DRG payment for each performed procedure, but are Source: 3 still reimbursed according to the ‘old’ reimbursement scheme. Currently, DRGs Reforming acute inpatient care in 1996 and was able to decrease capacity are implemented through HICs contracts, by roughly 30% by 2014. The Strategic applying various safety nets (from global Although transforming acute inpatient Framework for Health 2014–2030 aims to budgets to a combination of old and care had been addressed in previous decrease acute care beds by another 50%. 2 new payment systems). This scheme is reform programmes, the 2002 – 2004 mainly based on per hospitalisation case reforms in Slovakia received much more payment for a completed case differing by international attention. This was also A hospital sector plagued by specialty, but also among hospitals. The due to several controversial elements of underfunding basic payment rate will be harmonised the reform, such as transforming public The hospital sector has been over a five year period, from individual hospitals into joint-stock companies, a characterised by underfunding and ageing rates in 2017 and 2018 to a single rate process that has been halted twice in 2006 infrastructure. Although, the Slovak in 2022. Once the SK-DRG system is fully and after 2012 and the resulting confusion Ministry of Health had used several operational, hospital financing is expected about the long-term direction of the approaches (e.g. installing an agency to bring a higher degree of harmonisation reforms. Nonetheless, acute inpatient care called Veritel for the consolidation of in payments. Therefore, DRGs could in Slovakia was finally reformed following health care debts), hospital debts kept help raise comparability among concerted efforts by HICs, the Ministry of accumulating and had to be settled in Slovak providers and confer important Health and the Health Care Surveillance several “rounds” by the Ministry of Health information about utilisation of resources Authority (HCSA). (for an overview see Figure 2). Since 2011, in inpatient care. debts have been creeping up again to Since the early 1990s, many European reach a high of €592 million in June 2016. countries have aimed to reduce inpatient Ambitious plans to reduce inpatient Debt is a multi-causal problem based on capacity because advances in medical care capacity underfunding, but also failing governance, technology have allowed faster discharge lack of transparency and the introduction Inpatient care is jointly planned by HICs of patients and treatment in day care of minimum wages for physicians in 2011. and the Ministry of Health. First, HICs settings. In line with the countries of the contract individual providers specifying Visegrád 4 group, which includes the In theory, capital renovation of volumes and prices for inpatient care. Czech Republic, Poland and Hungary, inpatient care is also covered through In 2016, there were three HICs operating Slovakia has been able to reduce bed reimbursements by HICs to hospitals. in the Slovak market: two privately run capacity considerably (see Figure 1). Yet hospital infrastructure has been HICs and one publicly owned HIC (GHIC). In 2014, there were 4.9 acute care beds deteriorating. Indeed, health care capital Given this highly concentrated health per 1000 population in Slovakia, reaching formation was found to be well below insurance market, HICs have large market a comparable level to that of Poland, but that of neighbouring countries. Estimates power and can reduce acute bed numbers still above the EU-28 average. Indeed, of the additional investments needed in by not contracting providers or hospital the Slovak Republic started out with 6.9 order to meet EU-15 averages range from departments. For instance, the GHIC did acute care beds per 1000 population

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Figure 2: Chronology of debt settlements in the Slovak health care sector since 2002 power of public providers. 7 Indeed, all but one provider in the compulsory network 8 mil. EUR are state-owned. 1000 Despite the compulsory network, strong regional variance in inpatient care 800 capacities in Slovakia persists (see Table 1 for an example). This highlights that the compulsory network does not ensure 600 regional equality in access to inpatient

645 million debt relief 130 million debt relief services. The region around the capital,

400 Bratislava, has about 60% more beds per 310 million debt relief capita than more rural areas in the Western Slovakia (Západné Slovensko). 200 Waiting lists remain a point of concern 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Although there seems to be ample capacity as outlined above, perhaps ironically,

Source: 1 waiting lists are a persistent problem in certain areas and for certain specialties. The government that took office in Table 1: Regional variance of distribution of bed capacities in Slovakia, 2014 March 2016 made reducing waiting times a policy priority. 10 Waiting times in inpatient NUTS 2 regions Number of hospital Curative care beds Rehabilitative care care have caused several heated debates beds in hospitals beds in hospitals in previous elections. In 2010, legislation (per 1000 (per 1000 (per 1000 on public reporting of waiting times was population) population) population) supposed to increase transparency and Slovakia 5.8 4.9 0.15 collect data for several procedures and all Bratislavský kraj 7.6 6.8 0.24 hospitals. In general, waiting lists should Západné Slovensko 4.7 4.1 0.09 not exceed 12 months, as monitored by the HCSA. Subordinate legislation issued Stredné Slovensko 5.8 4.8 0.15 by the Ministry of Health regulates only Východné Slovensko 6.2 5.2 0.16 three types of waiting list (hip and knee replacements, cataract surgeries and heart Source: 9 surgeries). The impact of this decree is difficult to estimate precisely, but not contract several hospital departments Some providers are seen as crucial according to HCSA the average waiting during 2010–2011 which resulted in a to ensure accessibility times in 2014 decreased compared to 2013 nationwide reduction of 3000 beds. It by 14–53%. 1 11 However, only one HIC An exception to the principles above should be noted, however, that the HICs (Dôvera) publishes information on waiting is the so-called compulsory network are legally obliged to guarantee sufficient times and discloses this information to of providers, which was re-introduced availability. Second, strategic planning their insured population. Waiting times are in 2012. This network is based on by the Ministry of Health sets medium to also fuelled by weak patient management calculations of a minimum number of long-term goals for inpatient care. In 2002, and gatekeeping by GPs. A vast majority hospital beds for each of the eight self- the Ministry of Health implemented a Bed of consultations end with a referral to a governing regions and in 2016 consisted Reduction Plan, resulting in a cut of 6000 specialist or hospital, which also relates of 36 hospitals, specialised institutions and acute beds. In 2014, the Ministry of Health to the GP’s limited medical competences medical institutions. Minimum capacities targeted inpatient care by setting targets resulting from legislation in 2012. GP are calculated per capita, but they do not in the first Slovak Strategic Framework. competences were limited to basic and consider the specific health care needs By 2030, the goal is to achieve an administrative tasks and have been and resource use of the population. 1 occupancy rate of 85% (in 2014 it stood gradually broadened (e.g. pre-operative Enlisted hospitals have to be contracted by at 69%, well below the EU-28 average examinations and chronic care) since 2014. all HICs, irrespective of their quality and of 77%) and 2.5 acute beds per 1000 Furthermore, there are still ways to see effectiveness. Critics say this regulation inhabitants through a combination of specialists without a referral even though undermines the market and that it was reduced bed capacities and lower inpatient this has been required since 2013. 1 only established to improve the bargaining cases through strengthened primary care. 2 3

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Conclusions of hospitals has been an often overlooked 6 Government Office. Programové vyhlásenie vlády issue, although there remains great SR na roky 2016 – 2020 [Programme Declaration of Hospital reforms in Slovakia have mainly potential to make improvements. Taken the Government for the years 2016 – 2020], 2016. focused on financing and strategic Available at: http://www.vlada.gov.sk/programove- together, attention to these areas can pave planning of care as a way to increase vyhlasenie-vlady-sr-na-roky-2016-2020/?pg=2 the way to further promote quality of efficiency and sustainability of the 7 inpatient health services. Szalay T, Pažitný P, Szalayová A, et al. Slovakia: sector. As the implementation of some Health system review. Health Systems in Transition key reforms, e.g. the introduction of 2011:13(2):1–200. the Slovak DRG system, strengthening References 8 Ministry of Health of the Slovak Republic. Nariadenie vlády Slovenskej republiky o verejnej hospital governance and improving 1 Smatana M, Pažitný P, Kandilaki D, et al. Slovakia: minimálnej sieti poskytovate’ov zdravotnej primary care, are still ongoing, it is too Health system review. Health Systems in Transition, starostlivosti [Governement Decree no. 64 /2008 early to judge whether they will achieve 2016; 18(6):1–210. about the minimal network of providers], 2012. their goals. Some challenges remain: the 2 Ministry of Health of the Slovak Republic. Available at: http://www.zakonypreludi.sk/zz/2008- HICs have to contract the compulsory Strategic Framework for health for 2014 – 2030, 2014. 640) network providers which may affect their Available at: http://www.health.gov.sk/Zdroje?/ 9 Eurostat. Hospital beds by NUTS 2 regions Sources/Sekcie/IZP/Strategic-framework-for- ability to increase the efficiency of the [hlth_rs_bdsrg], 2017. Available at: http://ec.europa. health-2014-2030.pdf system. Moreover, decreasing waiting eu/eurostat/data/database times while simultaneously reducing beds 3 European health for all database [Internet]. WHO 10 Government of Slovakia. Programové vyhlásenie Regional Office for Europe, 2017. Available at: https:// sounds paradoxical but could be achieved vlády SR na roky 2016 – 2020 [Programme gateway.euro.who.int/en/hfa-explorer/#cftTVFMeak by stronger gatekeeping and better Declaration of the Government for the years patient management. How this plays out 4 Ministry of Health of the Slovak Republic. 2016 – 2020], 2016. Available at: http://www.vlada. will need close monitoring and perhaps Informácia o stave investícií v akútnej lôžkovej gov.sk/programove-vyhlasenie-vlady-sr-na-roky- additional reforms. zdravotnej starostlivosti na Slovensku a zámer 2016-2020/?pg=2 realizácie výstavby novej nemocnice v Bratislave 11 HCSA. Report on public health insurance [Information about status of acute inpatient care in for 2014, 2017. Available at: http://www. Other countries seeking to reform the Slovak Republic]. Bratislava: Ministry of Health of udzs-sk.sk/documents/14214/21128/Sprava_ the hospital sector can learn from the the Slovak Republic, 2013. Available at: https://www. o+stave+vykonavania+VZP_2014_final.pdf/ google.sk/url?sa=t&rct=j&q=&esrc=s&source=we Slovakian experience. It shows that a d1948cc6-023c-4529-be7d-15022d29f5ea multipronged approach is needed that not b&cd=1&cad=rja&uact=8&ved=0CB8QFjAAahUKEw jm8KqLzJbIAhXJORoKHR5QDEo&url=http%3A%2F only reduces beds or reforms payment %2Fwww.rokovania.sk%2FRokovanie.aspx%2FBodR methods. First, primary care reform should okovaniaDetail%3FidMaterial%3D22607&usg=AFQjC go hand in hand with reducing inpatient NGQiK6b-x4SvjxaUbApHkJnGo2QXQ&

care overcapacity. This not only includes 5 Pažitný P, Szalay T, Szalayová A, et al. improving the gatekeeping function and Modernizácia slovenských nemocníc: základné reducing unnecessary referrals, but also rámce zdravotnej politiky 2014–2016 [Modernization broadening the competences of GPs. of Slovak hospitals: basic policy framework Second, data collection on health service 2014–2016], 2014. Available at: http://hpi.sk/cdata/ Publications/hpi_zakladne_ramce_2014.pdf usage needs to be improved before it can be used to increase transparency and accountability of inpatient providers. Third, improving (financial) governance

Pharmaceutical policy in China: China has a complex pharmaceutical system that is currently undergoing significant reforms. This book provides Challenges and opportunities:17 Page 1 China pharma_book.qxp_covers 31/05/2016 10 P h

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THE TRUMP ADMINISTRATION LAUNCHES AMERICAN HEALTH LAW CHANGES INTO HEAVY SEAS

By: Timothy Jost

Summary: As promised, the Trump administration and congressional Republicans have begun an effort to repeal and replace the Affordable Care Act. While Republicans hope to pass legislation for President Trump to sign in April, they face political, procedural, and practical difficulties.

Keywords: US Health Care Reform, Affordable Care Act (ACA)

A slow start to repeal “Executive Order Minimizing the Economic Burden of the Patient Protection Rarely if ever has health policy in the and Affordable Care Act Pending United States undergone as revolutionary Repeal”. The executive order directed the a change as has occurred in the first two departments and agencies that oversee months of 2017. As of 19 January, the the ACA to: last day of the Obama administration, the Department of Health and Human • “waive, defer, grant exemptions from, Services (HHS) was still actively urging or delay the implementation of any Americans to enrol in health insurance provision,” of the ACA in order to coverage through the Affordable Care Act minimise costs and regulatory burdens (ACA) before the 2017 open enrolment imposed on states, private entities, period ended on 31 January. HHS was and individuals; issuing report after report documenting • “provide greater flexibility to States”; how the ACA, and in particular the and ACA’s expansion of Medicaid coverage • “encourage … a free and open market for low-income Americans and its ban on in … healthcare services and health the exclusion of insurance coverage for insurance”. pre-existing conditions, were benefiting Americans. President Obama himself The Executive Order led to apocalyptic and Sylvia Burwell, the departing HHS speculation about actions the Trump Secretary, sung the praises of the ACA administration might undertake to in their final remarks to the country. undermine the ACA, but had little Timothy Stoltzfus Jost is an immediate effect. In fact, executive orders Emeritus Professor, Washington On 20 January, Donald Trump was addressing domestic issues generally and Lee University School of Law, have no immediate legal effect outside the Harrisonburg, Virginia, USA. inaugurated as president of the United Email: [email protected] States. His first official act was to issue government; they rather state policy and a sweeping executive order entitled, aspiration, and this one was no different.

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During the week following inauguration – to enrol outside of the open enrolment The House Republican leadership the final week of the 2017 open enrolment period and increase eligibility verification introduced legislation on 6 March 2017 period – the Trump administration requirements for those who do, reduce that is now proceeding through Congress, withdrew advertisements urging people to oversight of and requirements for insurer but it is not clear that it can pass. It enrol in ACA coverage. ACA marketplace provider networks, allow insurers to refuse would repeal $600 billion (€562 billion) enrolment, which had been running to cover consumers who owed premiums (over 10 years) in taxes that the ahead of 2016, flat-lined in the final from prior years, and allow insurers to sell ACA imposed on health insurers, week, causing 2017 enrolment to come in cheaper plans. The proposed rule largely pharmaceutical companies and wealthy at 12.2 million, slightly behind 2016. The responds to demands that insurers have Americans; roll-back the ACA’s Medicaid Trump administration’s final enrolment made for their continued participation in expansions and change Medicaid from report rejoiced in the shortfall. The the individual market for next year. The an open-ended federal entitlement Internal Revenue Service also announced rules will harm some consumers, but they programme to a programme in which state that it was not initiating a planned new are not revolutionary. funding was capped; end the penalties programme to tighten up collection of the ACA imposed on individuals for penalties under the ACA’s individual Congress begins work being uninsured and on large employers responsibility provision, which penalises for not offering health insurance; require people who do not have health insurance As the Trump administration settles in, individuals to maintain continuous or qualify for an exemption, but it Congress has begun work on repealing coverage or face a premium surcharge, acknowledged that the penalty was still parts of the ACA. The Republicans have and abandon the ACA’s income-based in force. controlled the House of Representatives tax insurance affordability tax credits in since 2012 and have voted dozens of times favour of age-adjusted fixed-dollar tax to repeal the ACA. The Republicans only credits. The most conservative members of have a 52 to 48 majority in the Senate, the House are demanding more dramatic and under the arcane rules that normally changes in the ACA while the more govern Senate action, need 60 votes to moderate members urged patience while a Republicans do move major legislation if the Democrats consensus replacement plan is worked out. object to it. The party holding the majority The Republicans hope to pass legislation not have a repeal in the Senate, however, is able to move for President Trump to sign in April. legislation affecting the revenues and plan that all of expenditures of the United States in The procedural complexities of repeal the Senate by a simple majority vote are significant them can through a special procedure called budget reconciliation. The Republicans began As the Republicans have proceeded, the approve work on repealing the ACA through the procedural complexities of repeal and budget reconciliation process by enacting replace have become glaringly apparent. But President Trump’s revolution in a budget resolution in mid-January Budget legislation, subject to a simple health policy is starting‘‘ slowly. Nearly a instructing the jurisdictional committees majority vote, can only be used to enact month into the new administration, the of the House and Senate to begin drafting provisions that affect the revenues and major health programmes of the US are repeal legislation. outlays of the government. This is clearly functioning much as they always have. the case for legislation affecting the Former Congressman Tom Price, President Republicans are divided over the premium tax credits that fund coverage Trump’s designee to head the Department new legislation for low- and moderate-income individuals of Health and Human Services, which through the ACA’s marketplaces, and administers the Medicare, Medicaid, At this point, however, the Republicans even for the penalties that enforce the and ACA health subsidy programs, and a have run into four problems. First, they requirement that individuals be insured, sworn enemy of the ACA, was confirmed do not have a repeal plan that Republicans qualify for an exemption, or pay a tax. by Congress on 10 February. across the political spectrum can approve. But the ACA’s provisions that ban insurer For nearly seven years they had been in exclusions of pre-existing conditions But the first rule proposed by the new opposition without a chance of repealing or health status underwriting do not HHS, issued on 15 February, is billed the ACA as long as President Obama was clearly affect government expenditures as an attempt to stabilise the individual in office and could veto any legislation or revenues, and thus probably cannot be insurance markets, which were hit they adopted. (In fact, he did veto repeal repealed, much less be replaced, through with high premium increases and legislation in 2016.) As long as the reconciliation. Although Republicans are insurer withdrawals for 2017 and could Republicans were in opposition, they could hungry to repeal as soon as possible the collapse under the threat of ACA repeal vote for repeal without actually having a taxes the ACA imposed on the wealthy for 2018 without help from the Trump plan for replacement. But now that they and on health insurers and providers which administration. The rules would reduce actually have the possibility of repeal, they fund the ACA’s premium tax credits and the open enrolment period for 2018, must find a consensus clear way forward. Medicaid expansions, they realise that reduce opportunities for consumers they will need revenue from those taxes to

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finance their own assistance programmes. on Medicare, have also expressed their The response to changes is uncertain At the time of writing it remains to be seen concerns to Congress. Major medical The Republicans in Congress continue to how they can accomplish this, although and hospital associations have come out assert that they will repeal and replace the they seem to hope that they can cut federal against the Republican reforms. For seven ACA, and they likely will in some fashion. Medicaid funding enough to cover the years Republicans have made political hay The replacements they are now debating tax cuts. out of opposition to the ACA. It may be would very likely increase the number the Democrats turn to benefit from talk of uninsured, cut taxes dramatically for of repeal. The popularity of the ACA has the wealthy ($7 million (€6.55 million) been rising each annually for the 400 highest-income Individual insurance may become families) while raising the cost of health Third, although the ACA has rarely unavailable to millions of Americans insurance and health care dramatically for enjoyed a net favourable rating in low-income Americans, shift costs from opinion polls during its seven years in Finally, it has become clear that the the federal to the state governments, and force, its popularity has trended upward individual insurance market is quite reduce the cost of insurance coverage for with the threat of repeal looming. Over fragile. Precipitous withdrawal of federal the young and healthy while increasing the twenty million Americans are currently subsidies from the market, particularly if cost for consumers who are older and have covered under the ACA, and they are insurers are required to cover consumers health problems. Whether these changes unlikely to get a better deal from the with serious health problems, could will be popular or unpopular, and with Republicans. Republican members of make the sale of individual insurance whom, remains to be seen. Congress returning to their districts coverage untenable. The Congressional in February have faced mobs of angry Budget Office (CBO) earlier projected constituents. Congressional switchboards that repeal without replace, even if References are being flooded with calls demanding repeal were delayed for a couple of years, 1 Congressional Budget Office. How Repealing that members protect their constituents’ would lead to 32 million Americans Portions of the Affordable Care Act Would Affect coverage. As congressional discussion has losing coverage and individual insurance Health Insurance Coverage and Premiums. CBO, included major changes in the Medicaid being unavailable in three quarters of Washington DC, 2017. Available at: https://www.cbo. and Medicare programmes, the leaders of the country in ten years. 1 At the time of gov/sites/default/files/115th-congress-2017-2018/ reports/52371-coverageandpremiums.pdf states, which depend heavily on Medicaid, writing, the CBO has not weighed in on and senior citizens, who are dependent the present proposals.

Health system efficiency: How to The desire for greater efficiency motivates a great deal of decision-making, but the routine use of efficiency metrics to make measurement matter for guide decisions is severely policy and management lacking. To improve efficiency in the health system we must first be able to measure it and Edited by: Jonathan Cylus, Irene Papanicolas must therefore ensure that and Peter C. Smith our metrics are relevant and Copenhagen: World Health Organization 2016 useful for policy-makers and managers. In this book the Number of pages: xxii + 242 pages authors explore the state of ISBN: 978 92 890 50 418 the art on efficiency measurement in health Freely available to download at: http://www.euro.who. systems and international int/__data/assets/pdf_file/0004/324283/Health-System- experts offer insights into Efficiency-How-make-measurement-matter-policy- the pitfalls and potential management.pdf?ua=1 associated with various measurement techniques. Efficiency is one of the central preoccupations of health policy- The authors use examples from Europe and around makers and managers, and justifiably so. Inefficient care can the world to explore how policy-makers and managers have lead to unnecessarily poor outcomes for patients, either in used efficiency measurement to support their work in the past, terms of their health, or in their experience of the health system. and suggest ways they can make better use of efficiency What is more, inefficiency anywhere in the system is likely to measurement in the future. deny health improvement to patients who might have been treated if resources had been used better. Improving efficiency is therefore a compelling policy goal, especially in systems facing serious resource constraints.

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HEALTH CARE REFORM IN KOSOVO

By: Aferdita Ademi Osmani, Dorjan Marušic,ˇ Ramadan Halimi, Robert Muharremi and Valentina Prevolnik Rupel

Summary: Kosovo has one of the youngest populations in Europe. The death rate is almost half of the European average, accompanied by a low life expectancy of 72 years for females and 68 years for males. It has launched wide-ranging and ambitious health care reforms built on the introduction of a mandatory health insurance system, reforming the functions of the Ministry of Health, establishing chambers of health care professionals and changing the organisational structure of the health system.

Keywords: Health Care Reform, Health Insurance, Organisational Structure, Kosovo

Introduction of Health (MoH) to a strategic one and establish chambers (or associations) for Kosovo has a GDP (Gross Domestic key groups of health professionals to Product) per capita of €3,084 (in 2014); develop their practice. one of the lowest levels in Europe (see Box 1 for more key facts about Kosovo). A World Bank poverty assessment report 1 indicates that 45% Box 1: Key facts about Kosovo of Kosovo’s population lives below the poverty line, with another 15% living • Kosovo is located in the Western Balkans in south-eastern Europe in extreme poverty. The organisational 2 structure of the health care system • It has a land area of 10 908 km and a population density of is composed of the public health 177 habitants/km2 care network and facilities in private • It is administratively divided into ownership. Public health institutions 38 municipalities are organised into three levels: primary, secondary and tertiary. • According to the Kosovo Agency of Statistics (KAS) estimations, the resident population is approximately Aferdita Ademi Osmani is Chief The current health care reforms started 1.78 million Technical Adviser, Luxembourg in 2010 and consist of four pillars. The first Agency for Development • 28% of the population is under Cooperation, Prishtina, Kosovo; introduces universal health insurance with 14 years old and 7% are over 65 Dorjan Marušicˇ is Director, all the necessary organisational structures. • Life expectancy at birth in 2011 was Celjenje, Koper, Slovenia; Ramadan The second pillar introduces the Kosovo Halimi is Advisor to the Minister 74.1 years for males and 79.4 years 2 of Health, Prishtina, Kosovo; Hospital and University Clinical Services for females. Robert Muharremi is Assistant (KHUCS) as a coordinating body for Professor, Rochester Institute of the delivery of health care in health care Technology, Prishtina, Kosovo; institutions. The last two pillars change and Valentina Prevolnik Rupel is Senior Researcher, Institute the administrative role of the Ministry for Economic Research, Ljubljana, Slovenia. Email: [email protected]

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The current health system out-of-pocket expenditure has occurred The average daily bed occupancy rate in in the private sector and in payment Kosovo is low: for regional hospitals and The state in Kosovo is the owner of for medicines. UCCK it was 62% (in regional hospitals all public health institutions which are it was 51.9 % while at the UCCK it organised into three levels: In 2014, there were only 0.57 outpatient was 75.1% in 2014). In hospitals in 2014 • Primary health care with a network of visits per citizen performed in public there were on average 973 empty beds family health centres; hospitals in Kosovo, which is far below daily, which is much higher than 861 the EU25 average of 6.3 visits. However, in 2009. 5 • Secondary care, with seven regional taking into account that the EU figure hospitals for in-patient care and also includes data from private hospitals specialist services, professional mental Reform goals and not knowing the number of outpatient health services with nine community visits in private clinics in Kosovo, we The new Government (elected in based mental health centres and nine could conclude that in Kosovo this figure June 2014) recognises health as a priority integrated houses; and should be higher due to visits to private sector and is committed to modernising • Tertiary care comprising the University providers. There are multiple reasons the health system. The main goals of the Clinical Centre Kosovo (UCCK), for this: most importantly, the role of current reform package are to: National Institute of Public Health primary care is not yet fully functioning. • improve financial protection and with the Regional Institute for Public Furthermore, the gate-keeping function access to health care for the population, Health, Centre for Sports Medicine, of general practitioners (GPs) is not especially for vulnerable groups; and Telemedicine Centre, Institute for performed efficiently and a referral system Occupational Medicine, National Centre is not yet in place. • improve quality, appropriateness and for Blood Transfusion and Dentistry efficiency of health service delivery University Clinical Centre. The four key elements of the reform to In 2014, the private health care network achieve these goals are presented below. consisted of 1,069 licensed institutions, the 305 (28.5%) of which are dental practices Health financing reform and universal (see Box 2). government is coverage committed to The goal of improving financial protection and access to health care will be addressed Box 2: Physical and human modernising the by the introduction of mandatory health resources in the health sector insurance (MHI) from 2017, with a single health system statutory Health Insurance Fund (HIF). In 2014, there were 3,767 public beds Until the HIF starts its operations, its (2020 in secondary care and 1,747 in tertiary institutions) and 325 beds (8%) In public hospitals, there were 175,016 function will be carried out by the Health in private institutions, resulting in a total discharged patients, 93,599 from Financing Agency (HFA), established of 4,092 beds or 2.2 per 1000 inhabitants, regional hospitals and 81,417 from the as an executive agency of the MoH. which is less than half of the EU average UCCK (in 2014). With a hospitalisation The payment of contributions (called of 5.3 beds per 1000 inhabitants. ‘‘ rate of 94.88 patients treated per 1000 ‘premiums’ in Kosovo) is planned to In primary care, there are 1,068 doctors, inhabitants, Kosovo was far below the start during the second half of 2017. in secondary care 546 and in tertiary care EU28 average of 173 in 2012. 4 While that The contribution will be paid by all 1,050. In the private health care network, there are 3,024 employed health number excludes patients treated in private employees. A wide range of groups are professionals, out of which 1,457 (48%) hospitals, the difference is still substantial. exempt from paying such contributions: are doctors. There are 2.2 medical doctors One could conclude that activity levels in poor families under social assistance, per 1000 population, which is far below public hospitals in Kosovo are low. 5 prisoners, individuals who are living in the EU27 average of 3.4 doctors per state institutions (eg. children in foster 1000 citizens. 3 With 4.9 days average length of stay care and guardianship), older people and (ALOS) in regional hospitals and UCCK those with disabilities, repatriated people together (data is from 2012), this is one during the first year of repatriation, war of the lowest in the region; in regional casualties and their spouse and children, Currently, the health sector in Kosovo hospitals the ALOS was 4.1 and at the trafficking victims during the first year is largely tax-funded from general and UCCK 5.9 days. In contrast, the average after their official registration, permanent municipal taxes and direct payments. In ALOS in EU28 was 7.8 (2012). While residents of informal settlements in Kosovo, total health expenditure in 2013 low ALOS implies efficient provision Kosovo who are not registered and victims was estimated at 6.6% of GDP. Public of services, without precise data on of domestic violence. (government) sector spending on health diagnosis and severity of illness, reaching was only 2.7% of GDP, while 3.9% was a conclusion on this point about Kosovo is Citizens will be entitled to health care private (out-of-pocket). Most of the not possible. services defined under a basic benefit package (BBP). The basic health care

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services covered by the HIF will be all public hospitals during the first quarter within its constituent hospitals and determined at the beginning of every fiscal of 2013 and has subsequently implemented separate the providers from the purchaser year by a technical committee appointed them permanently. of services: currently, such operational by the HIF Steering Board and approved issues are undertaken by the MoH. by the Government in compliance with The next steps in implementing this pillar available financial resources and the of the reform include the HFA undertaking As the re-organisation of health facilities health needs of the population. Broadly, further planning, fully defining the BBP, is intended to split the purchaser-provider the BBP could potentially include: undertaking contracting with health care role, it is seen as one of the biggest protection and improvement of citizens’ providers, monitoring the performance elements of the reform. The HFA–and health through prevention and early of services and collecting contributions. eventually HIF–will be the purchaser diagnosis of diseases and other health However, more capacity building is in the system and KHUCS will be the disorders; medical procedures aimed at needed for the MHI system to become coordinator of public hospitals in the early diagnosis of diseases, treatment and fully operational. The task needs to be negotiation process. However, as a monitoring of citizens’ health conditions; supported by a health information system transitionary measure, since January 2015, treatment of diseases, injuries and other and staff training to analyse collected the KHUCS has been a budgetary health disorders; in-patient and out-patient data in order to adjust care processes organisation and receives budget hospital treatment; use of drugs and other within health facilities to meet needs. allocations directly from the Ministry of medical supplies from a defined essential Moreover, the implementation schedule Finance. Therefore, the HFA currently medicines list; use of dental and prosthetic for MHI and the introduction of criteria does not act as the purchaser, contrary to aids; use of orthopaedic and ortho- to define vulnerable groups (through a the main goal of the reform. prosthetic aids and other medical supplies specific legislative procedure) needs to be and aids. clearly established. Another shortcoming at the moment is that KHUCS lacks an institutional Re-organisation of health care development and operational plan; institutions thus, there is a lack of clarity about the relationship between the KHUCS and more As a second pillar of the reform, the the health care institutions it is tasked establishment of the KHUCS in 2014 is to co-ordinate. Overly complex and capacity building designed as a unitary health institution unclear management structures within composed of all secondary and tertiary the KHUCS, coupled with a lack of is needed for the health care facilities which have the staff experienced in the establishment status of autonomous units within it. and operation of performance-based MHI system to The definition of the role, obligations, contracts has led to the KHUCS operating responsibilities, supervision, norms, at a sub-optimal level. Consequently, become fully standards, strategies and the policies of the MoH plans to clarify the roles and the KHUCS should be developed by the responsibilities of each institution in the operational MoH and defined by statute. KHUCS as operationalisation of KHUCS. Above all, an operative body can cover negotiations, The price-list for basic health care the priority is to transfer the health budget management, analyses, planning and services will be applicable to all health from the KHUCS to HFA/HIF so that the ‘‘ monitoring, quality and safety. The care providers in the public sector. latter may begin to operationalise its role KHUCS is responsible for providing Supplementary health care services, i.e. as the main purchaser in the health system. quality health care services by focusing health care services outside of the BBP, on performance, efficiency, effectiveness, will be provided at market prices, with Re-designing the functions of the MoH and transparency in health care provision. patients paying out-of-pocket unless It is intended to create synergistic effects The premise for the current reform process they are covered under private health through the coordination of specialised is the need for the MoH to shift from being insurance schemes. health care services, and ensure the an operational government institution to transfer and sharing of professional one that is a strategic policy making entity As of July 2016, some of the activities knowledge and experience. that governs and has oversight of the whole related to the MHI have already been health sector. To actively play its role as implemented: the HFA has established the The KHUCS 6 is directed by a Managing a steward and regulator, the MoH has price list for in- and out-patient services Board comprised of seven members assigned new roles to several organisations as well as for BBP services for secondary who are appointed by the Government such as the Health Inspectorate, the and tertiary health care. Quality indicators after proposal by the Minister of Health. Pharmaceutical Inspectorate, KHUCS, have been prepared and implemented A General Director, appointed by the (new) Medical Chambers, and the HFA. through the contracting system which Managing Board, manages the operational To support the new developments and began in 2013. The MoH also piloted the affairs of KHUCS and is responsible for new responsibilities, the institutional introduction of performance contracts with its professional and financial performance. and organisational capacities of the KHUCS is expected to support MoH need to be further strengthened. management, planning and administration

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Unfortunately, this part of the reform is capacities and ability to absorb change, 3 Sanigest Internacional. Design and lagging behind schedule, to some extent launching such ambitious and wide- Implementation of Capitation-Based Performance due to political reasons. ranging reforms simultaneously has Payments at the Primary Health Care (PHC) Level, Inception Report. Prishtina, Kosovo, December 2015. impacted on the overall stability and Establishment of Health Professional continuity of the current regulatory 4 OECD. Health at a Glance: Europe 2014. Paris: Associations arrangements and service provision. It is OECD, 2014. our view that an effective monitoring and 5 Luxembourg Agency for Development Five chambers (or associations) evaluation mechanism is needed in all four Cooperation. Performance study of the health sector of health professionals have been areas to ensure that the reform is fully 2012. Prishtina, Kosovo, 2013. established for: doctors, dentists, implemented in a coordinated way. 6 Government of Kosovo. Law on Health pharmacists, physiotherapists and Insurance no. 04/L-249. 2014. Available at. http:// nurses, midwives and other health Moreover, the overly complex and www.kuvendikosoves.org/common/docs/ care professionals. The chambers are ligjet/04-L-249%20a.pdf unclear management structures within entrusted with several functions, namely the KHUCS, as well as staff capacity licensing, implementing professional challenges, present a high level of risk to supervision, verifying the legality of completing the reform process. The same the specialisation processes, organising concerns apply to the HFA/HIF. At the specialisation exams, organising MoH, where people are facing changes in and supervising sub-specialisations, their positions and responsibilities, there is planning and implementing continuous also a risk of the MoH focusing exclusively professional education. on policy formulation and supervision and it may refrain from intervening in operational aspects of the KHUCS and the HFA should these not proceed adequately. effective The main concern here is that the MoH may be moving forward with establishing monitoring and the legal and institutional framework for MHI without devoting the necessary evaluation is attention and resources to building the required human and structural capacity needed to for implementation. Meanwhile, public support for the reform could diminish ensure full and if improvements in public health care co-ordinated services are not visible. More broadly, in order to introduce implementation performance-based management a ‘‘ fundamental restructuring of the health The chambers will be financed from the care institutions is required, not only central budget for a three-year transitional in terms of structure and process, but period and then will be financed from also in the mindsets of its managers membership fees, charges and fees for and employees, to be customer-, and licensing certifications and other sources. performance-oriented. Therefore, the MoH Technical assistance and secondary and KHUCS should make more efforts to legislation needs to be prepared to enable develop required capacities. the full operationalisation of the chambers. In addition, the role and relationship between the chambers and other References organisations in the health system needs 1 World Bank. Report No. 39737-XK Kosovo Poverty to be clearly defined. Assessment Volume II: Estimating Trends from Non-comparable Data. Washington D.C., World Bank, 2007. Available at: http://siteresources.worldbank. Progress so far and the way forward org/INTKOSOVO/Country%20Home/21541688/ KosovoPAvol2.pdf (accessed on 3 March 2017). The various pillars of the reform have attained different levels of policy 2 Statistical Agency of Kosovo. Health System, attention and have reached varying levels Social Statistics, Health Statistics, Series 5. Prishtina, Kosovo, 2014. of development. The sequencing and synchronisation of actions in all four pillars has not been well coordinated. Given the health system’s current

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WHAT DOES BREXIT MEAN FOR HEALTH IN THE UK?

By: Nick Fahy and Tamara Hervey

Summary: The EU has a significant impact on health and social care, and Brexit will create major issues in this sector. A Parliamentary inquiry has identified six areas: the health and social care workforce, reciprocal health coverage, regulation and research on medicines and medical devices, public health, funding and wider market and trade rules. The major impact on health, though, is likely to come from the economic cost of Brexit putting even more pressure on financing an already stretched health and social care system.

Keywords: Brexit, Health, Social Care, Impact, United Kingdom

Introduction The EU has a greater impact on health than is often recognised Of all the areas that will be affected by Brexit, it’s tempting to think that It is often said that health and health care health and social care will escape largely is not an EU competence; indeed, this was unscathed. Indeed, one of the most visible recently repeated by the UK’s Secretary slogans of the official Leave campaign of State for Health, 1 , question 2 *. Repetition, in the referendum was to divert money however, does not make it true. The EU supposedly sent to the EU into the has wide-ranging competences affecting National Health Service (NHS) instead, health and health care, ranging from so some people may even think that the legislation affecting health determinants NHS will end up with more money after such as the environment, food safety and the UK leaves the EU. Unfortunately, living and working conditions, to detailed neither of these two things is correct. regulation and licensing procedures The EU has a much greater impact on for medicinal products and medical health than is often recognised, meaning devices. 2 This is widely misunderstood in Brexit will have major effects here, too; part because the EU’s impacts on health Note: Both authors are specialist advisors to the Inquiry on Brexit and leaving the EU seems likely to harm arise from EU powers in a range of areas. and health and social care by the the finances of the NHS, not to improve But this does not diminish their impact. Health Committee of the House of them. The Health Committee of the Commons of the UK Parliament. House of Commons of the UK Parliament The Health Committee’s inquiry has is investigating the impact of Brexit on identified six major areas of concern health and social care in the UK, and this where leaving the UK is likely to have an Nick Fahy is a consultant and has already thrown light on a wide range impact on health in the UK: 3 a senior researcher at the of areas of concern. University of Oxford, United Kingdom; Tamara Hervey is Professor of European Union Law at the University of Sheffield, * Question numbers refer to the specific question given in United Kingdom. the oral evidence. Email: [email protected]

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1. The UK’s health and social care professionals who seem likely to be able to Leaving the EU’s procurement rules may workforce – both those that are here come to the UK under future immigration result in some differences in contracting now, and those that the UK will need rules, the position for nurses is already arrangements for medical equipment and in the future; much more difficult, and social care is devices, although if European standards exactly the kind of low-wage employment are no longer recognised in the UK, the 2. Reciprocal health care coverage and where immigration restrictions would be cost of these will go up. Contracting for cross-border health care; expected to bite hardest. In his evidence health services is already effectively 3. Medicines, medical devices, clinical to the Health Committee, the Secretary of excluded from the scope of EU law: the trials and wider health research; State offered reassurances that this would choice to introduce private providers not be the case, 1 , question 50, but without into the NHS was a national one, not 4. Public health, including environmental proposing any concrete ways forward. forced by Europe, although this is often protections and communicable diseases; Even the best immigration status would misunderstood by those who experience 5. Resources, including EU agencies, not match the entitlements of EU law, or its frustrations arising from the ‘privatisation funding programmes, networks and administrative conveniences. Government of the NHS’. If Brexit does indeed reduce health in overseas aid; and narratives about immigration have not resources still further, then the frustrations helped health and care workers from the and unmet needs are likely to worsen, not 6. Market functioning and rest of the EU feel unwanted, like mere to improve. trade agreements. ‘bargaining chips’. Some key issues: medicines licensing and health workforce The impact of Brexit on funding for the NHS leaving Two particular issues that have emerged from the inquiry so far concern medicines Potentially the biggest impact on health the EU seems licensing and the health workforce. The and social care will be the impact on UK Secretary of State for Health has funding arising from the consequences likely to harm the made clear that the UK will be leaving of Brexit on the wider economy. Much the European Medicines Agency as part solace has been taken from relatively finances of of Brexit, 1 , question 67, so the UK will have to good economic performance since the put in place its own licensing regime for referendum. But this is misleading; legally, the NHS medicines. This is likely to mean some nothing has happened yet – not even the tricky choices, such as: formal notification of the UK’s intention Impact on health for the rest of the EU to leave, and certainly not the departure • does the UK try to remain closely itself. The UK has significant liabilities Of course, Brexit does not only affect aligned with the EU licensing to the EU, and there seems likely to be a the UK, but the whole of the rest of the system, effectively granting power ‘‘ substantial ‘exit bill’. Moreover, the UK is EU, too. As well as the personal impact over regulatory standards to an EU likely to lose investment from EU funds, on those who might have come to study system over which the UK no longer including the European Investment Bank, or work within the UK or Britons living has influence? which has invested over £3.5bn into the elsewhere in the EU, there are wider • does the UK deliberately diverge, British health system. 5 issues of cooperation; on pandemics and attempting to create a regulatory system communicable disease, for example, which that is attractive in different ways to We will only be able to see the economic are no respecters of borders. The Secretary pharmaceutical companies, and what consequences of Brexit after the Article 50 of State was clear that the UK will aim might that mean? process is completed and the terms of to remain part of such public health the UK’s departure are clear. The most cooperation, 1 , question 97, but only time will • or does the UK simply accept getting likely scenario remains a significant tell how feasible this is in practice from the drugs a few months or years later than deterioration in the UK economy UK’s future relationship with the EU. elsewhere in Europe? overall and its public finances, putting The UK also faces acute challenges with additional pressure on all aspects of public More broadly, the UK has historically its health and social care workforce. expenditure, including health and social played a strong role within Europe The UK is unusually dependent on care. 6 Health was a central issue in the in biomedical research, with British overseas workers in health and social referendum campaign, with frequent universities at the centre of research care, 4 with 90,000 EU staff working in complaints about people not being able generating new treatments and health social care in the UK and 58,000 in the to see their doctor or get timely health research in general under research and NHS, 1 , question 9. There’s no evidence of and social care. But these are actually development funded by the EU. If research significant numbers leaving the UK yet, symptoms of an over-stretched and and development in health becomes more but social care in particular is experiencing under-funded set of health and social fragmented across Europe after Brexit, lower numbers of applications, 1 , question 214. care services, not of liabilities to the this will have consequences throughout Whilst doctors are the kind of skilled EU or restrictions imposed by EU law. Europe, not only for the UK. If on the

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other hand the UK takes active steps to challenge of finding sufficient funding for 3 Wollaston S. Letter from Health Committee Chair secure its place as a world leader, for health and social care after the economic to the Secretary of State for Health concerning the instance through investment in the sector, consequences of Brexit become clear. Brexit and health and social care inquiry. House of Commons, 2016. Available at: http://www. 1 openness to recruitment of ‘the best’, , parliament.uk/documents/commons-committees/ question 226 , and continued participation in This article has focused on the short-term; Health/Correspondence/2016-17/correspondence- EU-funded research and development the immediate challenges thrown up by the Dr-Sarah-Wollaston-jeremy-hunt-brexit-health.pdf 7 programmes, there may be continued, Brexit process. In the longer term, though, 4 Wismar M, Maier CB, Glinos IA, Dussault G, or possibly even greater opportunities Brexit will mean that the current policies Figueras J. (eds) Health Professional Mobility and for collaboration. will be thrown open to change regarding – Health Systems. Brussels: European Observatory on well, everything. That will create both Health Systems and Policies, 2011. Conclusions risks and opportunities for health, as John 5 European Investment Bank. Health projects in the Middleton and Mark Weiss highlighted in UK financed by the European Investment Bank, 2017. It is still impossible to know what the a previous article in Eurohealth. 8 It will be Available at: http://www.eib.org/projects/loan/list/?f impact of Brexit will be. Negotiations vital to ensure that alongside attention to rom=®ion=§or=5002&to=&country=GB are just about to begin, and the British the drama of the Article 50 negotiations, 6 Office for Budget Responsibility. Fiscal Government has been studiously attention is also given to shaping the future sustainability report. Norwich: The Stationery Office, unforthcoming about what new health policies of the UK for a future 2011. relationship with the EU they are seeking. outside the EU. It is also vital that the EU 7 HM Government. The United Kingdom’s exit But even in an area such as health, often seizes the opportunity to develop its health from and new partnership with the European Union. thought of as being a purely national policies for a future without the UK. London, 2017. matter, the UK’s departure from the 8 Middleton J, Weiss M. Still holding on: Public health in the UK after Brexit. Eurohealth EU raises a wide range of concerns, References and precious few opportunities, as the 2016;22(4):33–6. Health Committee has identified. These 1 Health Committee. Oral evidence: Brexit and range from the personal uncertainties health and social care, HC 640 (2016 – 17). House of Commons, 2017. of those working in the health system and those depending on health care and 2 Greer SL, Fahy N, Elliott HA, Wismar M, Jarman H, rights both in the UK and elsewhere, to Palm W. Everything you always wanted to know about European Union Health Policies but were afraid to ask. the regulatory challenges of devising Brussels: European Observatory on Health Systems new licensing systems, and the overall and Policies, 2014.

Slovakia: Health system review insurance companies, and the lack of data sharing capacity, promote repetitive testing and this contributes to the second highest spending on ancillary services in the EU in 2013. On By: Martin Smatana, Peter Pažitný, Daniela Kandilaki, the one hand, there is a strong will to improve the Slovak health Michaela Laktišová, Darina Sedláková, Monika Palušková, system, for example the current strategic documents and Ewout van Ginneken, Anne Spranger reform efforts by the Ministry Copenhagen: World Health Organization 2016 of Health aim at a complete Health Systems in Transition (on behalf of the Observatory) Vol. 18 No. 6 2016 overhaul of enduring inefficiencies in the Slovak Number of pages: 210 pages; ISSN: 1817-6127 health system. On the other Slovakia Freely available to download at: http://www.euro.who. Health system review hand, health policy has been int/__data/assets/pdf_file/0011/325784/HiT-Slovakia.pdf?ua=1 unstable over the last years and characterised by two The Slovak health system is based on universal coverage, rigid ideological positions. compulsory health insurance, a basic benefit package and • Peter Pažitný Martin Smatana Contents: Preface, • Michaela Laktišová Daniela Kandilaki a competitive insurance model with selective contracting of • Monika Palušková Darina Sedláková • Anne Spranger Acknowledgements, health care providers. However, 14 years after the introduction Ewout van Ginneken Abstract, Executive of a competitive insurance model, some health indicators, such summary, Introduction, as life expectancy, healthy life years and avoidable deaths, Organisation and are troubling. This hints at persistent room for improvement governance, Financing, in the delivery of care, especially primary and long-term care. Physical and human resources, Additionally, inequity in the distribution of health providers Provision of services, Principal health reforms, Assessment of needs to be addressed, especially given the ageing workforce. the health system, Conclusions, Appendices. Allocative efficiency also remains a challenge for the Slovak health system. For instance, the parallel systems of health

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NEW PUBLICATIONS

How can structured cooperation between countries How can voluntary cross-border collaboration address health workforce challenges related to in public procurement improve access to health highly specialized health care? technologies in Europe?

By: M Kroezen, J Buchan, G Dussault, I Glinos, Matthias Wismar By: J Espín, J Rovira, A Calleja, N Azzopardi-Muscat, E Richardson, W Palm, D Panteli Copenhagen: World Health Organization, 2016 Copenhagen: World Health Organization, 2016 Observatory Policy Brief 20 Observatory Policy Brief 21 Number of pages: 36; ISSN: 1997–8073 Number of pages: 28; ISSN: 1997–8065 Freely available for download: http://www.euro.who.int/__data/ assets/pdf_file/0008/331991/PB20.pdf?ua=1 Freely available for download: http://www.euro.who.int/__data/ assets/pdf_file/0009/331992/PB21.pdf?ua=1 This Policy Brief draws on the experience of different cross-border collaborations in highly specialised health care in order to address This Policy Brief examines the legal framework put in place by the health workforce challenges that countries face. It identifies the EU to foster voluntary cross-border collaboration in the field of factors that can enable or block structured cooperation and public procurement of health describes the institutional framework in place. It also examines the technologies. It looks at recent policy implications for supporting structured cooperation in the EU. experiences and developments HEALTH SYSTEMS AND POLICY ANALYSIS in cross-border collaboration Key messages include: resolving health workforce challenges and across Europe and explores improving cooperation between health professionals will make it POLICY BRIEF 21 the challenges and more likely that patients will How can voluntary cross-border collaboration in public procurement opportunities that such receive high-quality specialised improve access to health technologies in Europe? collaboration presents. care in their own country. Jaime Espín HEALTH SYSTEMS AND POLICY ANALYSIS Joan Rovira Voluntary structured cross- Antoinette Calleja Key messages include a Natasha Azzopardi-Muscat border cooperation can help Erica Richardson growing interest in further POLICY BRIEF 20 Willy Palm Dimitra Panteli How can structured cooperation address the health workforce developing cross-border between countries address health workforce challenges related to challenges that currently force collaboration in the field of highly specialized health care? patients to travel to find health. This is supported Improving access to services through voluntary cooperation in the EU appropriate care. Structured No. 21 by EU legislation and ISSN 1997-8065 Marieke Kroezen James Buchan cooperation works at policies, and extends Gilles Dussault Irene Glinos different levels (linking to improving access Matthias Wismar countries, health care or to health technologies. Changes in health technologies training bodies, and/ or markets, such as the generalisation of managed entry agreements clusters of organisations and the prevailing lack of price transparency, require different No. 20 ISSN 1997- 8073 and individuals) but is approaches to those applied in the past. There is a sound always influenced by the rationale for increased voluntary collaboration between countries institutional and the underlying policy in procurement of health technologies; however, in practice, frameworks. Evaluation of different models is still scarce, but developing sustainable collaboration seems challenging. policy-makers can enhance the chances of structured cooperation Experiences are still limited and too recent to really allow succeeding by reviewing the five main groups of factors that can clear lessons to be drawn about effectiveness and impact. enable or block success. The ways in which policy-makers can Nevertheless, it is clear that in order to succeed initiatives would support structured cooperation and address health workforce require strong political commitment and mutual trust between challenges in highly specialised care are also discussed. purchasing partners.

Contents: Acknowledgments; Key terms / Key messages; Contents: Acknowledgments; Key messages; Executive Executive summary; Policy brief; Conclusions; References. summary; Policy brief; Findings; Discussion; Conclusions; References.

These policy briefs were produced to inform discussions under the Maltese EU Presidency in 2017

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NEWS Antimicrobial resistance remains high: and programmes and compare policy new EU report development and approaches in different European countries. Country profiles Bacteria found in humans, animals and provide an at-a-glance visual summary food continue to show resistance to of the situation in 31 European countries. International widely used antimicrobials, says the In addition, in-depth reviews, reports latest report on antimicrobial resistance and case studies on rehabilitation and European Reference Networks (ERNs) (AMR) in bacteria by the European Food return-to-work strategies are available. begin work Safety Authority (EFSA) and the European The project also examined specific Centre for Disease Prevention and Control issues facing women in the context of ERNs are new innovative cross- (ECDC). The findings underline that AMR an ageing workforce. border cooperation platforms between poses a serious threat to public and animal The report is available at: http://tinyurl.com/ specialists for the diagnosis and treatment health. Infections caused by bacteria glr2qpq. The interactive tool is available of rare or low prevalence complex that are resistant to antimicrobials lead at: https://visualisation.osha.europa.eu/ diseases. 24 thematic ERNs, gathering to about 25,000 deaths in the EU every ageing-and-osh#!/ over 900 highly specialised health care year. The report highlights that countries units from 25 EU countries and Norway, in northern and western Europe generally began work on 1 March on a wide have lower resistance levels than those in Kyrgyzstan: policy options to reduce range of issues, from bone disorders to southern and eastern Europe. This may out-of-pocket payments for medicine haematological diseases, from paediatric be due to differences in antimicrobial use cancer to immunodeficiency. A conference across the EU. The report is accompanied A new WHO/Europe report examines the on ERNs was held in Vilnius on 9 March to by a data visualisation tool, which causes of high out-of-pocket payments celebrate their launch and discuss how to displays data by country on AMR levels for prescription drugs in Kyrgyzstan and maximise their benefits and impact. The of some bacteria found in foods, animals presents ways to address the problem hope is that bringing together expertise and humans. through policy reform. WHO/Europe on this scale will benefit thousands of The report and data visualisation tool are conducted a study of prescription drug patients with diseases requiring a particular available via http://www.efsa.europa.eu/en/ costs in Kyrgyzstan between 2013 concentration of highly specialised health interactive_pages/AMR_Report_2015 and 2015. During this time, co-payments care in medical domains where the for reimbursed medicines in outpatient expertise is rare. There should also be care increased by 20% in the country. economies of scale allowing resources to EU-OSHA launches visualisation The report proposes a number of be used in a more efficient way. tool on safety and health of Europe’s recommendations to limit and bring The ERNs are virtual networks that have ageing workforce down high out-of-pocket payments, been set up under the EU Directive on including: regulating the price of medicines Patients’ Rights in Healthcare (2011/24/ By 2040, almost 27% of the EU’s reimbursed by public health insurance; EU). They will develop new innovative care population is expected to be over the age regulating retail sector margins; updating models, eHealth tools, medical solutions of 65. This has serious implications for legislation on the criteria and processes for and devices, as well as strengthening workers, employers and society as a whole. adding or removing medicines from the list research through large clinical studies and The objectives of a three-year project, of reimbursed medicines; and improving development of new medicines. ERNs carried out by the European Agency for data collection on reimbursement prices. are not directly accessible to individual Safety and Health at Work (EU-OSHA) at The report is available at: http://tinyurl.com/ patients. However, with patients’ consent, the request of the European Parliament, hwpphha and in accordance with the rules of their were to examine the safety and health national health systems, cases can be of older workers and to identify ways of referred to the relevant ERN member ensuring sustainable work. Among other in their countries by their health care things, the project highlighted examples of providers. The ERNs will be supported by workplace safety and health strategies that Additional materials supplied by: European cross-border telemedicine tools, consider workforce ageing, and the drivers EuroHealthNet Office and will be able to benefit from a range of and barriers to the implementation of such 67 rue de la Loi, B-1040 Brussels EU funding mechanisms including the EU strategies. The results aim to inform policy Tel: + 32 2 235 03 20 research programme “Horizon 2020”. development in this area. Fax: + 32 2 235 03 39 Email: [email protected] A full list of ERNs is available at: http:// A final overview report combines all of ec.europa.eu/health/ern/networks_en the project’s findings and discusses their policy relevance. It includes a user-friendly, interactive visualisation tool. Users can examine existing policies, strategies

Eurohealth incorporating Euro Observer — Vol.23 | No.1 | 2017

11th OBSERVATORY VENICE SUMMER SCHOOL 2017

Placing the person at the centre of the health system: concept, strategies, results

23 – 29 July 2017 Isola di San Servolo, Venice, Italy.

Theme A one-week intensive course that brings together policy makers, planners, managers, professionals and civil society representatives who will be learning, debating and sharing experiences about the conceptual, strategic and practical issues around achieving person-centred health systems. Objectives • Explore how ‘person-centredness’ is understood at the different levels of the system and by different Accreditation stakeholders and what this means for The Summer School has applied to More information and on-line the development of person-centred the European Accreditation Council application on our website: strategies for Continuing Medical Education and www.theobservatorysummerschool.org it is expected that participation will • Review key approaches to achieving or email us at: count towards ongoing professional person-centred health systems in [email protected] different contexts development in all European Union Member States. Twitter account: • Examine ways of monitoring the @OBSsummerschool performance of person-centred How to apply strategies Submit your CV and application form Assess the evidence about the impacts • before 31 May 2017. of person-centred strategies at different system levels and understand Summer School’s fee: €2,200 (including who benefits and what the possible teaching material, accommodation, unintended consequences are meals, social programme). • Discuss future trends, key challenges and policy options towards achieving person-centred health systems. WE AWAIT YOU IN VENICE!