Quarterly of the European Observatory on Health Systems and Policies EUROHEALTH RESEARCH • DEBATE • POLICY • NEWS European Health Forum Gastein 2016
• Inter-culturally competent health care • Innovation and patient benefit
› 2016 Demographics and • Health literacy • Hearing loss |
Diversity in Europe : • EU policies to aid innovation • Health priorities of Slovak EU Presidency • Dementia challenges
New Solutions Number 3
• Refugees and German | • Life-course approach and hospital care for Health intersectoral action • Big data for health services • Life-course vaccination research :: Special Issue :: Volume 22 1356 ISSN Still Steve Production: and Design permission. prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of part No 2016. Policies and Systems Health on Observatory European of behalf on © WHO Medicine. &Tropical Hygiene of School London the and Science Political and Economics of School London Funds), Insurance Health of Union National (French UNCAM Bank, World the Commission, European the Italy, of Region Veneto the and Kingdom United the Switzerland, Sweden, Slovenia, Norway, Ireland, Finland, Belgium, Austria, of Governments the Europe, for Office Regional Organization Health World the between apartnership is Policies and Systems Health on Observatory European The consideration. for authors by submitted or editors the by commissioned independently are Articles sponsors. or partners its of any or Policies and Systems Health on Observatory European the of those necessarily not and alone authors in expressed views The beyond. and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for Eurohealth at: Available Guidelines Submission Article White: Caroline MANAGER SUBSCRIPTIONS North: Jonathan MANAGER PRODUCTION Still: Steve EDITOR DESIGN B. Richard Mossialos, Elias McKee, Martin Lessof, Suszy Palm, Willy Grand, Le Julian Holland, Walter Figueras, Josep Busse, Reinhard Belcher, Paul BOARD ADVISORY EDITORIAL aboutUs/LSEHealth/home.aspx http://www2.lse.ac.uk/LSEHealthAndSocialCare/ 6803 7955 20 +44 F: 6840 7955 20 T: +44 Kingdom United 2AE, WC2A London Street, Houghton Science Political and Economics of School London Health, LSE Mossialos: Elias EDITOR FOUNDING Palm: Willy ADVISOR EDITORIAL 6381 7955 20 +44 McDaid: David Maresso: Anna 6194 7955 20 +44 Merkur: Sherry TEAM EDITORIAL SENIOR http://www.healthobservatory.eu Email: 0936 2525 +32 F: 9240 2524 T: +32 Belgium Brussels, 1060 Horta Victor Place 07C020) (Office Eurostation Policies and Systems Health on Observatory European the of Quarterly EUROHEALTH [email protected] 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
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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 for Health New Solutions Diversity in Europe: › Demographics and •vaccination Life-course •approach Life-course and • Dementia challenges • EU policies to aid innovation • Health literacy • Inter-culturally competent health care inter-sectoral action European Health Forum Gastein 2016 Gastein Forum Health European • Big fordata health services • Refugees and German • prioritiesHealth of Slovak • Hearing loss • Innovation and patient benefit research hospital care EU Presidency RESEARCH • DEBATE • POLICY • NEWS • POLICY • DEBATE • RESEARCH
:: Special Issue :: Volume 22 | Number 3 | 2016 Ausblick genießen gespiegelt © Gasteinertal Tourismus GmbH CONTENTS 18 14 10 33 4 29 25 21 2 7 Eurohealth Observer Observer Eurohealth Eurohealth International Eurohealth
IMPLEMENTATION DEMOGRAPHICS HEALTH Monika Gauden – ACTION INTERSECTORAL STRENGTHENED COURSE – CHALLENGES Tapani Barranco, – HEALTH FOR IN and Matthias – LEVEL NEXT TO THE GETTING VOICES and HEALTH INTERCULTURALLY – MATTERS CULTURE and – CHALLENGE EUROPEAN AND RECONCILING Helmut Josep SECURITY DEMOCRACY, DEMOGRAPHY, Els OVER PRIORITISING “HEALTHY” Adel COURSE FINDING DEMENTIA:
EUROPE
Torreele
Ljubiša Helmut Martin
Ali DIVERSITY
Figueras, ECONOMIC Piha
Brand
Kosinska and
Galea,
FROM Wismar,
LITERACY CARE APPROACH THROUGH THROUGH APPROACH
Manfred
THE VACCINATION Dominik
McKee
… Stojanov Brand and Lucia and – INNOVATIVE SOLUTIONS SOLUTIONS INNOVATIVE – PRESSING POLICY POLICY PRESSING
INNOVATION:
AND
Isabel
BALANCE
Gunta Martin
– –
SOLIDARITY, PATIENT
Arila EUROPE Yannis DEMOGRAPHICS Willy
– A COMMON COMMON A – DIVERSITY,
Helmut Dorli Pastore Huber,
Schnichels, AND
HEALTH INTERESTS
i
OF c IN DELIVERING De
Pochet
´
Palm COMPETENT
Lazdane
Knapp
Kahr-Gottlieb
Natsis
EUROPE:
THE La DIVERSITY
– – Brand
BENEFIT
Tobias IN Celentano
and Mata Karam –
LIFE- LIFE-
and
– Vogt
46 42 40 37 50 49 and Systems Eurohealth Eurohealth Monitor Eurohealth
Policies HOW BIG AND CHALLENGES – – CHALLENGES AND RESEARCH: Marc SEEKERS Tomas Greisigerova, EU PRESIDENCY THE Patrick HEARING FROM SUFFERING QUALITY TECHNOLOGIES NEWS PUBLICATIONS NEW Ostermann Renner, THE THE REFUGEES
SLOVAK HEALTH DATA
Schreiner CAN
Kuca D’Haese
Julia
OF IN GERMANY’S HOSPITALS – HOSPITALS GERMANY’S IN
FOR INNOVATIVE
AND
Eurohealth and BALANCING POTENTIALS POTENTIALS BALANCING
Bobek Olga PRIORITIES REPUBLIC’S LIFE
HEALTH
Eva
ASYLUM – – IMPROVE
FOR PEOPLE PEOPLE FOR Zajicova,
Anna-Theresa
Dominika
and Slovakova —
Vol.22
Herwig
SERVICE OF OF
LOSS?–
| THE
No.3 |
2016 1 2 Eurohealth fundamental values of solidarity and solidarity of values fundamental threatenour even may which and surfing are politicians populist several which on fear and insecurity of waves dangerous creating is institutions, financial and political our in trust shook severely also but hard economies our hit only not that crisis financial a of aftermath the with together This, flows. migration growing with combined is population ageing steadily Our societies. our in diversity economic socio- and cultural increasing and change demographic to another or way one relatein news the dominating now are that events the of debates. Many policy European current of core very the upon touches Gastein Forum Health European year’s this of theme the again Once SECURITY DEMOCRACY, DEMOGRAPHY,
—
Vol.22 |
No.3 ability of our society to face the challenges ahead, ahead, challenges the to face society of our ability the strengthen actually protection of social levels high that to show evidence good is there though Even migrants. or refugees more attract may they that fears amidst benefits social generous” “overly their on down to cut started have countries several it, with goes that burden tax high the as well as by beneficiaries, abuses state, the welfare of the failures –the overstate –and to demonstrate keen are who interests political by vested on spurred Often of solidarity. to desirability the feasibility the from moving risks even argument political the migration, global and downturn economic the from coming pressure Now, increasing with unsustainable. them make would ageing demographic that arguing states, welfare of European doomsday the spell to begun have pundits many now time some For |
GUEST EDITORIAL 2016
…
AND
SOLIDARITY,
DIVERSITY,
democracy.
HEALTH deprived groups who were already badly hit by the by the hit badly already were who groups deprived more the time same At the welfare. social for bill ever-increasing an paying with left be will they fear they corporations, large the and rich by the evasion tax and paradises fiscal papers, Panama about reads middle-class so-called the When division. becomes diversity where is This “disenfranchisement”. of a feeling from stemming primarily groups, other with identification and of unity alack reveals It implemented. are goals policy and values underlying way its the and of society to conception the relates also it media, by some inflated often beliefs, preconceived and perceptions to with do only not has This opinion. public swaying in alone let makers, policy persuading in success limited only had have to we seem economies, our sustain and force labour our to rejuvenate necessary be will South and East the from people of young inflow and mobility that and GUEST Editorial 3
recession and who have not felt much of the benefits The Opening Plenary, for instance, will focus on the of Europeanisation or globalisation, see migrants increasing diversity in Europe, raising its health policy and refugees arriving and fear losing their jobs or implications and seeking reactions from a range of social support. In both cases they feel abandoned high level stakeholders. The Thursday Plenary led by the political, professionals and business ‘elites’ by Nobel prize-winner Paul Krugman, will centre (and by extension the ‘Eurocrats’) who have failed on the economics of healthy ageing. Several forum to deliver on economic improvement and equal sessions will delve into related areas such as the distribution of the benefits and the burdens. issues faced in delivering health care to multi-cultural populations; the importance of, and approaches This also seemed to be at play in the recent UK to, strengthening health literacy to make citizen referendum on Brexit. The consensus view is that empowerment more meaningful; addressing the the ‘leave’ vote had little to do with the perceived health implications of diversity; or the implementation ills of the EU but rather reflected a protest against of life course based health interventions which are the ‘establishment’. This growing disenchantment tailored to the needs of specific demographic groups. with the ‘establishment’, both nationally and internationally, is not a phenomenon unique to the As we plunge ourselves into the policy debates, in UK but seems to occur in other EU countries as well. sharing, learning and networking in the Forum, our A recent survey, which was conducted before the plea from these pages is that we must continuously Brexit referendum, shows large divisions in views ask ourselves whether and how these policies benefit and values within and between Member States, as our populations, how we best communicate those well as a mounting disaffection with the EU across benefits and ensure a buy-in from both populations the board.* In seven out of ten countries surveyed, and decision-makers, and ultimately, how we make a half or more of the public said their country should real difference through advocacy and implementation. let others fend for themselves. In five countries Some may say that the EHFG’s constituents are more than half of the population felt that refugees part of this reviled ‘establishment’ of professionals constitute a threat. Similarly, the survey showed and intellectuals that have become more remote new declines in favourable opinions of the EU in to the health realities of the common folk. That is France, Spain and Germany in comparison to the certainly far from the aims and values underpinning same time last year, although we have seen signs the EHFG. This is why we should prove them wrong of rising EU sympathy after the Brexit vote and the with our deeds and actions again and again. turmoil it created. Brexit has shown that there is also a demographic divide with much of the younger Josep Figueras generation in the UK standing in the ‘remain’ camp. Director of the European Observatory on Health Systems and Policies. The questions we want to pose to Eurohealth readers and EHFG participants are how the demographic Willy Palm transformation and increasing societal diversity as Dissemination Development Officer of the European well, as the changing political climate of mounting Observatory on Health Systems and Policies. Euroscepticism and anti-globalisation, will influence future health policy development at European and Helmut Brand national level? And, more importantly, how can we President, European Health Forum Gastein. respond both as individual health professionals and as members of the ‘European health community’? The forum sessions, summarily introduced in the Cite this as: Eurohealth 2016; 22(3). pages of this journal, will offer participants some of the armamentarium of evidence, arguments and politics to better comprehend these phenomena as well as a range of best practices to address them.
* Stokes B, Wike R, Poushter J. Europeans Face the World Divided. Washington, DC: Pew Research Centre, 2016. Available at: http://www. pewglobal.org/2016/06/13/europeans-face-theworld-divided/
Eurohealth — Vol.22 | No.3 | 2016 4 Eurohealth OBSERVER
RECONCILING DEMOGRAPHICS AND DIVERSITY – A COMMON EUROPEAN CHALLENGE
By: Tobias Vogt and Helmut Brand
Summary: The trias of ageing of European societies – fertility decline, increased life expectancy and migration – is often overshadowed by current crises that need immediate attention. Because European states will get older, smaller and more diverse, all branches of our welfare systems will be affected with, health care being in a key position to shape the demographic development. Investing in health and maintaining high-quality living into older ages will allow us to make the most of our longer lives. Diversity in demographic developments will put additional pressure on European unity, thus we should perceive population ageing as a common challenge.
Keywords: Life Expectancy, Fertility, Migration, Population Ageing
Population ageing – a common babies born in this decade have very good European experience chances to live to very old ages: in some countries every second girl born today Among the many crises that Europe faces will celebrate her 100th birthday. 2 Living today, population ageing is perceived, long and healthy lives is what most of us almost with relief, as a challenge that want and should therefore not be seen as we will face only in a distant future. It is a catastrophe but as a desirable societal certainly right that population processes achievement. Nevertheless, older and are slow and demographic realities do not smaller populations need adjustments. change overnight, but the seed to address Decision makers across Europe still have future challenges must be planted today. ➤ #EHFG2016 Opening and time to react to the changing demographic Low fertility and rising life expectancy Closing Plenaries conditions, as demography is not destiny. among many European countries during A central aim should be to maintain good the last decades has led to a situation health and to finance the availability of where nine out of the top ten oldest good health care for all European citizens Tobias Vogt is Research Scientist countries worldwide are European. 1 This to make most of our gained years of life. at the Max Planck Institute for development will continue in the future Demographic Research, Rostock, Germany; Helmut Brand is Jean and put European economies and the Monnet Professor for European financial sustainability of social security Long live Europe – diversity across Public Health at Maastricht systems under pressure. the continent University, The Netherlands and President of the European Health Europeans across the continent born today However, the fact that we are getting Forum Gastein, Austria. will enjoy longer lives than their parents Email: [email protected] older and older may be also seen as an do. However, there are still substantial extraordinary European success. Most
Eurohealth — Vol.22 | No.3 | 2016 Eurohealth OBSERVER 5
differences in the expected length of life only a cost that we have to bear because retirement age – around 65 years old – that between individual countries. The Swiss, we are getting old, 7 it is an investment in has existed for several decades. 11 Instead, as the European champions, have a life our human capital that Europeans need we could peg retirement age to life expectancy at birth of 83 years and live on to face the demographic challenges of expectancy and retire when our remaining average around thirteen years longer than diminishing labour market potentials and life expectancy is 15 or 20 years. Moldovans or Russians. 3 productivity losses. Investments in our health stock enable us to make longer use On the latter point, it might also help At the same time, we spend most of our of improving average education levels and to redistribute work more equally over lives in good health, and despite longer prolong phases at older ages where we the individual life course to keep older phases with disabilities and chronic are self-sufficient and not dependent on people in the labour market for longer. conditions at the end of our life, current financial transfers. 8 In the rush hour of life between age 25 research suggests that the additional and 45, Europeans work hard to get their years of life gained in wealthier societies education, build a career, start a family 4 Finding adjustments to population are mainly healthy years. Again, there imbalances and take care of their children and older are larger disparities between European parents, while the number of hours countries but as with life expectancy we The affordability of successful ageing in worked decreases markedly already observe forerunners predominantly in high most European welfare states is heavily before retirement age. 12 A reshuffling income western countries and followers dependent on younger generations and of workloads may alleviate the time and that witness health improvements later. 5 their ability and willingness to pay for priority constraints for younger age groups A catch up of central and eastern European the needs of older people. The number and make it easier to consolidate families countries depends to a large extent on the of Europeans in the age groups who are and jobs. availability of modern health care and a also tax payers or contributors to the rise in living standards, a success story social security system is decreasing. Since A final approach is to attract people from that we have observed in several countries the 1970s, fertility in many European other populations and countries to fill since the fall of the iron curtain. countries has started to fall below perceived shortages. replacement level and every cohort born Meanwhile the leaders in life expectancy since then is smaller than the previous one. New Europeans – migration will face the challenge of degenerative With the exception of northern European and fertility diseases and questions as to what extent countries and France, there is no marked we can and want to afford further recovery in sight that would mitigate Migration is a central determinant of improvements in health and life population imbalances in the near future. 1 population change and currently, in the expectancy. This applies not only to the course of the refugee crisis, very present in question of rising treatment costs for Nonetheless, there are approaches to the public discussion. A predominant focus certain diseases or the intensification of reduce the imbalance between working of European policy makers with regard long term care needs, but also to services contributors and dependents at older to migrants, independent of their length and devices that maintain our quality ages. An intuitive way is to make use of stay, should be investments in their of life. of workforce reserves that are already human capital, especially in education there. Female labour force participation and health literacy. These measures Working with older populations in European economies is still below that are beneficial either for a prospective for men and we may have the chance to successful integration into European A large concern when it comes to ageing further engage women in the workforce if societies or it will help refugees to rebuild populations is that health and long we allow them to decrease the time they their home countries if there is a chance term care expenditures are consuming spend on informal care for children and for return. A far larger reason for concern increasing shares of national gross older parents. 9 than the current inflow of refugees is domestic products and are projected to the distribution and direction of general soar as populations get older during the Another approach is to prolong the migration flows between European next decades. Population ageing alone will phase of life in work, when we are countries. Migrants with EU citizenship or not have a significant impact on health giving transfers to the social security from outside the EU increasingly decide care expenditure. 6 Living long and healthy system. Currently, Europeans live for where they find promising perspectives is certainly not cheap and there is room around 30 years on their labour income or better wages which results in more for efficiency gains in health care delivery and finance parts of the remaining years population diversity and economic growth but a curtailing or rationing of health care of life by transfers and assets. 10 The of prosperous cities and regions. At the could be demographically problematic in ongoing improvements in life expectancy same time, less developed regions lose the long run. and health provide the chance to work a fraction of their population in the age longer and still have the same number of groups that are needed in the current and A certain change of perspective on health years in retirement as earlier cohorts did. future labour force. Unfortunately, the care costs seems necessary. Preserving Therefore, we should consider abandoning movement of industry and enterprises to good health in an ageing society is not static measures of old age, like a fixed less developed regions in search for lower
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costs is not as lively. Thus, European outside Europe. Despite the chances individual national states. Deeper social countries will be affected very differently that successful integration brings for integration could be a step towards this by population ageing. individual immigrants, the societal costs aim and act as a new narrative for Europe. of countries that suffer from an outflow Richer western European states may of mainly educated population subgroups References compensate for their low fertility and older are sizeable. populations and alleviate their projected 1 UN World Population Prospect, 2015. Available at: shortages in workforce and tax payers by While migration is certainly necessary, we https://esa.un.org/unpd/wpp/ immigration from Europe or elsewhere. should not forget that we have to provide 2 Kristensen K, Doblhammer G, Rau R, Vaupel JW. This has severe consequences for the EU the right environment and support for Aging populations: the challenges ahead. The Lancet member states, mainly in central and young Europeans to increase their fertility. 2009;374:1196 – 1208. eastern Europe, that struggle to catch This is especially true as migrant fertility 3 WHO European health for all database, 2016. up to western levels. Their populations over time converges to the lower level Available at: http://data.euro.who.int/hfadb/ 13 will age faster and welfare states will of the host countries. We should learn 4 Chatterji S, Byles J, Cutler D, Seeman T, Verdes E. face unsustainable financial pressure. To from successful countries, like France, Health, functioning, and disability in older adults – prevent increasing demographic pressure how European societies can become more present status and future implications. The Lancet on the EU’s integrity we should avoid one- family friendly in order to raise the size of 2014;385:563 – 75. sided solutions in which the already poorer our future generations. 5 Vallin J, Meslè F. Convergences and divergences European states have to shoulder the in mortality: A new approach of health transition. Demographic Research 2004; 2:11 – 44. demographic costs of losing larger parts of Slow changes but need for action their younger population to the wealthier 6 Werblow A, Felder S, Zweifel P. Population states. A viable way, worth discussing, Even though population ageing is often ageing and health care expenditure: a school of would be to include demographic described with alarmism, we have the ‘red herrings’? Health Econ 2007;16(10):1109 – 26. parameters into the distribution of EU chance to make our future less bleak or 7 Vogt TC, Kluge FA. Can public spending reduce funds. As it is already possible to use grey than predicted. Demographic change mortality disparities? – Findings from East Germany the structural funds for health this could is not a tornado or a natural disaster that after reunification. The Journal of the Economics of Ageing 2015;5:7 – 13. be accompanied by demographics. This will hit us by surprise, but rather a slowly would help to reimburse southern and rising tide. Because we are not yet in 8 Eurostat educational attainment statistics, 2015. eastern EU countries for their educational deep water, we have the time to find the Available at: http://ec.europa.eu/eurostat/statistics- explained/index.php/Tertiary_education_statistics investments and contribute to covering the right adjustments for the long process of needs of older populations. population ageing. 9 Eurostat Labour Force Survey, 2014. Available at: http://ec.europa.eu/eurostat/statistics-explained/ index.php/Labour_market_and_Labour_force_ Another adjustment to intra-EU Stay moderate: The increasing population survey_(LFS)_statistics imbalances is the intensification of pressure over the next few decades is 10 cross-border delivery of social security, particularly a result of the ageing baby National Transfer Accounts Network Europe, 2016. Available at: www.ntaccounts.org including health care. As we will not be boomer cohorts that were born after able to provide the highest level of health World War II. The cohorts that follow are 11 Sanderson WC, Sherbov S. Remeasuring aging. care in less populated regions, new ideas smaller and will lead to a stabilisation of Science 2010;329:1287 – 88. for delivering services like e- and m-health the ratio between old and young on a high 12 Vaupel JW, Loichinger E. Redistributing work in are explored and sharing the services level. 14 At the same time, we should look aging Europe. Science 2006;312:1911 – 13. of highly specialised treatment centres for alternative measures of age: being 65 13 Sobotka T. The rising importance of migrants between (especially small) countries will or 70 years old today, in terms of health for childbearing in Europe. Demographic Research be the norm. This would not only help to and cognitive functioning, is very different 2008;19:225 – 60. share the burden of demographic change, from what it was in the past. Despite the 14 Kluge F, Zagheni E, Loichinger E, Vogt T (2014) but may increase the chance for poorer need for political action, we should keep The Advantages of Demographic Change after the countries to catch up in terms of health the right measures. Wave: Fewer and Older, but Healthier, Greener, and and life expectancy. More Productive? PLoS ONE 2014;9(9):e108501. doi:10.1371/journal.pone.0108501 Stay balanced: Migration certainly When we speak about the general matters but equally important are 15 Vogt T, Kluge FA. Smarter, greener, healthier and chances of migration, we should keep changes in European fertility levels and more productive: the new old. OECD Insights, 2014. Available at: http://oecdinsights.org/2014/10/27/ in mind that it is a limited resource that improvements in health. smarter-greener-healthier-and-more-productive-the- can only partially solve the problems new-old/ created by population ageing. European Stay positive: Population ageing may cohorts are getting smaller and migration even provide some chances for younger may replace current shortages, but generations. 15 fertility has been below replacement levels for decades. This would require Stay united: Europe should face large numbers of migrants mainly from demographic pressures together and not as
Eurohealth — Vol.22 | No.3 | 2016 Eurohealth OBSERVER 7
CULTURE MATTERS – DELIVERING INTERCULTURALLY COMPETENT HEALTH CARE
By: Dorli Kahr-Gottlieb and Martin McKee
Summary: The growing diversity of Europe demands that both incoming and host populations understand each other’s cultural origins and values. This is particularly the case for the health care workforce, whose members are asked increasingly to deliver culturally sensitive care to patient groups with diverse backgrounds. This requires an open discussion about the cultural impact on health and a deliberate addressing of their own cultural imprints by both groups. These issues will be addressed throughout the European Health Forum Gastein 2016 programme, with topics such as values, diversity, migration and refugee health and the responses of health systems being discussed in the Opening Plenary and in parallel sessions such as “Desperate migration and health”, organised by the International Peace Institute and “Refugee health” organised by DG SANTE.
Keywords: Migration, Culture, Cultural Diversity, Language, Intercultural Awareness
People on the move religious minorities have lived among the ➤ #EHFG2016 Parallel Forum 4: majority populations for centuries. Some Not for the first time, the population of Desperate migration and health of these groups, such as Roma and certain Europe is changing. Throughout history, religious minorities, have, to varying people have been moving to, through and degrees, retained distinctive cultures. from Europe and have been bringing their ➤ #EHFG2016 Workshop 7: Events in the 20th century, especially genes, their customs, and their ideas to Refugee health during one of the darkest periods of Europe. Movement within Europe has Europe’s history, but also in the post-war been on a similarly large scale, most often period, have powerfully influenced the in the aftermath of conflict. However, distribution of different groups across Dorli Kahr-Gottlieb is Secretary today, the actual migration numbers are the continent. Movement on this scale General, European Health greater than ever, reflecting the urgent Forum Gastein; Martin McKee and over so many years has had profound need for non-European populations to flee is Professor of European Public implications for the composition of Health at The London School of their war-ridden territories, the growth in European populations. Hygiene and Tropical Medicine and the world’s population and the relative ease Research Director at the European Observatory on Health Systems and of transportation. Policies, United Kingdom. Email: Implications for health care [email protected] It is not, however, only contemporary As health facilities reflect the populations migration that has shaped the complex they serve, health systems increasingly cultural landscape of Europe. Ethnic and
Eurohealth — Vol.22 | No.3 | 2016 8 Eurohealth OBSERVER
provide care for patients from many which continue to protect them with members are requested to help, but this different ethnic and religious groups unquestioning loyalty. 3 An understanding raises issues of confidentiality and also, and cultures. The growing diversity of these and other cultural dimensions, like in some cases, control, especially where of European populations, bringing masculinity versus femininity or cultural women depend on male relatives. The with them an array of cultural values, differences in power-distance/hierarchy, challenges are even greater in some areas, challenges health care providers to could overcome problems that can arise in such as mental health, where additional adapt their services to more culturally many everyday health care situations. barriers and questions of stigmas and sensitive care and communication. Anand taboos may influence the care process. and Lahiri point out the importance Nowhere are cultural values more of health care choices and outcomes important than at the extremes of life, in It is well recognised that language barriers being understandable not only regarding birth and death. How do we welcome a matter; where health professionals language but also in terms of other new life into the world and how do we and patients do not share a common cultural frameworks and experiences. 1 ensure the best possible departure from language there is greater use of diagnostic On the other hand, the health workforce this earth? Who should be present at these investigations, poorer uptake of preventive also derives from many different cultural events? Patients from a collectivistic services, worse adherence to self- backgrounds as Europe has underinvested society will expect a large extended monitoring, and lower patient satisfaction. 4 in training health professionals for family to be present, with implications In contrast, training health professionals to decades. This has caused many national for the functioning of the facility. Even work with qualified interpreters improves health services to depend on migrants, in after death there may be strongly held quality of care and patient satisfaction. 5 6 all aspects of the delivery of care. In the beliefs about who can touch the body United Kingdom, for example, about 11% and what can be done with it. But there Language and culture come together in of health workers are migrants. 2 In some is much more. Is it deemed acceptable communication. Hall coined the terms areas, such as mental health and care of for someone of the opposite sex to see us high-context and low-context cultures. A older people, the figures are much higher. naked? Does our understanding of the patient from a low-context culture tends Indeed, contrary to what has been alleged world include the concept of asymptomatic to communicate directly and explicitly by some of Europe’s populist politicians, illness, such as hypertension, requiring with the goal of receiving and giving migrants in hospitals are much more likely long-term treatment, especially when that information. High-context communication to be providing treatment than receiving it. treatment may be causing side effects? is generally more context-oriented, less Different cultural groups may fail to explicit, with those involved tending to respond to treatment, simply because “beat around the bush”, with gestures and they are not taking it for varying reasons. tone of voice supporting the message. 7 A adapt These examples affect the relationship failure to appreciate these differences can between the individual patient and the have important consequences for diagnosis their services to health worker, but there are times when and the success or failure of treatment. 1 belief systems also impact on others, as Nor should we forget that the relationship more culturally when fundamentalist Christians prevent between the health worker and the patient their children from being immunised or is bi-directional. Given the dependence of sensitive care Jehovah’s Witnesses refuse a life-saving health systems on migrant workers, there blood transfusion. may also be cultural misunderstandings and when a health worker with a different Language and cultural barriers cultural background is treating a communication native patient. The situation is complicated further by Both aspects are important. The way differences in language. Recent migrants, Finally, we cannot ignore the that both‘‘ patient and carer understand and especially the extended family of those uncomfortable fact that, on rare occasions, many of the things that happen in health who move first, may have limited ability health workers not only fail to act in care facilities is shaped by their culture. to communicate in the working language the best interests of their patients but Amongst other cultural dimensions, of the country concerned. Sometimes this even abuse them. 8 This is most likely to Hofstede distinguishes collectivistic can be overcome but in many cases there occur when patients are disempowered and individualistic approaches to health. will be a need for interpretation. This, and vulnerable, as is often the case with Individualism dominates in societies in itself, creates many challenges. Are there migrants and other minorities. Such abuse which the ties between individuals are sufficient adequately trained interpreters, can take many forms, starting from an loose, who mainly take care of themselves are their costs covered by the health care active disregard for the cultural needs of and their immediate family (which tends system, especially when the language the patient concerned. to be seen in many European countries); involved is spoken by few people in the while collectivism is seen in societies in country concerned? Also, how well do the Language is, however, one area where which a person is integrated into strong concepts of modern medicine translate much has been achieved, with the and cohesive groups from birth onward, into such languages? Frequently family Netherlands and Sweden developing
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systems of “community interpreting” since workers, health policy-makers, patient 9 Durieux-Paillard S. Differences in language, the 1980s, 9 while in several countries a organisations, and researchers. It has since religious beliefs and culture: the need for right to have an interpreter is recognised in been endorsed by many European and culturally responsive health services. In: Rechel B, Mladovsky P, Devillé W, Rijks B, Petrova-Benedict R, law. However, in others, such services are international organisations. McKee M (eds). Migration and health in the European simply unavailable. This is an area where Union. Buckingham: Open University Press, 2011, technological advances offer considerable There is also a much greater awareness pp. 203 – 12. potential, whether through the involvement among those designing curricula for 10 Rechel B, Mladovsky P, Devillé W, Rijks B, of interpreters located remotely, using health professionals of the need to include Petrova-Benedict R, McKee M. Migration and health applications such as Skype, or if no cross-cultural competence, something in the European Union. Buckingham: Open University interpreting is available even automated that begins with becoming aware of and Press, 2011. 12 translation, such as Google Translate, understanding one’s own culture. This 11 Mladovsky P, Ingleby D, McKee M, Rechel B. Good though not optimal, can offer support in includes the importance of eliciting a practices in migrant health: the European experience. an acute care situation. patient’s language, culture and ethnic Clinical Medicine 2012;12:248–52. group, being aware of cultural stereotypes, 12 Fox RC. Cultural competence and the culture caution in using family members as of medicine. New England Journal of Medicine interpreters, understanding of culturally 2005;353:1316–19. specific expressions of distress, religious 13 Dosani S. How to practise medicine in a and social taboos, attitudes to health multicultural society. Student BMJ 2001;9:357–98. essential that workers of a different sex, and culturally health systems specific rituals, especially at death. 13 It is for these reasons that the focus of the recognise the European Health Forum Gastein 2016 will be on diversity, offering once again an importance of unparalleled opportunity for sharing ideas cultural and experiences. awareness References 1 Anand R, Lahiri I. Intercultural Competence in ‘‘ Health Care. The SAGE Handbook of Intercultural Intercultural awareness and Competence. London: Sage, 2009, pp. 387 – 402. competence 2 ‘Figures show extent of NHS reliance on foreign For all these reasons, it is essential that nationals’, The Guardian, 26 January 2014. Available at: https://www.theguardian.com/society/2014/ health systems recognise the importance jan/26/nhs-foreign-nationals-immigration-health- of cultural awareness and competence service?CMP=Share_iOSApp_Other among all their staff that come into contact 3 Hofstede GH. Cultures and organizations: software with patients. This requires intercultural of the mind. New York: McGraw-Hill, 2005, pp. 76. awareness training, not only for health 4 professionals, but for all staff in health Bischoff A, Perneger TV, Bovier PA, Loutan L, Stalder H. Improving communication between care facilities. physicians and patients who speak a foreign language. British Journal of General Practice Fortunately, there are many good examples 2003;53:541–6. from across Europe of how health services 5 Harmsen H, Bernsen R, Meeuwesen L, et al. can respond appropriately to the cultures The effect of educational intervention on intercultural of those for whom they care. 10 11 In 2004, communication: results of a randomised controlled the European project “Migrant-friendly trial. British Journal of General Practice 2005;55:343– Hospitals” published the Amsterdam 50. Declaration, describing the then available 6 Leanza Y, Boivin I, Rosenberg E. Interruptions and hospital services for migrants and ethnic resistance: a comparison of medical consultations minorities in Europe, noting many with family and trained interpreters. Social Science & Medicine 2010;70:1888–95. examples of poor quality services. It emphasised the importance of improving 7 Hall ET. Beyond Culture. New York: Anchor Books, quality for migrants and ethnic minorities 1989, pp. 105 – 116. as a means of achieving better care for 8 Guterman L, McKee M. Severe human rights all. It concluded with recommendations abuses in healthcare settings. BMJ 2012;344:e2013. on the specific contributions that can be made by hospital management and health
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VOICES FROM As in previous years we have asked some prominent ‘voices’ in Europe to reflect upon the topics to be discussed at the European Health Forum Gastein 2016.* They represent the various key EUROPE stakeholders attending the EHFG: international and national policy makers, academic researchers, industry and civil society.
EH: European health systems need to adapt to the demographic challenge as well as to the increasing diversity in citizens’ Vytenis Andriukaitis: EU Commissioner for health profiles and needs. How well-prepared are we to face Health and Food Safety this challenge?
Oberhauser: Looking at the various challenges that we’re currently facing, we need a strong public health system, now more than ever. We need to develop a new way of thinking about healthy ageing, not only to focus on the economic burden of Zsuzsanna Jakab: Regional Director, World ageing populations. This will allow older people to remain in Health Organization Regional Office for the labour force, to volunteer, to provide (informal) care and to Europe (WHO/Europe) maintain their consumption patterns. The ultimate goal of the Austrian government’s program is to “empower people to live and work longer in good health”. This requires interventions across the life-cycle. Following the Austrian Interdisciplinary Study on the Oldest Old (ÖIHS), the health of individuals Sabine Oberhauser: Federal Minister of aged 80 and older in Austria is much better than assumed. Health, Austria However, we will continue pursuing this approach in order to gain more healthy life years.
EH: WHO/Europe will organise a session in Gastein on implementing the life-course approach in health. What does this mean in practice and how will it require policy makers to change Tomáš Drucker: Minister of Health, Slovakia their policies accordingly?
Jakab: The life-course approach looks at health through the lifecycle and acts on the physical and social factors affecting health at critical times and transitions – such as during pregnancy, childhood, adolescence, young adulthood and later adult life. It seeks to build health advantages that can last a Natasha Azzopardi Muscat: President-elect, lifetime and reach across generations. This approach is one European Public Health Association (EUPHA) of the principles underpinning Health 2020, the WHO policy framework for health and well-being in Europe. It is also emphasised in the Sustainable Development Agenda where goal 3 seeks to “Ensure healthy lives and promote well-being for all at all ages.” A life-course approach calls for coherent, cross-sectoral policy-making where different sectors cooperate Richard Bergström: Director General of the to improve health. For example, evidence shows that when European Federation of Pharmaceutical reproductive-age women enjoy good nutrition this helps Industries and Associations (EFPIA) prevent their children from developing obesity later in life and reduces their risk of non-communicable diseases. The health, agricultural, social and economic sectors must therefore all play their part in ensuring that pregnant women have access to healthy and nutritious food. Nina Renshaw: Secretary-General of the European Public Health Alliance (EPHA) EH: With the European Innovation Partnership on Active and Healthy Ageing the Commission set out an ambitious agenda for meeting the societal challenge of demographic change. What lessons can be drawn from the experience so far? Have other pressing topics and crises diminished political attention for this challenge?
* The statements were selected from written contributions received from the various panel members to questions submitted to them, and re-organised by the Eurohealth editors.
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Andriukaitis: It is true that the EU has been beset by crises with truly frightening consequences. We require strong political in recent years. However, while events such as the economic commitment and action that addresses all facets, including crisis and the influx of refugees have dominated the headlines, human medicine, agriculture/food production and drugs Member States have continued to work together and to exchange manufacturing. We need better data and surveillance, rapid best practices and expertise on innovative ways to ensure active diagnostic testing, and ambitious targets. There is an essential and healthy ageing. Indeed, health is an area where the added role for Europe acting in solidarity and investing in everyone’s value of EU level cooperation is clearly demonstrated. Five years interest, with close coordination and control – none of us can since the launch of the European Innovation Partnership (EIP) afford a weak link in one country that will rapidly undo progress on Active and Healthy Ageing, innovative programmes on in others. adherence to medication, prevention of frailty, chronic disease management and integrated care, for example, are being EH: How can a common approach at international level rolled out, scaled up and replicated across the EU. This wide help to better achieve our goals? In which way do the health deployment of innovative practices is a prime example of how priorities chosen by the Slovakian government for its current EU combining our efforts can improve health and quality of life of Presidency match with the EHFG’s focus on demographics and citizens aged 65+ across the EU. diversity and the issues addressed in the various sessions?
EH: One of the EHFG sessions will deal with ‘healthy Drucker: International cooperation is key towards sustainable innovation’, i.e., how to ensure that innovation will indeed lead problem solving in the EU. We are no longer running our health to better health by focusing on the real priorities and ensuring care systems in silos. We need to pool our resources, best minds that the entire population can benefit. Can the current market- and practices in order to jointly create a better future. Slovakia driven model of pharmaceutical innovation deliver on these chose its health priorities for the EU Presidency based on conditions? two factors. Firstly, we aimed to create a continuum between the Dutch and Slovak Presidencies, to ensure that unfinished Bergström: It can absolutely do that, with over 7000 medicines projects are completed and value generated. Secondly, we aimed in development, the pipelines of the industry are filled with to choose topics that will benefit the population across the EU. In innovation that will help address currently unmet health needs, other words, we looked into topics that present a challenge, or a in everything from cancer over Alzheimer’s to rare diseases. But threat for a majority of the EU population. Therefore, the Slovak we need to strengthen collaboration with policy makers, payers, topics for the Presidency (access to medicines, MDR-TB and patients and other stakeholders to set priorities and we need to reformulation of food ingredients) reflect the international-level get the incentives right. The threat of anti-microbial resistance is interests and try to be equitable, solving problems that an entire a clear example of what can happen if the incentives to innovate population of the EU is facing†. are not there, and if there is a lack of frank discussion about this for many years. We are now making a lot of progress in that area EH: How can international collaboration also help to address to make up for lost time, but we must get better at having these the challenges of healthy ageing? The Austrian government conversations across all areas. identified quality of life of older people as a priority topic, with the development of an integrated national strategy for dementia EH: EPHA chose antimicrobial resistance (AMR) as the as one of the concrete outcomes. What can we learn from the focus for its next annual conference? Do you think that there Austrian experience? is not enough awareness of the public health threat that AMR represents? What needs to be done to improve national and Oberhauser: Non-communicable diseases (NCDs) are international preparedness to fight AMR? increasingly putting a burden on all health systems. Dementia is a silent NCD pandemic affecting all countries. We should Renshaw: AMR is a symptom of severe, long-term political jointly seek solutions addressing these challenges, by exchanging neglect of public health and failure to invest to head off an best-practice and putting an emphasis on a gender-sensitive and unprecedented humanitarian crisis. But we still have an human-rights based approach. Our dementia strategy provides opportunity to act and put in place health-coherent policies an integrated and inter-sectoral framework of objectives and across sectors and at all levels, from international to local. recommendations for improving the lives of people living with European researchers and governments have taken a leading role dementia, including their families and caregivers. It promotes in identifying the causes and costs of AMR, but must now put a better understanding of dementia, raises public awareness in place effective and urgent measures to stop its spread. Europe and engagement, including respect for human rights, reducing should also lead the coordination of international responses – stigma and discrimination, and promoting early diagnosis and as we did for climate change – that will be needed to avert a care. Key aspects are a better coordination between the health global disaster. The European discussion has so far neglected and social sector, as well as specific measures to tailor health the important role of environmental pollution in pharmaceutical promotion, health literacy, prevention and care to people living supply chains. Much still needs to be done to make sure everyone with dementia. understands the scale and severity of the threat. We need to emphasise that ‘superbugs’ can dismantle modern medicine, † A more detailed article on the Slovak EU Presidency health priorities can be found later in this issue.
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EH: So how should we tackle these NCD challenges together? EH: Clearly, ageing and diversity force us to rethink our In your view, what is the most pressing issue in this context that approaches to public health, prevention and health care needs to be addressed by policy makers both nationally and provision? In what way is this also offering a positive outcome or internationally? opportunity?
Jakab: Reducing inequities is the challenge of our time. Andriukaitis: The most pressing issue is also the greatest Although people living in the WHO European Region are living opportunity. We need to improve the health systems in all longer than ever before, there is an eleven year inequity gap Member States to make sure they are fit for purpose. This between countries with the highest (82 years) and lowest (71 includes strengthening their effectiveness, increasing their years) life expectancy. Similarly, there is a 10.5% inequity gap accessibility, and improving their resilience ‡. However, if we in primary school enrolment rates, and a 30.5% inequity gap in want to improve the performance of our health systems, we unemployment rates. If we are to respond to population ageing, have to assess them first. This is why I have recently announced the chronic disease burden and migration, we must ensure a Commission initiative called “State of health in the EU” § that the building blocks for a secure, rewarding, life of good which will bring together internationally renowned expertise to health and well-being – education, employment, housing, active strengthen country-specific and EU-wide knowledge on health participation in civic society and control over life – are available in a concise, digestible and coherent package. The aim of this to all. The Sustainable Development Agenda mandates and sets two-year exercise is to boost analytical capacity and support out a framework for individuals, civil society, governments and EU countries with their evidence-based policy making, so they the private sector to contribute to a fairer, safer and healthier can make the best decisions for them. The first results of this world. We must recognise and seize this opportunity. overview should be available in November 2017.
EH: The theme ‘All for Health – Health for All’ at the upcoming Bergström: I think the good news is indeed that we more or less European Public Health Conference aims to highlight persisting know what we need to do. Now we just have to do it. We need to inequalities in health. Why aren’t we managing better to close create more effective and responsive health care systems focused the gaps in healthy life expectancy? on improving patient outcomes. They have to deliver better value for money, and for this we need to focus more on patients with Azzopardi Muscat: Health inequalities are a key sentinel chronic diseases and multi-morbidity, since these are driving the indicator for general inequality. Growing inequalities have costs of health care and will do so even more in the future. profound political, social and economic consequences. A breakdown in intergenerational solidarity and inter-racial Azzopardi Muscat: We have to make health care professionals tensions are key political issues for Europe. Fostering better better understand how their roles need to change and evolve health, particularly for children, adolescents and young families in order to meet these new challenges. Health systems are in socially deprived communities is necessary to address increasingly about being able to deliver chronic care in these ominous trends. Investment in education, health systems the community adapted to the local contexts and needs, in and public infrastructure is necessary to address persisting partnership with social care organisations, as traditional family inequalities. Older populations and minorities compel us to structures have been replaced. prioritise such investments. The future of the European project must be built around health and social well-being for all. EH: In what should health systems invest to improve their Strong markets can be an important vehicle to achieve these performance and better meet the needs of an ageing and more goals, if managed well. European public health researchers diverse population? and practitioners have an onus and responsibility to contribute towards shaping a better future for all European citizens. Drucker: The more diverse needs of a population, the greater EUPHA, through the organisation of conferences such as the one the cost, the less flexible the system and the greater the being held in Vienna in November 2016, provides an opportunity likelihood of medical malpractice. Taking into consideration and a platform to rethink our approach in striving to achieve rising expenditure on health care and a growing number of Health for All in the 21st Century. reform activities across the EU, it is clear that current socio- demographical changes across Europe have become the key Renshaw: EPHA also advocates inclusive health systems that challenge of the Union. And most EU countries have only just are accessible to all, including people living in vulnerable started to address them. Diversity in the needs of the population situations. There has been much talk about healthy ageing in has to be addressed by a flexible system that can respond to Europe, but this can only be accomplished if people have the varying needs in a fast and effective manner. This will require opportunities and the best conditions to be healthy and access a broadening of competencies, more expandable capacities of employment throughout their lives. We must also better value providers, better support of home and self-care as well as mobile the experiences of older people in the job market and foster and telecare solutions. But the key to creating a more flexible increased intergenerational contact. ‡ See the Communication from the Commission on effective, accessible and resilient health systems. Available at: http://ec.europa.eu/health/systems_performance_assessment/docs/ com2014_215_final_en.pdf
§ See http://ec.europa.eu/health/state/summary/index_en.htm
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health care system is integration. Vertical integration – by experience an increase in the incidence of infectious diseases. sharing information between different levels of providers and However, we are currently facing increasing demand for ensuring a smooth flow of patients according to their needs, psychosocial support of refugees and aid workers. Therefore, facilitating self and preventive care. Horizontal integration – by the Austrian Federal Ministry of Health has commissioned the creating financing mechanisms that support cooperation and are establishment of a national coordination platform. Much more based on outcomes rather than on inputs or service provision. concerted action will be needed at a European level to effectively The most important type of integration is integration at an manage the current refugee influx and to identify best practices international level. and innovations.
Bergström: A key enabler for transforming health care in this EH: Thank you for this interesting exchange! direction is data management. We must dig out and connect all the data that today are scattered across the health system, but also data from outside the system, such as data generated by social media and health apps. Through a better use of data we can analyse what interventions actually give the best outcome for specific patients for available resources. This will require some investments in the short term to build the necessary health information infrastructure, including through electronic health records and disease registries. But if we make that investment now we will be in a much better place to meet the future.
Azzopardi Muscat: Ageing and diversity provide an opportunity for new recruits to the health system and this has so far been mostly overlooked.
Renshaw: Europe urgently needs more health workers and carers, at the same time our economies are restructuring further away from heavy industry due to technological change. We must better recognise the value of caring roles in our societies and economies. Many carers today are undervalued and underpaid, or unpaid in caring for relatives.
EH: Can migration help in that respect?
Renshaw: Migration can represent a huge opportunity for Europe in this context. It is simply not true that health services are at breaking point because of immigration; lack of investment in health services is a political decision. In fact, health workers from all over the world make an invaluable contribution. Their much needed skills can be an asset for sustainable, resilient health systems today and in future. While the current migration situation is problematic due to lack of solidarity in Europe, complicated asylum procedures and few opportunities for legal migration, Europe will continue to become more diverse and health systems will need to adapt. Opening up to new cultural perspectives will make us richer and more resilient in the long run.
Oberhauser: Social and health systems in countries with an ageing society will benefit from increasing mobility mainly of younger migrants who leave their home countries searching for new opportunities. However, for countries from where these young people depart this migration represents a major challenge for the health sector. Being both, a transit and a destination country for refugees, we do see the importance of a responsive public health system and intersectoral action for health. While there is high demand for basic medical examinations and treatment for refugees when arriving in Austria, we do not
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HEALTH LITERACY IN EUROPE: GETTING TO THE NEXT LEVEL
By: Matthias Wismar, Helmut Brand and Ljubiša Stojanovi ´c
Summary: Health literacy is the ability to access, understand, appraise and use information relevant to health. This may apply to joint decision making in clinical settings but it is equally important in disease prevention, health promotion and health policy making. This article reviews the definitions and concepts of health literacy, presents an overview on how health literate Europeans are and provides some perspectives on how to get from science and surveys to the next level, including the implementation of national programmes and action plans.
Keywords: Health Literacy, Joint Decision Making, Healthy Behaviours, European Health Literacy Consortium
Introduction understanding of new health technologies are all influenced by the level of health Why should we address health literacy? literacy. According to a Eurobarometer survey a large number of Europeans are unaware Typically, people who have higher levels of that antibiotics are ineffective against health literacy are healthier and use health viruses (57%), colds and flus (44%). 1 care resources more appropriately under This lack of appropriate and actionable similar conditions. Strengthening health knowledge, or in other words, the lack of literacy is possible. However, we need to health literacy, may affect the interaction be aware that it is a specific competency between doctor and patient, joint clinical people need to acquire and develop. decision making, the effectiveness of Simply increasing the flow of public health treatment and the patient experience. ➤ #EHFG2016 Lunch workshop 4: information is not enough: according In the worst case scenario this lack of Health literacy to the same survey, 1 only a third (34%) health literacy may result in unrealistic of those Europeans who have received expectations, incorrect decisions, information said that the information they ineffective therapies, poor outcomes received – from any source – led them Matthias Wismar is Senior and patient dissatisfaction. Moreover, to reconsider their use of antibiotics. In Health Policy Analyst, European an insufficient level of health literacy, Observatory on Health Systems contrast, people with better knowledge of for example through the continued and Policies, Brussels, Belgium; antibiotics use them less often. A recent Helmut Brand is Jean Monnet inappropriate use of antibiotics, may wave of health literacy surveys in Europe Professor of European Public Health undermine policy responses which aim and head of the Department of has shown deficiencies in existing health to tackle the challenge of antimicrobial International Health at Maastricht competencies in the population, but resistance. Health literacy is not only University, The Netherlands; and also the potential of this tool to increase Ljubiša Stojanovic´ is Deputy Head important in the clinical setting. Healthy awareness of the benefits stemming from of International Affairs Division, behaviours, including diet and physical Swiss Federal Office of Public strengthening health literacy. The time has activity, or the under- and overuse Health, Bern, Switzerland. come to act upon it and get to next level! Email: [email protected] of health systems’ resources or the
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Table 1: What the health literacy survey measured: matrix of sub-dimensions
Health literacy Access/obtain information Understand information Appraise/judge/evaluate Apply/use information relevant to health relevant to health information relevant to relevant to health health Health care 1) Ability to access 2) Ability to understand 3) Ability to interpret and 4) Ability to make informed information on medical medical information and evaluate medical decisions on medical or clinical issues derive meaning information issues Disease prevention 5) Ability to access 6) Ability to understand 7) Ability to interpret and 8) Ability to judge the information on risk information on risk evaluate information on relevance of information factors factors and derive risk factors on risk factors meaning Health promotion 9) Ability to update oneself 10) Ability to understand 11) Ability to interpret and 12) Ability to form a on health issues health related evaluate information on reflective opinion information and health related issues on health issues derive meaning
Source: Ref. 8
Box 1: Definition of health literacy Defining health literacy that the availability of highly processed, according the HLS-EU Consortium pre-packaged massively commercially Clearly, health literacy is an important pushed foods and drinks make the healthy ability for patients and citizens. But what ‘Health literacy is linked to literacy choice sound naïve. 4 Alcohol adverts is it exactly? Initially, the concept of and entails people's knowledge, were seen almost once-per-minute during health literacy emerged from the clinical motivation and competences to telecasts of the Euro 2016 games, where a context when health workers realised that access, understand, appraise, brewer replaced its brand name on pitch- patients with limited reading skills had and apply health information in side digital boards with one of its well- particular difficulties in understanding and order to make judgments and take known slogans. 5 This calls not only for complying with medical advice. Plenty decisions in everyday life concerning better information systems for consumers, of research has reproduced this causality. healthcare, disease prevention but also for a more level playing field in Much of the subsequent research has and health promotion to maintain which the commercial determinants of contributed to broadening the scope of or improve quality of life during the health have less opportunity to promote the definition of health literacy. 2 Today, life course’. unhealthy choices. health literacy comprises the ability to find, understand and assess health related Source: Ref. 3 information helping with co-decision making in clinical settings, helping to make healthy choices, and decision people In order to make informed choices, making on public health and health patients and citizens need interaction, system issues. who have higher independent information, easily accessible points of information covering different There are plenty of definitions of health levels of health languages for different parts of the literacy and many of them only differ in population. A great example is the “Health nuances. For this article, an important one literacy are with Migrants for Migrants” in Europe is the definition used by the European project run by the ethno-medical centre in Health Literacy Consortium (HLS-EU healthier Hannover Germany, which won last year’s Consortium) because it is the foundation of Health literacy has also to do with wider prestigious EHFG Health Award. 7 the main health literacy survey in Europe health system decisions. Would the NHS (see Box 1). be better off inside or outside the European How health literate are we? Union‘‘ (EU)? This was one moot point in Health literacy beyond clinical the discussion on the so-called “Brexit” The European Health Literacy Survey settings vote on whether the UK should leave the (HLS-EU) 8 was conducted during the EU. It was important because it included summer of 2011 across eight European Health literacy goes well beyond the questions of migration and financing. Key countries including Austria, Bulgaria, clinical setting. It is relevant for all areas issues were staffing, accessing treatment Germany (North Rhine-Westphalia), of daily decision making. Checking the in the UK and abroad, regulation, Greece, Ireland, Netherlands, Poland, ingredients of different foods, including cross-border cooperation and funding and Spain. The researchers in each salt, sugar, fats, calories, etc. can be quite and finance. 6 country sampled a random selection of cumbersome. It has actually been argued approximately 1000 EU citizens who, at
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Figure 1: Levels of general health literacy, % of those surveyed in European Health than the average level in the eight original Literacy Survey countries, the proportion of people with “problematic” health literacy was 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% rather higher (45%). A clear link appears Austria 9.9 33.7 38.2 18.2 between the levels of health literacy and Bulgaria 11.3 26.6 35.2 26.9 physical activity: among people with the lowest level of health literacy, 78% said Germany* 19.6 34.1 35.3 11.0 that within the last month they had not once practiced a sports activity for at Greece 15.6 39.6 30.9 13.9 least 30 minutes. This proportion drops
Ireland 21.3 38.7 29.7 10.3 linearly to 10% for the group of people with the highest level of health literacy. Netherlands 25.1 46.3 26.9 1.8 Furthermore, a lower level of health literacy was also associated with more Poland 19.5 35.9 34.4 10.2 frequent hospital stays and/or emergency ward consultations. Spain 9.1 32.6 50.8 7.7
Total 16.5 36.0 35.2 12.4 Health Literacy: from surveys to health(y) outcomes? Excellent general health literacy Problematic general health literacy Sufficient general health literacy Inadequate general health literacy The levels of limited health literacy in Europe are an issue of concern and may Source: Ref. 8 limit the effectiveness of health promotion, Note: * North Rhine-Westphalia disease prevention, health care and health policy. However, policy responses the time of the survey, were aged fifteen health literacy while this was the case addressing this issue are shaping up. years or over. Overall, they interviewed for only 37.7% of respondents from the Austria might be the country where health approximately 8000 people. The Netherlands. If general health literacy is literacy has attracted the highest interest researchers developed a questionnaire disaggregated into the three areas it shows from political decision makers in recent featuring 47 items. As presented in that limits in health prevention health times. In 2011/12, a set of ten general Table 1, they were based on twelve sub- literacy are higher (with 50.9%) than in health targets was defined, 10 one of them dimensions derived from crossing three health care literacy (40.9%), with disease being the strengthening of health literacy. areas (health care, disease prevention and prevention literacy in the middle (42.8%). Implementation was commissioned to health promotion) and four information- Fonds Gesundes Österreich, the national processing stages (access, understand, The publication of Figure 1 attracted a competence centre and central funding appraise, apply), following the definition lot of attention, particularly in German office for health promotion. But the results presented in Box 1. speaking countries. Some countries did from the HLS-EU have also mobilised not participate in the initial HLS-EU policy makers, health professionals and Overall, the survey provided, for the survey but used the same tool for their stakeholders in other countries. Many first time, a detailed though somewhat own surveys. For example, in Germany realised that the awareness generated by unflattering insight into health literacy in the initial survey conducted in North- the survey should be used as a window Europe. The value of the results must not Rhine Westphalia was extended to the of opportunity for action. Hence, for be underestimated, especially since the whole country with an additional focus on example, in the German speaking survey was conducted in several countries, health literacy in migrant populations. The countries national platforms have been allowing for comparison. results confirmed the data from the initial created to support projects aimed at HLS-EU survey. General health literacy strengthening health literacy. 11 Key Looking at the general health literacy in Germany was inadequate for 14.5% stakeholders in these countries also used level for the eight countries included in of respondents, problematic for 45.0%, the momentum to produce a German the survey, it has to be said that more sufficient for 33.7% and excellent for 7.0%. translation of a WHO-publication on than one tenth (12.4%) of respondents had health literacy facts 12 and to instigate a inadequate general health literacy and More recently, in 2015, Switzerland used three-country dialogue to build a joint more than a third (35.2%) had problematic the HLS-EU questionnaire to conduct basis for domestic discussions.* general health literacy. This means that a survey on health literacy. 9 In general, for the eight countries included nearly the results confirmed the findings of every second (47.6%) respondent’s general the earlier surveys in other countries. * This publication has been sponsored by the following health literacy was limited. There are Although in Switzerland the proportion organisations: Germany: Federal associations of AOK sickness fund (AOK-Bundesverband), Austria: The Main some variations between countries: 62% of people with an inadequate level of Association of Austrian Social Insurances (Hauptverband der of respondents from Bulgaria had limited health literacy (9%) is somewhat lower Österreichischen Sozialversicherungsträger) and Switzerland: the Swiss CAREUM foundation.
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This is a beginning, but further action Fourth, there are now talks of repeating 7 EHFG. European Health Award 2015. Available at: is needed. First, there is an abundance the HLS periodically to monitor the http://www.ehfg.org/years-of-award.html of health literacy interventions for development of health literacy in Europe. 8 Sørensen K, Pelikan JM, Röthlin F, et al. HLS-EU individuals in different settings. And there Through this we will be able to monitor Consortium. Health literacy in Europe: comparative are plenty of good practices sponsored by developments in the different dimensions results of the European health literacy survey sickness-funds, health administrations and of health literacy over time and place. (HLS-EU). European Journal of Public Health 2015;25(6):1053 – 8. civil society organisations. The robustness It will be possible to keep the same of health literacy interventions may vary methodological comparisons between 9 BAG. gfs-Studie im Auftrag des Bundesamts and transferability needs to be taken countries and regions and we will be für Gesundheit BAG. [Population survey health literacy 2015.] May, 2016. Available into account but there is no excuse for able to identify good practice examples. at: Bevölkerungsbefragung “Erhebung abstaining from action. Moreover, a general evaluation of the Gesundheitskompetenz 2015”, [Federal Office of different interventions will tell us if we are Public Health].
Second, we need health literate on the right track. 10 Rahmen-Gesundheitsziele. Austrian health organisations. You can operate your targets. Available at: http://www.gesundheitsziele- smartphone without knowing or In the field of education, the PISA-Surveys oesterreich.at/ understanding the highly complex have harmonised expectations in Europe 11 Austria: Österreichische Plattform technology working inside it. It is about and other OECD countries regarding the Gesundheitskompetenz [Austrian platform health the “user-interface” which makes people mathematical, verbal and science skills literacy] (www.oepgk.at); Germany: Action Plan on able to deal with complex issues. This is that students are expected to acquire Health Literacy initiated by the federal association also true for health. Trying to increase during their school years. When the results of AOK under the patronage of the Minister of Health (http://aok-bv.de/presse/pressemitteilungen/2016/ health literacy on an individual level first came out many countries were alerted index_16431.html); Switzerland: Allianz- has its merits but also limits. It has to to the mediocre performance of their Gesundheitskompetenz.ch be accompanied by re-thinking the youth. This awareness resulted in political 12 Kickbusch I, Pelikan J, Haslbeck J, Apfel F, organisations and structures in which action. School reforms were initiated, best Tsouros AD. Gesundheitskompetenz: Die Fakten © health and care is provided from a health practices from high-achieving countries Weltgesundheitsorganisation, [Health literacy: the literacy perspective to reduce complexity were examined and adapted to local solid facts]. World Health Organization, 2013. for the citizen and patient to have needs. This action has brought about many 13 McDaid D. Investing in health literacy. What do lasting effects. positive results during the last decade we know about the co-benefits to the education sector and student PISA-performance levels of actions targeted at children and young people? Third, we are getting a handle on have improved in many countries. This Policy Summary, European Observatory on Health intersectorality, including the framing is something we should also aim at with Systems and Policies, 2016. Available at: http://www. euro.who.int/en/about-us/partners/observatory/ of the issue. Health literacy has some respect to health literacy in Europe: the publications/policy-briefs-and-summaries/investing- direct contacts in the health sector where window of opportunity is open. in-health-literacy general practitioners, nurses and other health workers, ministries, competent References authorities and sickness funds may also play a role in commissioning or 1 Special Eurobarometer 445, Antimicrobial providing patient information. However, Resistance, April 2016. Available at: http://ec.europa. eu/dgs/health_food-safety/amr/docs/eb445_amr_ many fields where health literacy may be generalreport_en.pdf strengthened will be outside the health 2 sector. Therefore, ministries of health need Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education to reach out to other sectors for dialogue and communication strategies into the 21st century. and collaboration. And here are where Health Promotion International 2000;15(3):259–67. the ‘co-benefits’ come into the picture. 3 Sorensen K, Van den Broucke S, Fullam J, et al. Co-benefits are those which materialise Health literacy and public health: a systematic review in another sector. Instead of telling and integration of definitions and models. BMC Public the story of how good health literacy Health 2012;12:80. interventions in educational settings are 4 Kickbusch I. Addressing the interface of the for improving health, which no one will political and commercial determinants of health. deny (but few will get started on) we can Health Promotion International 2012;27(4). now produce a narrative on how good 5 The Guardian. Alcohol adverts seen ‘almost health literacy is with regard to the goals once a minute’ during Euro 2016 games. 27 June of the other sector: improving educational 2015. Available at: https://www.theguardian.com/ attainment, reducing bullying, lowering society/2016/jun/27/alcohol-adverts-seen-almost- rates of burnout of teachers are just a few once-minute-euro-2016-games examples that can make a big change in 6 McKenna H. Five big issues for health and the storyline. 13 social care after the Brexit vote. London: The King’s Fund. Available at: http://www.kingsfund.org.uk/ publications/articles/brexit-and-nhs
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DEMOGRAPHICS AND DIVERSITY IN EUROPE – INNOVATIVE SOLUTIONS FOR HEALTH
By: Isabel De La Mata Barranco, Dominik Schnichels, Tapani Piha and Arila Pochet
Summary: Whilst still recovering from the economic crisis, Europe’s health care systems are facing the growing challenges of an ageing population and a rise in chronic diseases. A new phenomenon is the migrant challenge. This article outlines various issues related to demography and diversity which affect health systems. It summarises the ways in which the Commission tries to support Member States both through tried and tested methods and through EU cooperation on innovative solutions for health – in particular, eHealth and Health Technology Assessment.
Keywords: Health Systems, Ageing, Chronic Diseases, eHealth, HTA, Migrants, Health Workforce
➤ #EHFG2016 Forum 9: Reality meets Reality Introduction ways that working together at EU-level can help address challenges related to Europe’s health systems are facing an demography and diversity. Much can be ageing population and rise in rates of ➤ #EHFG2016 Workshop 3: achieved through sharing expertise and chronic disease, threatening universal New frontiers in HTA best practice and working together in access to health care and the sustainability collaborative projects and joint actions. of health systems. The migration of health However, we also need new solutions care professionals within the European for health, and here we focus on two Union (EU), and the consequent shortages ➤ #EHFG2016 Forum 4: areas in particular – eHealth and Health in medical personnel in the countries they Desperate migration and health Technology Assessment (HTA). leave behind, is another predicament. A new phenomenon is the influx of migrants and refugees, which poses challenges for The ageing demographic and rise in Isabel De La Mata Barranco is countries on the frontline, particularly chronic diseases Principal Adviser for Health and Greece, as well as final destination Crisis Management; Dominik The ageing trend in Europe is set to countries such as Germany and Sweden. Schnichels is Head of the unit continue in the decades to come. Life “Medical products: quality, safety, These challenges are taking place against expectancy has increased for both sexes in innovation”; Tapani Piha is Head of a backdrop of the continuing effects of the the unit “Cross border Healthcare all EU countries. The average lifespan has economic crisis and the strain it has placed and eHealth”; Arila Pochet is risen from 74 years in 1990 to 80 in 2015, Policy Officer in the unit “Health on health budgets. determinants and inequality”, and by 2060 life expectancy will have risen by seven more years for men and DG Sante, European Commission, Whereas the organisation and delivery Brussels, Belgium. six for women. 1 Email: [email protected] of health care is in the hands of Member States, this article focuses on the many
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However, healthy life years are not 2. In the context of the European to overcome interoperability challenges increasing accordingly. Longevity and Semester, the Commission provides between EU health systems so that patients healthy life years are strongly affected by recommendations and advice to a can fully benefit from a digital single the cumulative effect of health behaviours number of EU countries to help them market in health – for example, through and inequities across the life cycle. Large design resilient health systems that can cross-border e-prescriptions or electronic health inequalities persist both between withstand current and future pressures patient summaries. and within EU countries. For example, and to continue to provide patients with in 2012 the gap in life expectancy between the best possible care. The EU also provides various tools the Member States at the lowest and to finance eHealth; for example, the 3. The CHRODIS Joint Action 5 of highest end of the spectrum was 18.7 years Connecting Europe Facility (CEF) is 25 countries is among the many projects for men and 19.3 years for women. 2 financing, amongst other things, the and joint actions co-financed by the building of an EU digital infrastructure Commission’s Health Programme for health. To date, 20 Member States aimed at preventing chronic diseases have applied for funding under this project and promoting healthy ageing across in order to build up concrete capacity to ageing the lifecycle. exchange health data, e-prescriptions and patient summaries. population and Furthermore, there is a growing pace of technological advancement and innovation Such EU collaboration and connectivity rise in rates of that has the potential for improving health in the area of eHealth aims to bring about in Europe. The challenge is to ensure four big wins: chronic disease the availability, affordability, cost- effectiveness and safety for products and 1) Empowered patients who are able In parallel, the burden of chronic diseases technologies for patients, whilst preserving to manage their own health thanks in the EU is growing, causing drawn an innovation-friendly environment. We to a better flow of information and out suffering for patients and placing a would like to highlight two particular interaction with health professionals. huge burden on health care budgets: an areas of innovation that can offer new estimated 70% to 80% of health care costs, 2) Increased sustainability and efficiency solutions for Europe’s health systems in representing some €700 billion in the for health systems. terms of providing more care with less ‘‘ 3 EU, are spent treating chronic diseases. expense: eHealth and Health Technology 3) Greater access to personal health data In 2012, EU countries devoted an average Assessment (HTA). for patients and health professionals, of 8.7% of GDP to health spending, up enabling faster diagnosis, improved significantly from 7.3% in 2000. 4 eHealth monitoring, more effective treatment and better health outcomes. The European Commission takes a eHealth and mHealth products and multi-faceted approach to supporting services have already become firmly 4) Support for patients’ access to health EU countries’ efforts to deal with an established within the public health and care services across Europe. ageing population and prevent, reduce health care sectors. More and more people and treat chronic diseases – supporting use smart-phones and other electronic HTA partnerships, providing fora for devices for prevention and monitoring In a climate where the challenge for all exchanging good practice on risk factors, of diseases. And more countries are countries in the EU is to do more with less, various sources of funding, advice, integrating telemedicine into their health cooperation on HTA at EU-level can help and more. Three examples include systems, such as consultations over decision makers in all 28 Member States the following: the internet. formulate safe, effective and cost-effective health policies. 1. The European Innovation Partnership This promising field is gaining momentum on Active and Healthy Ageing and acceptance across Europe; and the HTA answers questions like: Is the has, to date, brought together Commission is seizing the opportunities technology effective? For whom does over 3000 partners, 1000 regions and offered by the emerging European Digital it work? What costs are entailed? How municipalities, and 300 organisations Market to create an environment in which well does it work compared to alternative to examine new ways of addressing practical, innovative, and cost-effective technologies? Such questions are vital for the challenge of an ageing population. eHealth solutions can thrive. health policy makers and administrators This has led to innovative programmes to face the increasing burden on Europe’s being rolled out – for example, on The key to maximising the potential health systems. adherence to medication, prevention of of these various technologies is for EU frailty, chronic disease management and countries to ensure that their respective The benefits of a sustainable EU integrated care, and a strategy to scale- eHealth systems can communicate with cooperation on HTA are numerous. It can up successful practices. each other. To this end, the Commission ensure better use of resources in HTA is working closely with Member States production, contribute to the functioning
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of the internal market for health products, term, ensuring migrants’ integration While the mobility of health professionals ensure that patients have timely access into primary health care systems, and is a fundamental right under the Treaty, to innovative health technologies and protecting against stigma and health facilitated by the Directive on the mutual treatments, and improve the sustainability inequalities. Concrete actions include: recognition of professional qualifications, of health care systems. an EU Action Plan to address challenges • Producing a Personal Health Record to the EU’s health workforce 9 focuses The Commission has supported voluntary to reconstruct the medical history of on issues such as recruitment and cooperation in this area for more incoming migrants and refugees† jointly retention of health professionals. Last than 20 years. In 2013, the voluntary with the International Organisation for year, the Commission published a study EU-wide network on HTA composed of Migration (IOM) and the European on innovative and effective recruitment national HTA bodies or agencies was set Centre for Disease Prevention and and retention strategies 10 to assist up. This work, complemented by three Control (ECDC), and an accompanying EU countries with developing policy Joint Actions* on HTA, has enabled Handbook for health professionals. 8 responses to recruit and retain staff. us to build a solid knowledge base on In addition, a Joint Action on health • Mobilising the EU budget to help methodologies and information exchange. workforce forecasting and planning, co- countries on the ground with financed by the Health Programme and activities such as health care Now we are embarking on the next step. bringing together 28 European countries models for vulnerable migrants, Preparatory work on HTA is included and 16 stakeholder organisations, has just integration of migrants in primary in the 2016 Commission’s annual Work ended, delivering results such as: health care systems, and training of Programme. This is a crucial milestone, health professionals. • A handbook of good practices enabling us to build on our achievements and methodologies; and bring fresh impetus to the efficient • Coordinating activities within the use of HTA resources in Europe. We Health Security Committee, e.g. • A study looking at the main drivers are now working on an inception – gathering requests for vaccines of changes through to 2035, and impact assessment to carefully assess and other health supplies from the implications for the health workforce various options linked to continuing countries most affected, so that other in Europe; the cooperation on a permanent and Member States can provide support; • Data analysis to support improved data sustainable basis. – reinforcing surveillance of quality, availability and comparability, communicable diseases via the Early for the benefit of EU countries. The migrant challenge Warning and Response System; and There is commitment to continue this As of the end of February 2016, – connecting national contact points for work. Indeed, support for cooperation over 1.1 million people – refugees, health with those in charge of civil at EU level to address health workforce displaced persons and other migrants – protection and asylum, migration and shortages remains a key priority of the have made their way to the EU, either integration funds. Commission’s Health Programme. escaping conflict in their country or in search of better economic prospects. 7 • Participating in discussions on the Conclusion integration of third country nationals, Migrants entering Europe are, in general, particularly as there are health There are many ways in which the EU can healthy and do not bring diseases with workforce shortages in the EU, and help Member States with the challenges to them. However, most have travelled many incoming refugees and migrants their health systems – both in emergency in dreadful conditions to arrive at are health care professionals. situations such as the refugee crisis where overcrowded ‘hotspots’ in a state of mental the EU principle of solidarity is put to the and physical exhaustion. It is a desperate Migration within the EU test, and in serious long-term issues such situation for these individuals, and an as increasing rates of chronic diseases enormous strain for the countries on the This last example leads us to look and shortages of medical personnel. frontline, particularly Greece which is further at the migration challenge within These include methods with a proven already facing severe economic hardship. Europe. The “brain drain” affecting some track record, and vitally, ramping up countries, as doctors relocate to countries EU collaboration on new innovative The Commission’s immediate concern with better conditions and remuneration, solutions such as eHealth and HTA. is providing these countries with the has led to critical shortages and concerns With the commitment and solidarity of support they so desperately need – e.g., for access to health care for the patients in EU countries and stakeholders we can with piecing together migrants’ health the countries they leave behind. accelerate progress in these areas, which is records and vaccination history, training expected to bring direct benefits to health staff and volunteers, and, in the longer systems and patients in Europe. † Personal Health Record in English and Arabic, being * EUnetHTA Joint Action 1, 2010 – 2012, EUnetHTA Joint piloted in Greece with a view to initially extending it to Italy and Action 2, 2012 – 2015 and EUnetHTA Joint Action 3, 2016 – 2019: Slovenia. Available at: http://ec.europa.eu/dgs/health_food- http://www.eunethta.eu/ safety/docs/personal_health_record_english.pdf
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References DEMENTIA: PRESSING 1 Annual Ageing Report. Brussels: European Commission, 2015. Available at: http://ec.europa. eu/economy_finance/publications/european_ POLICY CHALLENGES economy/2015/ee3_en.htm
2 European Core Health Indicators (ECHI) data tool. Available at: http://ec.europa.eu/health/dyna/echi/ datatool/index.cfm?indlist=40a
3 OECD. Health at a Glance: Europe. Available at: By: Martin Knapp http://ec.europa.eu/health/state/glance/index_ en.htm
4 The 2015 Ageing report. Available at: http://www. aal-europe.eu/wp-content/uploads/2015/08/Ageing- Report-2015.pdf Summary: Dementia is one of the biggest clinical, social, economic 5 CHRODIS Joint Action. Addressing Chronic and policy challenges for European health and care systems today. Diseases and Health Ageing Across the Life Cycle. Available at: http://www.chrodis.eu/about-us/ I argue that a collective (policy) response to these challenges must be partners/ multi-dimensional. Societal responses to dementia in many countries 6 ECHO. Refugee crisis in Europe. Available at: http://ec.europa.eu/echo/refugee-crisis_en are already better today than they were ten years ago, but much 7 Handbook for Health Professionals: Health more needs to be done. There must be earlier and more effective assessment of refugees and migrants in the EU/ EEA (available in English, French, German, Greek, prevention, better care and treatment (although no ‘cures’ have yet Italian, Bulgarian, Romanian, Slovenian, Croatian and Hungarian), 2015. Available at: http://ec.europa. been discovered), more support for family and other unpaid carers, eu/dgs/health_food-safety/docs/personal_health_ handbook_en.pdf and continued investment in basic science to find disease-modifying
8 Commission Staff Working Document on an treatments. Action Plan for the EU Health Workforce, 2012. Available at: http://ec.europa.eu/health/workforce/ docs/staff_working_doc_healthcare_workforce_ Keywords: Dementia, Long-term Care, Prevention, Unpaid care en.pdf
9 Recruitment and Retention of the Health Workforce in Europe, 2015. Available at: http:// ec.europa.eu/health/workforce/key_documents/ Introduction Recent studies suggest that age-specific recruitment_retention/index_en.htm incidence rates may be falling in some Dementia is a major clinical, social, countries (e.g. England), probably due economic and policy challenge across to better health behaviours earlier in the whole of Europe. It is a devastating, life. 1 However, in reporting similar distressing collection of illnesses, the most overall findings from the well-known prevalent of which is Alzheimer’s disease. Framingham Heart Study in the US, 2 Recently, I have heard a number of people Satizabal and colleagues point out that describe dementia as the ‘new cancer’: this improvement is only found among a collection of different diseases, some of the better educated members of the them highly prevalent, none with a known cohort. The otherwise welcome reduction cure, all of them life-shortening, and all in dementia incidence is therefore far widely feared. from equally enjoyed across all sections ➤ #EHFG2016 Forum 10: of society. Dementia is already very costly, and The challenges of Alzheimer’s the costs – both to the public purse and and other dementias to individuals and families – will get Challenges of the near-future considerably greater over coming decades. Despite these important (if small and Since dementia prevalence has a steep unequal) changes in incidence rates, Martin Knapp is Professor of Social age gradient – fewer than 1% of people the total prevalent number of people Policy and Director of the Personal aged under 70 have dementia, but 30% of Social Services Research Unit, with dementia will continue to grow those aged above 90 – one could almost London School of Economics and considerably over the next few decades. Political Science; and also Director suggest that the policy challenge is Growth will be especially rapid in low- of the NIHR School for Social Care actually growing faster than the population Research, United Kingdom. and middle-income countries. According is ageing. Email: [email protected] to Alzheimer’s Disease International 3
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there are currently 47 million people with not bring down the costs of dementia – when compared with later savings. It is dementia worldwide, with the number then policy-makers may also start to think often said that ‘what is good for your likely almost to double every twenty about how to change health and social heart is good for your brain’, and certainly years, reaching 75 million by 2030 care financing arrangements. public health campaigns that target and 132 million by 2050. cardiovascular health will have spill-over Better prevention benefits for dementia. Lifelong learning and other efforts are also needed to build Reducing the number of people who or protect cognitive capital in a broader a develop dementia, or delaying the age at sense (i.e. not just in relation which these diseases begin to interfere to dementia). 9 collective significantly with their lives, must surely be a priority aim. There are a number ‘Better prevention’ is undoubtedly response to of known mid-life risk factors for the a sensible long-term policy aim for development of Alzheimer’s disease dementia, just as it is for many other dementia needs and other dementias: physical inactivity, conditions, but at the moment there is very smoking, diabetes, hypertension, obesity, little evidence on how to operationalise to be multi- depression, and lower educational it in ways that ensure effectiveness and attainment. 6 Alcohol consumption, social fairness, nor do we know anything about dimensional isolation and air pollution are among other the cost-effectiveness of such strategies. factors suggested as associated with a Taking a broader view, we need to higher risk of dementia, but the evidence Better care remember that healthy‘‘ life expectancy is not yet conclusive. These risk factors are (HLE) at age 65 is not growing as fast as clearly interconnected; after adjusting for Timely identification of dementia through life expectancy (LE), even though HLE is correlations, Norton et al 7 reckoned that better screening (both faster responses the same as LE at birth. 4 In other words, almost a third of Alzheimer’s disease cases to early signs of cognitive decline as well population ageing today is associated might be ‘attributable’ to risk factors that as better diagnostic accuracy) should with more years of poor health in many are potentially modifiable. help to improve the lives of individuals European countries. One particularly who are developing dementia and of their important feature of this changing A couple of years ago, my colleagues and close family members. Timely diagnosis demographic profile is multi-morbidity: I were asked to examine the economic helps them to plan ahead and, if health a growing number of older people have consequences of a range of future and social care systems are adequately more than one long-term condition scenarios for dementia. 8 Some scenarios prepared, it should also enable them to get (often including dementia). Given that looked at the wider availability and use of treatment and support, which in turn could most health systems are still dominated evidence-based interventions (see below), avoid some later crisis-related costs (such by the ‘single morbidity paradigm’, this while others looked at the consequences as emergency inpatient admissions). multi-morbidity considerably complicates of either better prevention or of a disease- treatment and care. modifying treatment (as yet undiscovered, Post-diagnostic support encompasses of course) with the aim of either slowing a range of community and other health Unless a cure or disease-modifying disease progression or delaying its onset. and care services, as well as the unpaid treatment is found very soon, and then We estimated that if such a strategy could (‘informal’) care of family members quickly made available at an affordable delay onset by a year or longer, aggregate and other carers. It includes specialist price, the attendant costs of dementia care costs would come down substantially. settings such as dementia cafes and will grow considerably for a few decades. Slowing the progression of the disease memory clinics, as well as specialist Projections of this kind are not new 5 but without changing the age of onset would housing and nursing homes for people they seem only recently to have begun to also potentially reduce costs, because it whose cognitive impairment has reached focus the minds of many governments on would delay the need for people to go into such a level of severity that they can how they might contain expenditure whilst care homes or hospital. There would also no longer live in their homes. Robust ensuring a good quality of life for people be important gains in health and quality of evidence is accumulating rapidly on living with dementia and their carers. life for the individuals at risk of developing what works in post-diagnostic support. 10 dementia and their families. There are symptomatic medications and What then should policy-makers be doing? psychosocial therapies that can slow It is clear that policy needs to be multi- The big challenge, of course, is to get cognitive decline or treat other symptoms dimensional, organised around four core people to engage in preventive strategies – such as agitation, and there is some aims: better prevention, better care, better giving up smoking, taking more physical evidence that better home-based care, support for family and other unpaid carers, exercise, ensuring a better diet and care co-ordination and targeted support and better support for basic research to so on – early enough in life to make a for family carers can improve wellbeing. find a cure. And, if cost containment is difference, and to make sure that the costs required – i.e. if pursuit of these aims does of prevention are not disproportionate
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There is now also a body of economic fertility rates and greater geographical modifying treatment for dementia have evidence to guide commissioning and mobility will be major influences on this failed. Billions of Euros have been spent delivery decisions. 11 supply. But because most carers have on dementia medications that never traditionally been women (and this is still made it to market. The pharmaceutical The ‘scenario exercise’ described earlier very much the case), rising rates of female industry has therefore become somewhat included examination of what might labour force participation over recent pessimistic about what can be achieved happen if evidence-based interventions decades are also highly pertinent. Indeed, in this therapeutic area, and hence were more widely available, given many women are today juggling paid increasingly cautious about making big that they are not currently rolled out employment with unpaid care not only for speculative investments. Of course, the to everyone who could potentially ageing parents but also for grandchildren. flipside is that the prize for the winner benefit from them. 8 We focused on would be very lucrative indeed. four: anticholinesterase inhibitors (the most commonly used anti-dementia International bodies such as the World medications), cognitive stimulation much Dementia Council are trying to find therapy, case management and carer ways to generate a collective pool of support. The overall economic impact more needs to resources to keep the science going, and was actually rather modest: there some national governments and research were important health and wellbeing be done to charities are committing additional funds, improvements, but little change in cost. So, as illustrated by the establishment of more widely implementing what we know develop better the UK’s Dementia Research Institute. 16 today to be effective and cost-effective There are also discussions about how would definitely improve people’s lives but care to harmonise regulatory pathways to it would not bring down the total economic accelerate drug development, efforts to impact of dementia. (We are continuing Good family care for someone with share knowledge, and the beginnings of to explore this area in greater depth in dementia can certainly greatly improve investment in ‘big data’. the MODEM study; see www.modem- that person’s wellbeing, whilst also dementia.org.uk.) delaying nursing home and hospital Even if there were to be a major scientific ‘‘ 13 inpatient admissions. Yet being a carer breakthrough in the next few months, it Clearly, much more needs to be done to – especially of someone with moderate would probably be more than a decade develop ‘better care’. One emphasis should or severe dementia – can be enormously before a new medication was widely be responses to need that are person- stressful, with a high risk of anxiety or enough available to make any noticeable centred, better attuned to individuals’ depression, 14 as well as the well-known difference to people living with dementia preferences and that protect their dignity. potential ‘burdens’ of out-of-pocket costs across Europe. This obviously does not The tremendous potential of assistive and lost opportunities for paid employment mean that efforts should not be made in and other technologies has not yet been or social activities. basic science, but it does mean that – today realised in any clinical area, and certainly and for the immediate future – we also not in relation to dementia where there Although the pivotal roles played by need to make major efforts to improve are anyway particular complications. 12 family and other carers in dementia care and support within the present There is also a need to think through how care have been recognised for a long therapeutic environment. to invest in housing that adapts to needs time, there has not been a great deal of as people age. The design of communities research into what can be done to support Funding reforms to make them age-friendly and dementia- them. One successful approach that has friendly should be another aspiration. End- been evaluated is START (STrAtegies Many European countries have already of-life care is generally poor across all for RelaTives). This is an intervention embarked on reforms that change how European countries, and especially poor to help family carers to develop better health and long-term care are financed. for people with dementia. Managing multi- coping strategies, delivered by psychology Rapid population ageing means that the morbidities better is also likely to improve graduates over eight one-to-one sessions. previously assumed ‘balance’ between health and wellbeing, and could potentially An evaluation of START over 24 months years spent in education, employment be cost-effective. found very positive outcomes for carers (in and retirement – on which post-Second terms of health-related quality of life and World War pension, health care and other Better support for carers mental health), no effects on people with systems were constructed – no longer dementia (either negative or positive), and holds. Financing reforms are generally The demographic challenge of dementia clear evidence of cost-effectiveness. 15 shifting the balance of responsibility is perhaps exacerbated because projected from the collective to the personal. The trends are not only rapidly increasing the Finding a cure burgeoning cost of dementia care is number of older people with long-term obviously not the only pressure on health conditions, but also reducing the potential It has often been said that perhaps 99 systems, but it does reflect very well the supply of unpaid family carers. Falling out of 100 attempts to find a disease- growing fiscal challenge.
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Multiple policy aims 4 Jagger C. Trends in Life Expectancy and Healthy 11 Knapp M, Lemmi V, Romeo R. Dementia Life Expectancy. London: Foresight; Government care costs and outcomes: a systematic review. I have argued that a collective response to Office for Science, 2015. International Journal of Geriatric Psychiatry, dementia needs to be multi-dimensional: 2013;28(6), 555 – 61. 5 Comas-Herrera A, Wittenberg R, Pickard L et al. earlier and more effective prevention, Cognitive impairment in older people: future demand 12 Knapp M, Barlow J, Comas-Herrera A et al. better care, more support for families for long-term care services and the associated costs. The Case for Investment in Technology to Manage the and greater investment in science to International Journal of Geriatric Psychiatry, 2007;22: Global Costs of Dementia. London: Policy Innovation find a cure. But if dementia really is the 1037 – 45. Research Unit, 2016. ‘new cancer’ then perhaps we should be 6 Barnes D, Yaffe K. The projected impact of risk 13 Yaffe K, Fox P, Newcomer R et al. Patient heartened by how scientific endeavour in factor reduction on Alzheimer’s Disease prevalence. and caregiver characteristics and nursing home that field, allied to (some) public health Lancet Neurology 2013; 10(9), 819–828. placement in patients with dementia. Journal of the American Medical Association 2002; 287: 2090 – 7. successes, better therapeutic alliances and 7 Norton S, Matthews F, Barnes D et al. Potential altered societal attitudes have changed for primary prevention of Alzheimer’s disease: an 14 Mahoney R, Regan C, Katona C et al. Anxiety things for the better. analysis of population-based data. Lancet Neurology and depression in family caregivers of people with 2014; 13(8), 788 – 94. Alzheimer disease: the LASER-AD study. American Journal of Geriatric Psychiatry 2005; 13(9):795 – 801. 8 Knapp M, Comas-Herrera A, Wittenberg R et al. References Scenarios of Dementia Care: What are the impacts on 15 Livingston G, Barber J, Rapaport P et al. Long- 1 Matthews FE, Stephan B, Robinson L et al. A two costs and quality of life? London: PSSRU, London term clinical and cost-effectiveness of START decade dementia incidence comparison from the School of Economics and Political Science, 2014. (STrAtegies for RelaTives) psychological intervention Cognitive Function and Ageing Studies I and II. Nature for family carers and the effects on cost of care for 9 Rosser M, Knapp M. Can we model a cognitive Communications 7, 2016 doi:10.1038/ncomms11398. people with dementia: a randomised controlled trial. footprint of interventions and policies to help meet Lancet Psychiatry 2014; 1(7), 539 – 48. 2 Satizabal CL, Beiser AS, Chouraki V et al. the global challenge of dementia? The Lancet 2015; 16 Incidence of dementia over three decades in the 386: 1008 – 10. UK Government. PM announces funding for UK’s Framingham Heart Study. New England Journal of first Dementia Research Institute. Press release, 10 Winblad B, Amouyel P, Andrieu S et al. Medicine 2016; 374:523 – 32. 25 November 2015. Available at: https://www.gov.uk/ Defeating Alzheimer’s disease and other dementias: government/news/pm-announces-funding-for-uks- 3 a priority for European science and society. Lancet Alzheimer’s Disease International. Dementia first-dementia-research-institute statistics, 2016. Available at: www.alz.co.uk Neurology, 2016;15(5), 455 – 32.
The Netherlands: The fact that the Netherlands has one of the highest per capita health expenditures in Europe remains an important concern Health system review although growth has slowed considerably after reverting to Health Systems in Transition By: M Kroneman, W Boerma, M van den Berg, Vol. 18 No. 2 2016 more traditional sector P Groenewegen, J de Jong, E van Ginneken agreements on spending. However, the most Copenhagen: World Health Organization 2016 Netherlands Health system review transformational change has (acting as the host organization for, and secretariat of, the been the impact of the two European Observatory on Health Systems and Policies) major reforms implemented Number of pages: xix + 239 pages; ISSN: 1817-6127 since the mid-2000s. These ongoing reforms are Freely available to download at: http://www.euro.who. • Wienke Boerma Madelon Kroneman • Peter Groenewegen Michael van den Berg changing the way the • Ewout van Ginneken int/__data/assets/pdf_file/0016/314404/HIT_Netherlands. Judith de Jong Dutch health system pdf?ua=1 operates today. The 2006 reform replaced the The Dutch population enjoys access to essential health care division between public services that are within easy reach and with reasonable and and private insurance with decreasing waiting times. The basic health insurance and one universal social health insurance compensation package for citizens on lower incomes protects and introduced managed competition in the health care against catastrophic spending. Out-of-pocket payments system. Although the reform was initiated almost a decade ago, are low from an international perspective. The Dutch rate its gradual implementation continues to alter the health care the quality of the health system and their health as good. system in general and the role of actors in particular. The newly International comparisons show that the Netherlands has low implemented long term care reform aims to achieve a transition antibiotic use, a small number of avoidable hospitalisations from publicly provided care to more self-reliance on the part of and a relatively low avoidable mortality. National studies show citizens and a broader role for municipalities. Whilst these that healthcare has made major contributions to the health of reforms are ongoing, a particular point of interest is how the Dutch population as reflected in increasing life expectancy. effectively the new governance arrangements and Furthermore, some indicators such as the prescription of responsibilities in long term care will work together. generics and length of stay reveal improvements in efficiency over the past years.
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IMPLEMENTATION OF THE LIFE- COURSE APPROACH THROUGH STRENGTHENED INTERSECTORAL ACTION
By: Manfred Huber, Gauden Galea, Gunta Lazdane and Monika Kosinska
Summary: Reliance on policies that address narrowly defined stages of life is not enough to improve health and reduce inequalities. A strong case exists for coherent policies that consider the influence of early or timely action on health throughout life and across generations. Important points in people’s lives – particularly transitions during changes in role and status – offer opportunities to act that improve health outcomes later. Adoption of a life-course approach that mobilises a range of actors across government and society presents policy-makers with unique opportunities to improve health and well-being, promote social justice and contribute to sustainable development and inclusive growth.
Keywords: Life-Course, Public Health, Non-Communicable Diseases, Intersectoral Action, Health-in-all-Policies
➤ #EHFG2016 Forum 1: Overview At the 2015 WHO European Ministerial Life course and intersectoral Conference on the Life-course Adopting a life-course approach is one of approaches to public health Approach in Minsk, Belarus, Member four strategic principles of Health 2020, States agreed on the importance the WHO policy framework for health of the life-course approach for and well-being in Europe. 1 This approach the successful implementation of Manfred Huber is Coordinator, builds on growing evidence on the Health 2020 and the goals and targets healthy ageing, disability and pathways by which health advantages and long-term care; Gauden Galea of the United Nations 2030 Agenda for disadvantages accumulate throughout is Director, Division of non- Sustainable Development. communicable diseases and life. New and remarkably consistent promoting health through the findings are available from a range of life-course; Gunta Lazdane is The Minsk Declaration 2 includes a scientific disciplines – including genetics, Programme Manager, sexual commitment to an agenda for acting: and reproductive health and epidemiology, psychology, neuroscience, Monika Kosinska is Programme economics and environmental sciences – • early Manager, governance for health, adding to the knowledge on factors that World Health Organization Regional • appropriately during life’s transitions Office for Europe, Copenhagen, influence health throughout the life-course Denmark. Email: [email protected] and across generations. • together.
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Figure 1: A life-course approach to action areas across stages and transitions in life Other important early interventions are programmes that prevent adverse childhood experiences, which have been associated with health-harming behaviours such as smoking, substance misuse, physical inactivity, attempted suicide and being a victim or perpetrator of violence, among other risks.
Among the most important early interventions with lifelong benefits is protection against vaccine-preventable diseases and their consequences. While vaccination coverage across the European Region remains high, with first-dose measles-containing vaccination coverage at around 94%, 5 significant recent measles outbreaks in a number of countries show the dangers of remaining gaps.
Acting during life’s transitions and preventing inequalities Several distinct transition life phases present both risks and opportunities
Source: Ref. 7 for dealing with inequities. Negative experiences from previous phases can This article reflects on the implications Acting early: the importance of have an important compounding effect, of evidence on life-course trajectories for investing early on with the risk that an individual may fall policies that fit this agenda and illustrates to a lower level on the social ladder. The importance of action in the earliest key policy interventions. This has special relevance for transitions days of life is a strong message within the during mid-life, such as becoming parents, life-course approach, supported by new entering and staying in the workforce and evidence in recent years. 3 For example, preparing for active and healthy ageing. if a woman is malnourished before she These transitions offer opportunities to becomes pregnant and during pregnancy, stop the intergenerational transmission of it may increase the risk that her offspring inequities and to rise to a higher level on importance of will develop obesity and diabetes during the social ladder. action in the middle age. Reaching adolescents before they start Moreover, good nutrition during the first to adopt unhealthy behaviour can have earliest two years of a child’s life is particularly a sizeable impact on later health. Health important to combat morbidity and promotion initiatives in schools can play days of life mortality and to reduce the risk of chronic an important role, linking health to the disease in later life. Early initiation of The three principles for action involve core task of schools – education. The fact breastfeeding is recommended to protect many different actors across a range of that most adults who smoke acquired the the newborn from acquiring infections. sectors. A life-course approach thus aims habit in adolescence demonstrates the need Exclusive breastfeeding for the first at solutions that encompass a wide array of for early intervention; peer pressure, role ‘‘ six months of life has many additional possible areas (see Figure 1). These often models and societal norms all contribute to benefits and can have important protective focus on early years or target important this outcome. Conversely, adolescents who effects throughout life – for example, life transitions, supporting people during reach early adulthood without smoking by reducing the risk of overweight and family-building, the working career and almost never take up the habit. The obesity in later life. Despite this evidence, in transition to retirement, including emphasis must therefore be on actions that breastfeeding rates in many countries interventions that facilitate active and ensure environments free from harmful in the WHO European Region are low, healthy ageing. substances such as tobacco, alcohol and and in some cases mothers with low recreational drugs. socioeconomic status are much less likely to begin breastfeeding. 4 A major upsurge has been seen in the availability and affordability of energy-
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dense foods that are high in saturated Acting together: mobilising all lengthening of the absence period is fats, trans fats, free sugars and salt, and in sections of society strongly associated with reduced chances sugar-sweetened beverages. Schools have of return to work. Partnerships between Awareness is growing that actions been identified as a high-priority setting employers and the health service have proposed in a life-course perspective for policies that address unhealthy food been shown to be effective. should target all segments of society, environments for all ages: implementation tackling the different underlying of comprehensive standards that apply to Preventing or postponing health-related mechanisms that lead to health inequity in all foods available on school premises can retirement – not only that caused each group. This includes giving special have an important impact. 6 by mental health issues – remains a care and attention to disadvantaged and challenge for all countries in Europe. minority groups, and addressing mental Progress has also been made in promoting Early retirement and permanent living on health and occupational health issues. sexual and reproductive health and well- disability benefits in early old age puts These initiatives are often more effective being in the WHO European Region, but people at higher risk of social exclusion if they bring together a broad coalition important opportunities for improvement and faster health decline. Health systems of sectors of government, academia, are often missed. Comprehensive health can contribute by improving their capacity civil society, private sector, media and education includes education about to prevent and treat common causes of communities, making full use of available people’s sexuality and sexual health. This early retirement, such as chronic back pain policies, tools and resources. calls for close collaboration between the and common mental disorders. health and education sectors, but because Stakeholder coalitions for better health are of its sensitive nature, such education Another important area of policy in fact at the heart of many communities is often complicated and sometimes innovation in cross-sectoral cooperation within the movement for healthy cities. neglected. Moreover, Europe is rich is the development of age-friendly cities, Local knowledge, leadership and resources in examples of programmes ensuring communities and environments. Age- can make a difference in public health that schools are free from bullying and friendly supportive environments can for the two thirds of the population of the other forms of violence, but successful help older people stay active, engage WHO European Region living in towns interventions can still be further scaled up. socially and live independently as long as and cities. possible, even when living with functional On leaving school, many young people limitations or dementia (see Figure 2). There is room to improve intersectoral face important barriers that prevent them cooperation for mental health, in from gaining work experience and further Safe and attractive environments for particular. Mental health and well-being qualifications in today’s labour markets, active transport and physical activity in and mental disorders are associated with which are still affected by the financial daily life, for example, can be one of the socioeconomic and material determinants and economic crisis. The association most powerful ways to reach all people from birth onwards. For example, low between education level and health over and ages. These investments in the income and low social status both predict the life-course is well established, but urban physical and social environment postpartum depression*, which negatively there are also immediate risks: periods of also combat the rise in obesity and affects long-term mother-child bonding. unemployment of two years or more in noncommunicable diseases. early adulthood, for example, have been About 50% of mental disorders have their correlated with higher rates of risk-taking Policies for healthy ageing include onset before the age of fifteen; some last a behaviour, such as heavier drinking and raising health literacy and awareness lifetime, causing suffering to individuals smoking in mid-life and higher prevalence of the health changes in older age and and families and a burden to society. of mental health issues. Ultimately, the creating understanding about how to Early intervention, particularly in the danger is that the combined effects of cope with them better, including for most prevalent problems such as anxiety poorer health and lower employment and those living with dementia. A life- disorders and depression, is possible, as income security in early adulthood create course approach for healthy ageing also demonstrated by effective partnerships a vicious cycle. 7 includes training and counselling, as well between mental health services as respite care and income support for and schools. Supporting families to build parenting family carers – important measures to capacities can be crucial for the health protect carers’ health, many of whom are Depression and anxiety are major of parents and the next generation. themselves 50 years or older. causes of long-term sick leave and This includes access to evidence-based early retirement and are associated information and services that address with noncommunicable – particularly the medical, psychological and social cardiovascular – diseases. Prevention impacts of pregnancy, supported by of sick leave or measures to encourage Strengthened intersectoral the use of public information portals early return are important, since any governance for health and well-being and other – preferably interactive – dissemination methods. Strengthening partnerships across
* Postpartum depression is a moderate to severe form of government and society as part of the depression in a woman after she has given birth. It may occur life-course approach means also investing soon after delivery or up to one year later.
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Fig. 2.4. A public-health framework for Healthy Ageing: opportunities for action Figure 2: A public health framework for healthy ageing: opportunities for action Poor health is both a cause and across the life-course consequence of deprivation. Policies need to recognise this reality and seek High and stable capacity Declining capacity Signi cant loss of capacity to address it. Solutions should be sought beyond the health sector: society as a whole needs to work together. A life- Functional course approach involving early, timely ability and collective action offers the chance to ensure that no opportunity is missed – from pre-conception to the last years of Intrinsic old age – to maximise health and well- capacity being and to meet the ambitious goals of Health 2020 and the 2030 Agenda for Sustainable Development.
Promote capacity-enhancing behaviours Environments: Remove barriers to participation, compensate for loss of capacity References 1 Health 2020: a European policy framework and strategy for the 21st century. Copenhagen: Prevent chronic conditions WHO Regional Office for Europe, 2013. Available Health services: or ensure early detection Reverse or slow Manage advanced at: http://www.euro.who.int/en/publications/ and control declines in capacity chronic conditions policy-documents/health-2020.-a-european-policy- framework-and-strategy-for-the-21st-century-2013 Support capacity-enhancing 2 Long-term care: behaviours The Minsk Declaration: the life-course approach Ensure in the context of Health 2020. Copenhagen: WHO a dignied late life Regional Office for Europe, 2015. Available at: http://www.euro.who.int/en/media-centre/events/ events/2015/10/WHO-European-Ministerial- Source: Ref. 8 Conference-on-the-Life-course-Approach-in-the- Context-of-Health-2020/documentation/the-minsk- in the instruments, mechanisms and preparation and relationship building– declaration capacities that facilitate working across which can then be leveraged when political 3 Halfon N, Larson K, Lu M, Tullis E, Russ S. sectors. The diversity of the European windows arise. Lifecourse health development: past, present and Region has given rise to a rich experience future. Matern Child Health J. 2014;18(2):344–65. of building partnerships between sectors, Finally, collective whole-of-society 4 Bagci Bosi AT, Eriksen KG, Sobko T, Wijnhovena with a number of commonalities emerging approaches and stakeholder coalitions TMA, Breda J. Breastfeeding practices and policies in as pre-conditions and challenges to mean the involvement of communities WHO European Region Member States. Public Health intersectoral working. and populations into the design, Nutr. 2016;19(4):753–64.
implementation and evaluation of policies 5 Global and regional immunization profile. In World Successful whole-of-government and services impacting on their health Health Organization [website]. Geneva: World Health approaches means strengthening the policy and well-being. Community involvement Organization, 2015. Available at: http://www.who.int/ coherence between sectors, including can improve the quality, relevance and immunization/monitoring_surveillance/data/en/ through various concrete measures such ownership of the policies and services, as 6 Adolescents’ dietary habits, HBSC Fact Sheet, as impact assessment, common targets well as contribute to empowerment though 15 March 2016. Copenhagen: WHO Regional Office and shared budgets. This sustained and an increased ability to influence and for Europe. http://www.euro.who.int/en/health- systematic action takes commitment, control decisions that affect them. topics/Life-stages/child-and-adolescent-health/ health-behaviour-in-school-aged-children-hbsc/ political will and leadership to implement background-briefs/dietary-habits and sustain. Conclusions 7 Review of social determinants and the health divide in the WHO European Region: final report. Where there is an absence of political will, The policies outlined in this article Copenhagen: WHO Regional Office for Europe, 2014. the experience of the European Region illustrate important opportunities to Available at: http://www.eurwho.int/en/health- shows that progress is still possible: improve health and well-being using a topics/health-policy/health-2020-the-european- successful partnership and work across life-course approach. The more general policy-for-health-and-well-being/publications/2013/ sectors needs time, buy-in from others, implications are that public policies and review-of-social-determinants-and-the-health-divide- in-the-who-european-region.-final-report and institutional and human capacity to services should be designed to promote the take work forward. Bringing the right health of each generation and to prevent, 8 World report on ageing and health. Geneva: World stakeholders to the table, developing as far as possible, disadvantage passing Health Organization, 2015. Available at: http://www. who.int/ageing/events/world-report-2015-launch/ shared goals and accountability requires from one generation to the next. en/
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FINDING THE BALANCE IN LIFE- COURSE VACCINATION
By: Karam Adel Ali and Lucia Pastore Celentano
Summary: Progressive changes to the EU’s demographic structure have given impetus to renewed research on more effective and sustainable ways of investing in health and healthy ageing. The role of prevention is paramount in this regard, and it has been suggested that expanding vaccination programmes to embrace the entire life-course could be instrumental in helping to meet disease elimination goals, as well as to maximise opportunities for reducing disease burden in later years of life. There are nonetheless a number of challenges that will require careful consideration in prioritising vaccinations across all age groups, and to develop the necessary evidence that can drive a radical shift.
Keywords: Vaccination, Life-course, Prevention, Healthy Ageing
Progressive changes to the EU’s In the face of such challenges, attention demographic structure have given impetus has been given to the identification to renewed policy interest and research of more effective, sustainable and on innovative and more effective ways efficient ways of delivering health care of investing in health. Life expectancy, underpinned by a strong evidence-base migratory flows, and dynamics in fertility for resource allocation. The role of are expected to significantly change the prevention is paramount in this regard. age structure of the EU’s population According to the OECD, overall spending over the coming decades. By 2060, on prevention generally stands at less those aged 65 and over will become a than 3% of the general government much larger proportion of the population health expenditure (GGHE); since 2009 ➤ #EHFG2016 Lunch workshop 1: (from 18% to 28%), and those aged 80 spending on preventative care has Life-course vaccination and over will be almost as numerous continued to bear the ‘brunt of cuts’ with as the young population (0 to 14 years an estimated contraction of 0.6% on an old). 1 Long-standing concerns around annual basis. 2 This has encouraged calls the viability of sustaining increasing for re-balancing spending on care and cure Karam Adel Ali is Programme Manager Vaccine-Preventable health care costs as a consequence of versus opportunities to maximise health Diseases and Lucia Pastore demographic change, together with the promotion and protection, and disease Celentano is Head of the Vaccine- observed rise in the burden of chronic prevention programmes. Preventable Diseases Programme within the Office of the Chief diseases, and demands for improved Scientist at the European Centre quality and patient-centred care have been Vaccination is a mainstay of prevention for Disease Prevention and Control further exacerbated by the most recent programmes in Europe and worldwide, (ECDC), Stockholm, Sweden. Email: [email protected] financial and sovereign debt crisis. and remains one of the most cost-effective ways to prevent disease. Traditionally,
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however, it has been looked at as a childhood years as a consequence of a women has been implemented by some primarily childhood-focused public variety of factors. This could leave them countries to protect new born babies still health intervention. In recent years, it has unprotected against some of the most too young to be vaccinated. been argued that expanding vaccination common vaccine-preventable diseases programmes to include adults and (VPDs) associated with an age-related At the same time, new generation vaccines embrace the entire life-course could increase in severity and complications, are being licensed and promoted as be instrumental to meeting disease such as measles, rubella, and pertussis. being indicated to meet health needs in elimination goals, as well as to maximise These diseases become of particular populations other than children. Examples opportunities for reducing disease burden concern in settings where childhood include those aimed to prevent human in later years of life. immunisation rates are sub-optimal, or papilloma virus-caused cancers, and other where coverage is not uniform across vaccines that can respond to age-related One reason for this suggested approach sub-national geographic areas. The specific needs. has been the fact that over the last few accumulation over time of non-immune decades there has been a shift in the people and social and geographical Older age groups represent a burden of diseases that were traditionally clustering of under-vaccinated people heterogeneous population, with different those of childhood towards older age will continue to be a significant challenge needs and whose health status is impacted groups, and new vaccines are being for measles and rubella elimination in by multi-faceted determinants beyond licensed as indicated for adults. Adult the EU. In October 2015, the European biological and medical factors alone. vaccination, immune-senescence and Regional Verification Commission Nonetheless immune-senescence and vaccine immunology will progressively for Measles and Rubella Elimination declining immune response to antigen constitute central topics of interest in (RVC) reported immunisation gaps in challenges with advancing age can result recognising the ageing demographic and adolescent and young adult sub-sets of in the elderly being more susceptible to the EU’s commitment to healthy ageing. the population in several countries. It infectious diseases than younger adults. At the same time, more diseases will was concluded that closing immunity In such populations, infectious diseases become preventable as new vaccines gaps may require targeted supplemental of high incidence such as influenza, are developed, with the potential of immunisation activities. pneumococcal disease, or herpes zoster accruing fundamental public health and can have debilitating consequences, economic gains. Closing immunisation gaps is also relevant severely affecting quality of life, or be a in the light of the most recent migratory significant cause of death. In the light of such factors, the 2014 influx into the EU. Migrants arriving EU EPSCO * Council Conclusions on from countries where certain diseases Vaccination is also critical for individuals Vaccinations as an Effective Tool in are endemic, or where vaccination with underlying chronic conditions to Public Health invite the Member States programmes have been interrupted reduce the burden of co-morbidities and and the European Commission to consider due to political circumstances are risks and challenges of poly-medication, vaccination beyond infancy and early vulnerable to VPDs and should be including the potential for interactions childhood by creating programmes with prioritised for vaccination. For those between antimicrobial treatments and a life-course approach. whose vaccination status is unknown or chronic disease treatments and the risks undocumented, EU Member States might of some antimicrobial treatments in This article describes and discusses the consider immunisation activities for patients with impaired renal or hepatic rationale for life-course vaccination, children, but also adolescents and adults, function. Though multimorbidity is the current status and challenges of its particularly against the priority diseases not just a problem for older adults, the introduction, and the already ongoing targeted for elimination and eradication prevalence is significantly higher in initiatives at the EU level. (measles, rubella, and polio). Additional older age groups, with 65% of people vaccinations should be considered based aged 65 – 84 and 82% of people aged at on risks arising from living conditions, least 85 years being affected. 4 Patients The whats and whys of life-course 3 vaccination season, and the epidemiological situation. affected by heart disease, stroke, chronic obstructive pulmonary disease, and There are a number of fundamental Acquired immunity through earlier diabetes – among the most burdensome reasons for considering immunisation vaccination or infection can also wane disorders according to the WHO Global strategies with a life-course approach as a over time, requiring the administration Burden of Disease – or disorders affecting public health imperative. of periodical boosters in adulthood. For the immune system are at higher risk certain VPDs, adult vaccination can of experiencing complications and a First, adults may not have received all confer indirect protection to susceptible worsening of their pre-existing condition if of the necessary vaccinations during populations unable to fully benefit from they contract infections such as influenza immunisation. For example, in the case or pneumococcal disease. This can result of pertussis, the vaccination of pregnant in higher hospitalisations and fatality * EPSCO is the Employment, Social Policy, Health and Consumer Affairs Council which brings together ministers cases. There is thus a fundamental link responsible for employment, social affairs, health and between chronic and infectious diseases, consumer policy from all EU Member States.
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which must be recognised, and for which These examples show not only that be used to prioritise among vaccines comprehensive preventative approaches policies on indications for use are available for different age groups and are key. different, but that funding mechanisms for populations, particularly in a context implementing recommendations differ. of limited economic resources and Finally, other adult vaccinations might This is an important element, as the way a competing priorities; and what are the best be needed or tailored to meet variations vaccine is funded can have an impact on vaccination strategies considering direct in risk determined by occupation, e.g. in the overall levels of vaccination coverage and indirect effects of a given approach. the case of health care workers to protect that can be achieved. The magnitude of themselves and their patients, or for such policy effects is difficult to assess, With an ever-increasing number of travelling needs. since routine adult vaccination coverage vaccines on the market, making the data are often lacking or poorly available, right choices, both in terms of vaccine State of play in Europe making it challenging to evaluate the effectiveness and budget planning, has performance of existing adult and elderly become increasingly important. In order Currently, vaccination policies for vaccination programmes. 7 The challenge to find the ideal balance between cost and adults vary significantly across Europe. of measuring vaccine coverage is greatest quality (i.e. providing the best possible Data extracted from the ECDC Vaccine in countries where recommendations protection to those who benefit the most Schedule Platform 5 on three selected mainly target at-risk categories, as the size in a given population), it is essential to vaccinations targeting the elderly of the denominator population may not first assess all of the relevant evidence in are reported below to illustrate the be known. a transparent and standardised manner heterogeneity of the situation. before introducing a new vaccine to a The decision-making challenge national immunisation programme. More In the EU/EEA 31, nineteen EU/ so at a time of tighter overall fiscal space EEA countries currently recommend Decisions concerning the introduction, in EU Member States. vaccination against pneumococcal disease financing, organisation, and delivery for older individuals above 60 or 65 years, of vaccination programmes, including The decision to introduce a new vaccine, mostly as a general recommendation adult vaccination, are the preserve of or to offer a vaccine to a new population (in 17 out of 19 countries). In more than individual EU Member States. The group, is not the end of the process of half of these countries, the vaccine is not decision-making process can be guided assessing the impact of such decisions. funded as part of the national vaccine by several weighting factors that are Post-implementation monitoring of the programme. Five EU/EEA countries offer/ inevitably context-specific, such as disease effectiveness of vaccination programmes, recommend the vaccination for adults epidemiology and burden, groups at higher including the assessment of the below the age threshold for universal risk, cost-benefit and cost-effectiveness frequency of rare or very rare adverse pneumococcal vaccination if they are analyses vis-à-vis resources available and reactions, the assessment of whether considered to be at increased risk of acceptable thresholds, where these are strain-specific vaccines give rise to the pneumococcal infection; however, the applied. Countries may also have different phenomenon of strain-replacement, and age range that is vaccinated on this basis priorities and so set for themselves the impact not only on the incidence of can vary significantly depending on the different immunisation or prevention targeted VPDs, but also on longer term country. In the case of the herpes zoster policy goals. While, for some, closing consequences of infection, such as liver vaccine, only four EU/EEA countries immunisation gaps and achieving high cirrhosis or cancer development, are an currently recommend it for their older vaccination coverage levels with current essential component of modern vaccine populations. All four have a general vaccines could be of highest priority, for programme management. recommendation in place, with two others, particularly those with higher rates recommending it without public funding. of childhood immunisation coverage, On a political level, the feasibility of The latter two countries recommend it the goal might be to expand the existing driving a radical shift towards a life- for individuals over 50, and in the two schedule through the introduction of newly course approach to vaccination will others, one country recommends its available vaccines. And such choices require leadership and commitment to administration between 65 and 80 years, might often be constrained by budgetary drive change and expand the fiscal space while the other for those aged above 70 availability and considerations. for immunisation programmes as part of years. Seasonal influenza is the only the GGHE. On an operational level, such disease for which a recommendation on While the argument for the public health a shift will also require putting in place vaccination for older age groups is in place and economic value of implementing a new, or expanding existing, components across all EU/EEA countries. In fifteen life-course approach to immunisation, of immunisation programmes in order countries the vaccine is not funded by the is compelling and should continue to be to meet the needs of adult segments of national health system. Seasonal influenza explored, its actual implementation can the population. The introduction and vaccination for the elderly is also the be challenging. The integration of new recommendation of new vaccines will only case where specific EU vaccination vaccines or vaccination strategies brings not per se be sufficient, but should be coverage targets exist and have been about a number of challenging questions. accompanied by: agreed upon by the EU Council. 6 For example, what criteria can or should
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• systems capable of comprehensive and evidence on effectiveness and impact of to vaccination uptake on the part of both reliable monitoring of coverage and vaccination strategies in the paediatric and general public and health care workers uptake rates across all age groups; older populations. will be continued, including based on specific vaccinations. • organisation and establishment of In the area of scientific advice, the appropriate channels or infrastructures ECDC’s VPD Programme will continue As new vaccines will continue to become necessary to identify, reach out, to develop up-to-date evidence-based available to meet today’s demographic and and deliver the vaccination to the guidance on priority disease and health care needs, a life-long vaccination targeted population; vaccinations across all age groups as calendar is likely to become the norm in • integration of appropriate identified by the Member States. Such the EU. surveillance systems; guidance will help in providing elements for use in national decision-making Now is the time to discuss the • monitoring activities that can generate concerning the introduction of new opportunities and value of life-course evidence on vaccine effectiveness and vaccines and vaccination strategies, immunisation, but also to understand the vaccination impact so as to inform including evidence derived from relevant challenges and information needs faced strategies over time; experience available at EU and global at decision-making level to promote such • training of health care workers on levels. Also, the recently launched ECDC a shift. And while the quest for increased adult and elderly recommendations and Burden of Communicable Disease in and sustainable resource allocation to vaccination needs; Europe toolkit 9 aims at helping Member health services is easy to postulate, it will States to generate evidence on the be key to also agree and define the right • design and roll-out of effective burden of VPDs in the adult and older evidence that would help in prioritising communications and educational person populations, thus supporting the vaccinations across age groups, as well as activities that are adapted to the needs formulation of most appropriate policy the relevance and scope of EU level action of an adult population in an era of responses, including vaccination. to support country efforts in this regard. increasing ‘vaccine hesitancy’ and complacency towards disease risks. Furthermore, following up on one of the References recommendations of the Second External EU added value and ECDC strategic 1 10 European Commission DG ECFIN. The 2015 actions Evaluation of ECDC, the Centre will increase focus on facilitating the use of Ageing Report, Economic and budgetary projections for the 28 EU Member States (2013 – 2060). As set out in its Strategic Multi-Annual its scientific outputs by bodies involved Luxembourg: Publications Office of the European 8 Programme 2014 – 2020, and in line in the national immunisation policy- Union; 2015. Available at: http://europa.eu/epc/pdf/ with the afore-mentioned EPSCO making process. Frameworks for the ageing_report_2015_en.pdf
Council Conclusions on Vaccination decision-making process on vaccination 2 OECD. Focus on Health Spending, OECD Health as an Effective Tool in Public Health, programmes can vary between countries, Statistics 2015. Paris, OECD; 2015. Available at: COMMENTARY within the ECDC, one of the strategic but in general the core evidence base https://www.oecd.org/health/health-systems/ aims of the VPD Programme is to assist for decision-making is common for any Focus-Health-Spending-2015.pdf the EU Member States and the European given vaccine and target population. To 3 ECDC. Infectious diseases of specific relevance to Commission in the needs and impact avoid unnecessary duplication of effort in newly-arrived migrants in the EU/EEA – 19 November assessment for, and the implementation developing this evidence base, a potential 2015. ECDC: Stockholm; 2015. Available at: http:// of, life-course vaccination at EU level, by key added value offered by ECDC is to ecdc.europa.eu/en/publications/Publications/ Infectious-diseases-of-specific-relevance-to-newly- providing tools and evidence for national improve the qualitative and quantitative arrived-migrants-in-EU-EEA.pdf decision-making. efficiency of the analysis required to 4 inform the decision-making process at the Banerjee S. Multimorbidity – Older adults need health care that can count past one. The Lancet A set of strategic initiatives are already national level, with assessment of options 2014;S0140-6736(14)61596-8. Available at: http:// ongoing with a view to contributing to for implementation, including their cost- dx.doi.org/10.1016/ this goal. In the area of surveillance, a benefit analysis, while also encouraging 5 ECDC. Vaccine Schedule Platform. Available number of key hospital sentinel-based peer-learning and experience-sharing. at: http://vaccineschedule.ecdc.europa.eu/Pages/ EU-wide surveillance networks are Scheduler.aspx being funded at EU level with the aim Ongoing work in the area of scientific 6 Council Recommendation 2009/1019/EU on of driving excellence in the collection of and technical advice on electronic seasonal influenza vaccination. Available at: http:// data on VPDs, complementing routine immunisation registries is also critical, eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ: surveillance activities. In particular, the and should in the long term help to L:2009:348:0071:0072:EN:PDF
ongoing ECDC-funded PERTINENT, strengthen capacity and expertise 7 Kanitz EE, Wu LA, Giambi C, et al. Variation in SpIDNet, and Horizon2020-funded to implement functional systems to adult vaccination policies across Europe: An overview IMOVE+ projects focusing on pertussis effectively monitor and evaluate the from VENICE network on vaccine recommendations, and invasive pneumococcal disease performance of vaccination programmes funding and coverage. Vaccine 2012;30:5222-8. are expected to generate fundamental across all ages. Finally, sustained efforts to generate evidence on drivers and barriers
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8 ECDC. ECDC strategic multi-annual “HEALTHY” programme 2014– 2020. Stockholm: ECDC; 2014. Available at: http://ecdc.europa.eu/en/aboutus/ Key%20Documents/Strategic-multiannual- programme-2014-2020.pdf INNOVATION:
9 ECDC. Burden of Communicable Diseases in Europe. Available at: http://ecdc.europa.eu/en/ healthtopics/burden_of_communicable_diseases/ PRIORITISING pages/index.aspx
10 The second independent evaluation of the ECDC in accordance with its Founding Regulation PATIENT BENEFIT (European Parliament and Council Regulation (EC) no 851/2004). 2014. Available at: http://ecdc.europa. eu/en/aboutus/Key%20Documents/ECDC-external- OVER ECONOMIC evaluation-2014.pdf INTERESTS
By: Els Torreele and Yannis Natsis
Summary: Unaffordable medicines prices, restrictions on access, and unmet patient needs are a new reality and a new debate for Europe. There is growing consensus among experts around the need to adopt alternative models for conducting and financing pharmaceutical research and development (R&D) – in particular for essential and life-saving health technologies. This article examines the deficiencies and challenges of the current system and some of the forces that are working against effective and patient-focused medical innovation. It suggests shifting the paradigm from a focus on the economic interests of pharmaceutical companies to health needs-driven innovation as a public good.
POLICY ADVOCACY Keywords: New Medicines, Access to Medicines, Innovation, Therapeutic Value, Pharmaceutical Pricing ➤ #EHFG2016 Parallel Forum 3: “Healthy” Innovation Introduction high prices of the new medicines that come out of the medical innovation Over the past two to three years there has pipeline. Faced with unapologetic high Els Torreele is Director, Access to been an unprecedented debate around the pricing strategies of pharmaceutical Medicines and Innovation, Open pricing and financing of new medicines Society Foundations, New York, companies, there are polarising debates, in Europe, and how to ensure patients United States; Yannis Natsis is even in the wealthiest of European Policy Coordinator for Universal can benefit from the exciting progress Union (EU) Member States, about the Access & Affordable Medicines, in medical sciences in a timely way. European Public Health Alliance, reimbursement of certain new medicines, Notwithstanding major public investments Brussels, Belgium. as well as rationing of some treatments, in biomedical science and technology, Email: els.torreele@ whereby patients at the early stage of their opensocietyfoundations.org public health systems face growing disease are excluded until their condition challenges to cope with the increasingly
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worsens. 1 Meanwhile, medical needs, leaving important health needs to transform the current pharmaceutical innovation is lacking for important unmet; and questions around the real innovation model into one that is more health concerns, such as antimicrobial added therapeutic value of new medicines. health and public interest-oriented, there is resistance, 2 while the large majority of a need to contest the prevailing narrative new medicines developed have no or little These issues increasingly appear on the and underlying economic rationale that added therapeutic value to what already agenda at the highest political level in maintains that the current monopoly-based exists. 3 These debates often pit financial the EU, 4 despite opposing pressure. 5 incentive model not only works, but is also and economic concerns against patient Moreover, echoing the global character the only option we have. needs, and are a clear indication that the and growing importance of the problem, current private, market-driven model of the United Nation’s Secretary General The pharmaceutical industry has been medical innovation, which relies on patent- has called for the misalignment between effective at promoting its innovation based monopolies and profit-maximising the rights of inventors, international model and justifying high medicine prices, pricing, is not fit for purpose. human rights law, trade rules and public but this narrative is increasingly being health where it impedes the innovation challenged. 9 The myth of ever-increasing Affordability and curbing patent of and access to health technologies to be R&D costs that must be recouped to monopolies addressed. It has established a High Level finance further innovation (now into Panel to propose a way forward. 6 Healthy the €1 – 3 billion range for a new drug) Unaffordable prices for medicines, innovation and access to affordable does not hold up to data scrutiny (real restrictions on access, and unmet patient medicines are no longer challenges for low expenditures are more in the range of needs are a new reality and present a and middle income countries alone, but €50 – 200 million, as documented for new debate for Europe, including in the topical issues in high-income countries instance by DNDi), 10 much of which is Council of EU Health Ministers. During too. This political momentum offers an paid for through public funding. 11 the first half of 2016, and spearheaded by unprecedented window of opportunity the Dutch Presidency, some of the major to look at the real problems and develop The public at large as well as policy flaws of the current model of medical creative ways forward. makers, however, are not sufficiently innovation were brought centre-stage aware that the current model is in the political arena, in particular the inadequate by being overly expensive unsustainability of ever rising prices. while delivering little health value, and At both national and international level, we excluding the majority of people from fierce debates are unfolding about: the accessing products of innovation. Thanks need for healthy and robust generic need new to well-financed marketing and lobbying competition; the importance of health campaigns, the pharmaceutical industry technology assessment (HTA); the pricing medicines that remains highly influential with opinion strategies adopted by pharmaceutical leaders (e.g., the medical establishment) companies; the need for pricing regulation offer real and at multiple policy levels, and dominant and transparency; the misuse of orphan in shaping public discourse. Their business drug incentives in combination with therapeutic model relies on a strong legal framework the trend of “orphanisation” of the drug of intellectual property and market development pipeline*; the need to advance exclusivity protections that industry balance intellectual property rules as lobbyists have been effective in expanding innovation incentives in ways that also A broken innovation model globally through various policies that ensure accessibility and affordability; ‘‘ extend the life of patents, including free the structure of the pharmaceutical There is growing consensus among trade agreements. sector and its financialisation; the proper experts about the need to adopt alternative implementation of competition rules; the models for conducting and financing This presents a major challenge in way in which priority setting in medical research and development (R&D) – in promoting a counter-narrative despite innovation is misaligned with public health particular for essential medicines (e.g., growing evidence on the failures and antibiotics, hepatitis C drugs, certain harms of the current system. At a cancer medicines). 7 In this new model, fundamental level, this will require critical health needs are prioritised, re-examining what is meant by medicines are considered public or social innovation in the field of medicine (if * There is a well-documented increase in marketing authorisations for new medicines for niche indications under goods and the cost and risks of R&D are there is no therapeutic benefit, does that various “orphan drug” incentive schemes on both sides of not commercialised in the market place constitute true innovation?); how should the Atlantic, including authorisations of a single product for and recouped via high prices. 8 Given pharmaceutical innovation be measured, segmented patient groups within a disease area and repeat the significant public investments in incentivised and rewarded, and what are authorisations of the same product for several rare diseases or medical R&D, there is a strong case for the roles and responsibilities of public and niche populations. Companies typically seek, and obtain, very 12 high prices for these products. In fact, seven of the top 10 best- the price of the end product to reflect this private sectors? ; and what constitutes selling drugs in the United States for 2014 came on the market investment and be affordable. In order a fair price for such innovation? While with an “orphan” designation.
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patents and the associated monopoly companies’ time and money by changing affordable products that benefit society pricing are currently used to reward the way we develop and approve new as a whole. Regulators should send a innovation, pharmaceutical patents are drugs, and shifting the responsibility and strong message to manufacturers about ill-suited to incentivise therapeutically burden of demonstrating an acceptable the quality of the innovation they want useful innovation as there is no correlation benefit/harm ratio to after the drug is to see, in particular – added therapeutic between patentability and medical approved in the market, de facto lowering value – rather than lowering standards benefit (i.e., a patent rewards chemical evidentiary requirements, mostly via for marketing authorisation. Secondly, novelty, not medical innovation and prioritising medicines’ efficacy over Europeans pay for medicines twice, as a therapeutic advance). In fact, evidence safety. This is the spirit of a range of large portion of medical R&D is publicly shows that in the field of pharmaceuticals, policy proposals such as the Adaptive funded–from support to early research patents incentivise firms to reshuffle Pathways pilot project and the Priority to various forms of subsidies throughout old combinations of compounds or Medicines (PRIME) scheme, both run by the pipeline. Hence, it is essential to have argue for second uses of existing ones, the European Medicines Agency (EMA) full transparency on actual R&D costs instead of searching for breakthrough and initiatives within the Innovative and contributions from both public and drugs. This explains, in part, why Medicines Initiative (IMI), all supported private sectors, and on how prices are the current pharmaceutical pipeline by drug-makers. Importantly, while set and take the respective contributions delivers ‘me-too’ drugs that offer little these discussions also aim at regulating into account. Public financing to R&D or no added therapeutic value. Another reimbursement conditions, the notion of should comprise criteria that safeguard important issue to consider is the extent affordability is notably absent. In addition, the public interest and guarantee a return to which the pharmaceutical sector is it is difficult to see how lowering the on public investment (in the form of increasingly “financialised” and focused burden of proof about efficacy and safety, accessibility and affordability). Thirdly, on maximising shareholder value and its including a focus on niche populations, public health needs should dictate research “bottom-line”, resulting in more spending will address the current innovation deficit priorities and public funding should be on marketing and share buybacks (to boost that results in a large majority of the new allocated accordingly whilst promoting stock prices) than on productive R&D. 13 drugs having no added therapeutic benefit open access to research data. Fourthly, compared to what we already have. a level-playing field, transparency and Deregulation by stealth? balanced involvement of all stakeholders While much of these discussions are in decision-making are critical in order to While the pressing issue of high drug held behind closed doors, it should be avoid regulatory capture. prices and inadequate medical innovation understood that these are not minor in Europe demands a comprehensive technical issues but constitute a paradigm The Council of the EU’s recently policy solution along the principles shift with far-reaching economic, political released conclusions on medicines is a outlined above, there are systematic and public health consequences. first step in the right direction. 15 The efforts to: (a) shift attention away from time has come for the EU to review the the core problem (i.e., that the current The way forward: prioritising impact of the current incentives on real pharmaceutical business model thrives therapeutic advance for patients medical innovation, and the availability, on ever higher monopoly prices for accessibility and affordability of the even mediocre medical advances); and A growing movement of patients resulting products–and for it to consider (b) reframe the debate by focusing on groups, consumer organisations, health possible solutions away from exclusivities “earlier and faster access to medicines and practitioners, researchers, clinicians, and and patent-based monopolies. A recent innovation” in ways that misdiagnose the health advocates is calling upon policy joint initiative of the Belgian and Dutch real problems with our current innovation makers at national and international levels health authorities already made a model, including pricing. to start addressing this pressing issue. 14 noteworthy effort to come up with four First and foremost, we need new medicines creative scenarios about drug development The long-term strategic goal of the that offer real therapeutic advance. and pricing that would provide patients proponents of this approach, including the Independent reviews from organisations, sustained and affordable access to the pharmaceutical industry, is to restructure including the Cochrane Collaboration, safe and effective drugs they need. 16 Last, the EU medicines regulatory framework, Prescrire and several national HTA bodies, but not least, it should be emphasised such that more products can be sold in point to the fact that most new drugs offer that access to medicines is a human right the market faster, even if their medical no or only marginal therapeutic benefits as well as a matter of social justice for value is not (yet) established. They argue in comparison to the best alternatives millions of Europeans, and from their that the current regulation is too complex already on the market. It is therefore perspective, an unaffordable treatment is and stands in the way of patients having critical to re-think current incentives to as good as a non-existent one. timely access to medical innovation, while move the industry away from its focus on proposing a new frame of reference to deal developing ‘me-too’ drugs and increasing with the risks around potential benefits their market share to focus on “healthy” and harms of experimental medicines. innovation that addresses priority Practically, what is sought after is to save health needs, delivers safe, effective and
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References 7 Balasegaram M, Bréchot C, Farrar J, Heymann D, 13 Lazonick W, Hopkins M, Jacobson K, Erdem et al. A Global Biomedical R&D Fund and Mechanism Sakinç M, Tulum O. Life Sciences? How ‘Maximizing 1 Reflector. Europe. What price medicines? The for Innovations of Public Health Importance. Shareholder Value’ increases drug prices, restricts subject that won’t go away. Pharmexec. 4 May 2016. PLoS Med 12(5): e1001831. doi:10.1371/journal. access, and stifles innovation. United Nations Available at: http://www.pharmexec.com/europe- pmed.1001831 Secretary-General’s High-level Panel on Access to what-price-medicines-subject-wont-go-away Medicines website, 1 March 2016. Available at: 8 Torreele E. Health Innovation as a Public Good. 2 O’Neill J. Chair. Securing new drugs for future https://highlevelpaneldevelopment.squarespace. United Nations Secretary-General’s High-level Panel generations: the pipeline of antibiotics. The review on com/inbox/2016/3/1/the-academic-industry- on Access to Medicines website, 28 February 2016. antimicrobial resistance. 2015, http://bit.ly/1sGrNZ9 research-networka Available at: http://www.unsgaccessmeds.org/ 14 3 Light D, Lexchin J. Pharmaceutical research and inbox/2016/2/28/els-torreele EU Alliance for Responsible R&D and Affordable development: what do we get for all that money? BMJ Medicines. Joint Declaration, signed by over 50 civil 9 Gagnon MA. New drug pricing: does it make 2012;344:e4348 society organisations, 2016. Available at: www. sense? Prescrire International 2015;24(162):192 – 5. medicinesalliance.eu 4 New W. Leaked EU document lays out major 10 Drugs for Neglected Diseases Initiative (DNDi) 15 evaluation of EU drug pricing. Intellectual Property Council of the European Union. Note. June 2016 An innovative approach to R&D for neglected Watch. 25 May 2016. Available at: http://www. Council conclusions on strengthening the balance in patients: ten years of experience and lessons learned ip-watch.org/2016/05/25/leaked-european- the pharmaceutical systems in the EU and its Member by DNDI. Report 2013. Available at: http://www.dndi. council-document-on-major-evaluation-of-eu-drug- States. Available at: http://data.consilium.europa.eu/ org/images/stories/pdf_aboutDNDi/DNDiModel/ affordability/ doc/document/ST-10086-2016-INIT/en/pdf DNDi_Modelpaper_2013.pdf 16 5 EPHA. Joint Statement: Civil Society urges Vandenbroeck P, Raeymakers P, Wickert R, 11 Stevens A, Jensen J, Wyller K et al. The role of Member States to defend the need for a critical review Becher K, et al. Future scenarios about drug public-sector research in the discovery of drugs of the intellectual property system and incentives development and drug pricing. Brussels: Belgian and vaccines, New England Journal of Medicine for medical innovation. Available at: http://epha. Health Care Knowledge Centre, Diemen: Zorginstituut 2011;364:535 – 41. org/a/6535 Nederland. 2016. Available at: http://kce.fgov.be/ 12 Mazzucato M. Statement on innovation. United sites/default/files/page_documents/Drug%20 6 United Nations Secretary-General’s High-level Nations Secretary-General’s High-level Panel on Pricing%20Scenarios%20Summary_ENG_final.pdf Panel on Access to Medicines. Available at: http:// Access to Medicines website, February 2016. www.unsgaccessmeds.org/ Available at: http://www.unsgaccessmeds.org/ inbox/2016/2/28/mariana-mazzucato
Slovenia: Health system review Another important challenge is how to ensure the future financial stability and sustainability of the health care system through diversifying its By: T Albreht, R Pribakovic´ Brinovec, D Jošar, M Poldrugovac, funding base. Currently, T Kostnapfel, M Zaletel, D Panteli, A Maresso Health Systems in Transition Vol. 18 No. 3 2016 Slovenia's compulsory health Copenhagen: World Health Organization 2016 insurance system relies (acting as the host organization for, and secretariat of, the almost exclusively on payroll Slovenia European Observatory on Health Systems and Policies) Health system review contributions, making it very susceptible to economic Number of pages: xv + 207 pages; ISSN: 1817-6127 and labour market Freely available to download at: http://www.euro.who. fluctuations. Overall, the int/__data/assets/pdf_file/0018/312147/HiT-Slovenia_rev3. share of out-of-pocket Radivoje Pribakovic´ Brinovec Tit Albreht • Mircha Poldrugovac Dušan Jošar • pdf?ua=1 • Metka Zaletel payments, including Tatja Kostnapfel • Anna Maresso Dimitra Panteli co-payments, is high. Slovenia has a well-developed health system with good While the latter are population health outcomes. Access to health care is also buffered by generally good. Despite this, there are persistent disparities complementary health in morbidity and mortality between regions and population insurance (CHI) there is groups and waiting times for some outpatient specialist some concern that CHI flat-rate services have increased in recent years. These present premiums are regressive and may become unaffordable for challenges, as do relatively high cancer rates and increasing lower income groups. Finally, more efficient use of health care multi-morbidity linked to population ageing, requiring a resources needs to be addressed through reform of the strengthening of prevention activities and co-ordination of purchasing system and provider payment mechanisms, both care. There is also a need to address the funding and provision of which are out-dated and lack incentives for rational of long-term care as service users incur large out-of-pocket reimbursement levels and quality services. expenditures and consolidation of eligibility criteria, funding and benefits is overdue.
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HOW CAN INNOVATIVE TECHNOLOGIES IMPROVE THE QUALITY OF LIFE FOR PEOPLE SUFFERING FROM HEARING LOSS?
By: Patrick D’Haese
Summary: In Europe, around 20% of women and 30% of men have a degree of hearing loss by age 70. Untreated hearing loss puts pressure on Europe’s already struggling health and social care systems, partly because it risks the onset of other diseases. Innovative technologies such as the Cochlear Implant offer a real solution for the individual with a hearing loss too high to benefit from a hearing aid. Action from European policy-makers is called for to help raise awareness of the condition, facilitate access to these technologies where appropriate, and share best practice amongst Member States.
Keywords: Sustainability, Active ageing, Hearing Loss, Health Economics
Introduction of men suffer from a degree of hearing loss by the age of 70. 2 The inevitable Europe’s population is ageing fast. act of ageing is the most common cause By 2025, it is predicted that 20% of the of hearing loss in adults. In Germany, population of the 28 EU member states for example, 1% of 14 to 19 years old will be over 65 years old. Whilst there are experience hearing loss, and that statistic obvious benefits to living longer, such as rises to 54% for those over 70 years opportunities to pursue a lengthier career, old. 1 The statistics are similar across discover new hobbies, explore further Member States. Couple this with an ageing education and spend quality time with
POLICY ADVOCACY demographic, it is evident that the burden family, there are also associated risks. of untreated hearing loss will increase. Perhaps when one considers the risks of growing old they think of increased frailty, ➤ #EHFG2016 Workshop 5: Age-related hearing loss is caused by or maybe cognitive decline–but what Hear today, here tomorrow the degeneration of sensory cells and about the impact of hearing loss and its cannot be reversed. Studies show that associated morbidities on quality of life? hearing loss has a negative impact on overall health; it increases the risk of the Patrick D’Haese is Corporate There are currently an estimated onset of other diseases in older adults Director of Awareness and Public 300 million people in the world with Affairs, Med-EL Medical Electronics, (see below) and is associated with an age-related hearing loss and it is predicted Innsbruck, Austria. increased use of health and social care Email: [email protected] that this statistic will triple by 2050. 1 In systems. 3 Given the current risks to the Europe, around 20% of women and 30%
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sustainability of health systems, in part of other costly and debilitating diseases; The World Health Organization (WHO) due to Europe’s ageing demographics but this includes blindness, cognitive decline, estimates that the total cost of untreated also due to a rise in chronic diseases, it dementia 1 3 and diabetes. 5 There is also hearing impairment in the EU amounts makes sense for European policy-makers the risk of more frequent falls. 5 to a startling €213 billion each year. 10 to take action to ease this burden where People who suffer from hearing loss are possible. Understanding the impact less likely to be employed and therefore of hearing loss on older people, and are less likely to be able to actively subsequently its impact on the European contribute to the economy. Unemployment economy and society is therefore crucial. also increases the likelihood of the need European policy-makers could seek to Untreated to receive state benefits. For the older take appropriate measures and invest generation, this means that hearing loss in innovative technologies to tackle hearing loss puts has the potential to cut the working life this burden. span of an adult, weakening the potential unnecessary of Europe’s silver economy. Helping keep Europe’s older generation socially active pressure on The benefits of an integrated and innovative approach Currently in Europe, we see an older Europe’s health generation that is more engaged in their First, national screening programmes community and society than ever before. and social care play a significant role in the treatment For European citizens to benefit the most ‘‘ and care of hearing loss sufferers. They from their later years, they need to be able systems allow hearing loss to be treated early, and to communicate independently, remain the patient to be referred to the correct active and maintain their autonomy. For Diabetes is considered a serious threat to specialist care. The National Screening this reason, even early signs of hearing the sustainability of European health care Programme for the over 65s in the loss could be tested. Untreated hearing systems. According to the International United Kingdom is estimated to produce loss very quickly leads to social isolation Diabetes Federation, estimates indicate £2 billion (€2.34 billion) worth of national and depression. Patients speak of the that diabetes was responsible for 9% of savings in ten years. 11 Moreover, economic impact of fragmented communication, the total health expenditure in the Europe modelling has shown that £28 million inability to participate in conversation and Region for 2015. 6 Untreated hearing loss (€32.7 million) in national savings could therefore diminishing circles of friends. makes the onset of diabetes more likely; be made in total in the United Kingdom this is, in part, related to the fact that those alone, by properly managing hearing Hearing loss also has the potential to living with hearing loss are less likely to loss in people with severe dementia and restrict a person’s independence. It can be active or feel comfortable participating delaying admissions into residential care. 9 become difficult for an older person to in sport. take care of themselves and hearing loss Clearly, early intervention can help our sufferers are likely to depend on their Looking at cognitive decline and the health care systems remain sustainable by friends and family for support. This leads risk of the onset of dementia, there is a relieving costs, related to the prevention of to the risk that it will accelerate their growing body of evidence to suggest that other diseases, the risk of more frequent progression into facilitated living or social they are strongly associated with hearing falls and necessary social care as a result care. It is also important to remember loss. Hearing loss has been linked to of these conditions. There should be a that a lot of older people act as carers to amplifying cognitive decline in the ageing push from policy-makers to see more of their partners. That role can be restricted process. 7 This is because communication, these types of screening programmes by the onset of hearing loss, accelerating which is facilitated by hearing, leads to across Europe. Furthermore, there needs the chances of their partner’s progression cognitively stimulating abilities such as to be increased education of health care into facilitated living. Therefore, hearing social interactions and improved mood. workers and general practitioners to better loss has a huge impact on an individual’s People with mild hearing loss have nearly understand the severity of hearing loss, quality of life. twice the chance of going on to develop and encourage older patients towards dementia as people without any hearing screening and appropriate treatment. 8 The economic impacts of hearing loss loss. Furthermore, the EU is estimated to have invested €400 million on Despite the severity of consequences of Public spending on ageing in the EU research on neurodegenerative diseases. 9 hearing loss, treatment is more advanced accounts for 50% of general government Understanding these diseases better will than ever before. Hearing implants expenditure. 4 This is a significantly high facilitate work to prevent and treat them. have been used successfully for over 30 proportion and the EU needs to look for By treating hearing loss we can hope to years. For example, Cochlear Implants ways to minimise such spending. Research remove a contributing factor. are used to treat those who experience shows that people living with hearing loss hearing loss too severe to benefit from a are more likely to experience the onset hearing aid. The surgery required for a
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Cochlear Implant is largely considered hearing loss and the necessity of screening we can hope to improve hearing care routine with a low complication rate: after programmes and treatment. WHO defines across Europe, contributing to the active implantation, transient dizziness is the ‘active ageing’ as the process of optimising ageing of our society and helping to keep most common side effect, which is usually opportunities for health, participation Europe’s health care systems sustainable. treatable and temporary. 1 Furthermore, and security to enhance the quality of life the benefits to older adults of the Cochlear as people age. From an EU perspective, References Implants are almost the same as the there are a variety of schemes, policies benefit to the younger person. A small and organisations which exist to facilitate 1 MED-EL. Hearing in Older Adults: Hearing loss – difference in the benefits felt by an older this, including active ageing guidelines, cognitive decline and the latest hearing implant technology for people 60 and older. MED-EL 2014:7. and younger person is found in the ability an ‘Active Ageing Index’ and the work to differentiate speech from background being done by the European Innovation 2 Roth TN, Hanebuth D, Probst R. Prevalence noise. This is because later in life, human Partnership for Active and Health Ageing. of age-related hearing loss in Europe: a review. European Archives of Oto-Rhino-Laryngology, hearing is less able to distinguish speech However, minimal attention is being 2011;268(8):1101 – 07. Available at: http://www.ncbi. in complex hearing situations. paid to the impact of hearing loss on a nlm.nih.gov/pmc/articles/PMC3132411/ person’s quality of life as they enter their 3 Lavis JN, Posada FB, Haines A, Osei E. Bending Thus, innovative medical technologies, ‘silver years’. In its guiding principles the Spend: Expanding access to hearing technology targeted at the appropriate patient group, on Active Ageing, the European Council to improve health, wellbeing and save public money. can play a part in reversing the impact of outlines three key priorities. These are: The Lancet 2004;364:10. hearing loss on the health and wellbeing of employment, participation in society 4 European Commission. Research Innovation the individual and also reduce the impact and independent living. Treating severe Union: The Silver Economy. Available at: http:// on the economy and society. For example, hearing loss can facilitate all three. ec.europa.eu/research/innovation-union/ in a study that looked at 93 Cochlear index_en.cfm?section=active-healthy- Implant users, six years after they had In addition, can an ageing Europe afford ageing&pg=silvereconomy been implanted, statistics demonstrated not to address hearing loss? A key focus 5 Archbold S, Lamb B, O’Neill C, Atkins J. The Real that the unemployment rate had dropped of the health agenda of the EU and of Cost of Adult Hearing Loss: reducing its impact by from 60% to 49%. The same study also many Member States at the moment increasing access to the latest hearing technologies. The Ear Foundation, 2014. demonstrated the impact of hearing loss is on how to help keep our health care on personal income – 31% of respondents systems sustainable. It is clear to see that 6 International Diabetes Foundation. IDF diabetes had increased income enough to move the impact of untreated hearing loss puts atlas: amount of adults with diabetes. Available at: http://www.diabetesatlas.org/ income brackets. 3 It is also important to unnecessary pressure on Europe’s health note that the economic positive impact of and social care systems, especially as 7 Amieva H, Ouvrard C, Giulioli C, et al. treating hearing loss in a child continues treatment by innovative technologies can Self-reported hearing loss, hearing aids, and cognitive decline in elderly adults: A 25-year up until old age. Children who live with be so effective. Furthermore, there are study. Journal of the American Geriatric Society untreated hearing loss are less likely to further implications of untreated hearing 2015;63(10):2099 – 104. attend mainstream education and this has loss for the economy, society and the 8 ESRC Deafness Cognition and Language Research an overall impact on their employment quality of life of an individual. Centre. Joining Up: Why people with hearing loss or opportunities and earnings potential. deafness would benefit from an integrated response Later on in life this can lead to reduced There are appropriate circumstances to long-term conditions. University College London. pensions and smaller savings, thus where people could be fitted with a Available at: https://www.ucl.ac.uk/dcal/documents/ hindering financial security. Treating Cochlear Implant if their degree of hearing Joining_Up_long_term_conditions_report.pdf hearing loss saves society money over a loss warrants this treatment, especially 9 European Commission. Rapid press release: EU patient’s lifetime. as implantation is largely complication summit on Active and Healthy Ageing, 13 June 2013. free. Furthermore, screening programmes Available at: http://europa.eu/rapid/press-release_ SPEECH-13-531_en.htm Cochlear Implants are largely funded by could be introduced in Member States and Europe’s national health care systems, play an increasingly integrated part of the 10 WHO. Priority Diseases and Reasons for Inclusion. yet at present, evidence suggests that routine care of Europe’s ageing citizens. Available at: http://www.who.int/medicines/areas/ priority_medicines/Ch6_21Hearing.pdf p.2. more work needs to be done to ensure Early intervention plays a significant role patients have access to this technology. in the prevention of the onset of other 11 Action on Hearing Loss. Hearing screening for life. It is estimated, for example, that only one costly diseases. Available at: https://www.actiononhearingloss.org. uk/get-involved/campaign/hearing-screening-for- in twenty people who could benefit from life.aspx a Cochlear Implant have access to the The ask of policy-makers is straight- technology in the United Kingdom. 11 forward: support awareness-raising of the impact of age-related disability on Conclusion quality of life and hearing impairment in older adults, acknowledge access to To support its older population, EU hearing impairment care as a right and initiatives on active-ageing could pay facilitate best practice sharing amongst particular attention to the impact of governments. Through these measures,
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THE HEALTH PRIORITIES OF THE SLOVAK REPUBLIC’S EU PRESIDENCY
By: Dominika Greisigerova, Olga Zajicova, Tomas Kuca and Eva Slovakova
Summary: The Slovak Republic, which will be is at the helm of the Council of the European Union until the end of the year, has embraced some key health priorities, building on previous Presidency agendas. These priorities include: tuberculosis, antimicrobial resistance and vaccination, medicines shortages and access to innovative medicines, as well as, combating chronic non-communicable diseases and putting greater emphasis on food reformulation. The legislative agenda will focus on making progress on regulatory proposals for medical devices and the authorisation and supervision of medicinal products. The Presidency will promote the health agenda through engaging experts and civil society representatives in mutual dialogue.
Keywords: Slovak Presidency Health Priorities, AMR, Food Reformulation, Tuberculosis, Medicine Shortages
Introduction Legislative agenda Due to the fact that the Slovak Republic As the complex negotiations under the has taken over the Presidency of the previous Presidency resulted in a few European Union (EU) in a time of vivid legislative proposals not reaching a political challenges, the Presidency has conclusion, these are being continued. had to approach its general goals in a Firstly, further work on the proposal for flexible manner. The scope of general a ‘Regulation on medical devices’ aims priorities is comprehensively cross–cutting to create a clearer, stricter and a more based on four elements: an economically manageable framework for the medical strong Europe, a modern single market, devices sector, with significant benefits Dominika Greisigerova is a sustainable migration and asylum policies, expected for patients, health professionals Policy Officer and Olga Zajicova and a globally engaged Europe. Against and other consumers. Secondly, in relation is Director of the Department of EU Affairs and International Relations, the backdrop of these priorities, which to the proposal for a ‘Regulation on the Ministry of Health, Slovakia; Tomas are closely interlinked with, for example, authorisation and supervision of medicinal Kuca is Director and Eva Slovakova migration and potential health threats, products for human and veterinary use’, is a Communication Officer of the Press Department, Ministry of the Presidency will strongly endeavour to the Presidency will continue to examine Health, Slovakia. Email: Dominika. make progress in these health domains. this proposal further, with a view to [email protected] making as much progress as possible.
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Presidency priorities Medicine shortages and access to including loss of productivity, the innovative medicines profound negative impacts on the quality The Slovak Presidency has contextualised of life of patients as well as their relatives its health priorities to synchronise with On the one hand, the Presidency surmises or carers, and significant associated stigma the agenda of previous Presidencies – that shortages of medicines are of utmost (see also the article on Dementia: pressing that is, within current political realities. importance all over the Europe. These policy issues, in this issue of Eurohealth). The package of health priorities includes shortages are occurring across the supply Therefore, the Presidency will organise tuberculosis; antimicrobial resistance chain and are caused by various factors a conference specifically on Alzheimer’s and vaccination; medicines shortages such as non-compliance with Good disease to bring together people from and access to innovative medicines; Manufacturing Practices (GMP), parallel various fields of expertise in order to non-communicable diseases and food trade, labour disruptions, economic address key scientific, medical and social reformulation; and Alzheimer’s disease. reasons or changing market situations. aspects of dementia. On the other hand, throughout Europe, Tuberculosis there is no harmonised definition of ‘drug shortages’ or ‘availability of medicines’. In The way forward Tuberculosis (TB) is considered a major most cases, non-availability or shortages public health challenge in many countries The EU is constantly being challenged of medicines are addressed at the national worldwide. Even though overall EU by very diverse points of view when it level, depending on the type of a medicine countries recorded a decline of 3.8% comes to searching for compromises and and on the type of shortage. The Slovak in the number of TB cases over the last addressing health issues. The Slovak Presidency aims to encourage a common five years, 1 eastern European countries Presidency firmly believes that bringing reflection process on the different ways recorded a corresponding increase about at least a partial solution to the to tackle this problem. With regard to of 6.2%. Bearing in mind the Riga issues outlined here will contribute to innovative medicines, the Presidency will Declaration from 2015 which reaffirmed better health practice delivery across build upon the Netherlands’s initiative partnership efforts between eastern the Union. to explore ways of accessing innovative European states’ governments and the treatments that might not qualify for EU, 2 the Slovak Presidency will focus registration or reimbursement within the References on the problem of TB and facilitate the current medicines authorisation and health 1 discussion on next steps to enhance ECDC. Tuberculosis surveillance and monitoring in insurance system. cooperation in this field, thus promoting Europe, 2014. Available at: http://ecdc.europa.eu/en/ publications/Publications/tuberculosis-surveillance- an integrated EU policy framework on Non-communicable diseases and monitoring-Europe-2014.pdf TB. The subsequent debate on TB will food reformulation 2 follow at the political level during the EU Joint Declaration of the Eastern Partnership Summit, Riga, 21– 22 May 2015. Available at: http:// Informal Health Council in October 2016 The Slovak Presidency aims to strengthen eeas.europa.eu/eastern/docs/riga-declaration- in Bratislava. the objectives and activities in combating 220515-final_en.pdf chronic non-communicable diseases 3 TB Europe Coalition. Press Release: Anti-microbial Antimicrobial resistance and vaccination via raising awareness and bringing Resistance – ¼ of deaths linked to tuberculosis, together experts to share their views and Antimicrobial resistance represents 19 May 2016. Available at: http://www.tbcoalition. knowledge. Equally, food reformulation is eu/2016/05/19/press-release-anti-microbial- a major threat to global, regional one of the most effective ways to reduce resistance-14-of-deaths-linked-to-tuberculosis/ and national health security and is health risk factors such as saturated fats 4 interconnected with TB, as evidenced McGovern Institute for Brain Research at MIT. or elevated quantities of sugar and salt Brain disorders: By the Numbers. Available at: https:// by the WHO European Region showing in food products. Therefore, the Slovak mcgovern.mit.edu/brain-disorders/by-the-numbers the highest incidence rates of multidrug- Presidency will focus on the exchange of resistant TB. Especially alarming is best practices among EU Member States the fact that multidrug-resistant TB is in the area of food product improvement. also responsible for more antimicrobial resistance deaths than any other infectious Alzheimer’s disease agent. 3 The Presidency also considers high population vaccination rates to be a More than 600 disorders afflict the major tool in combating over-consumption nervous system: they include a variety of antibiotics and expanding resistance of dementia diseases (including to antibiotics. As a result, the topic of Alzheimer’s), brain cancer, encephalitis, vaccination will be discussed during epilepsy, stroke and multiple sclerosis. the Informal Council of Ministers in According to World Health Organization October 2016. (WHO) data, up to 35% of the European Region’s population live with brain disorders. 4 The direct costs of brain disease are accompanied by indirect costs that are more difficult to enumerate,
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REFUGEES AND ASYLUM SEEKERS IN GERMANY’S HOSPITALS
By: Marc Schreiner
Summary: The influx of migrants to Germany is relevant to the health care and hospital systems and has developed strong dynamics since 2014. This article provides an overview on how German hospitals are incorporated into migrants’ health care, the problems that occur at the organisational and financing levels for hospitals dealing with the special health care regime for migrants, and which measures have been taken to address evolving needs by politicians and responsible authorities. Additionally, the article explores the invention of the migrants’ health card.
Keywords: German Hospitals; Health Care for Migrants; Default Risk for Helping Hospitals; Migrants Health Insurance Card; Extra-budgetary Accounting of Migrants
Introduction First health check The influx of refugees and asylum seekers In principal, people arriving in Germany (referred to herein as “migrants”) has need to get registered, which for logistical been subject to extraordinary dynamics reasons is often organised by the first since 2014, but especially since the second admission centres. Migrants are obliged half of 2015. Since Angela Merkel’s to have their health status checked within “Wir schaffen das” * policy stance this the first few days after they arrive at their fact is extremely relevant for Germany. final destination. Therefore, they have In 2014 and 2015, there was a net influx to present themselves to a doctor who of 1,715,000 refugees (see Table 1) – a reviews their general health status and population comparable to the size of their vaccination coverage. Additionally, Hamburg. Asylum applications are a chest x-ray to detect infectious also on the increase (see Table 1); tuberculosis has to be performed as long however, these figures are incomplete. as the migrant is neither pregnant nor According to Federal police assumptions a minor. approximately 500,000 additional refugees are actually living in Germany in recent The Federal States (Bundesländer) are years, without being registered by the responsible for these “first health checks”. responsible authorities. In general, the federal state governments (regional governments) use the capacities of their public health services. However, * Chancellor Angela Merkel coined the expression Marc Schreiner is Director, “We’ll manage this!” during the annual summer press due to cost cuts over recent years, EU Policies/International Affairs/ conference on 31 August 2015. This expression became a capacities have not been sufficient in Health Economics, German Hospital Federation, Berlin, Germany. synonym for the so called “welcome culture” in Germany which most of the Federal States to cope with Email: [email protected] represents an open door policy with respect to the European the large number of migrants in 2015 migration crises. See also: http://www.faz.net/aktuell/politik/ and 2016. In order to have access to an angela-merkels-sommerpressekonferenz-13778484.html
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Table 1: Refugees and asylum applications in Germany, 2014–2016 women are entitled to the same care services as those insured under statutory 2014 2015 2016 (Jan – June) health insurance (preventive medical Registered refugees 1,342,529 1,997,000 examination, delivery and midwife-care), while minors have access to the full range Departed refugees 765,605 859,000 of care. Net influx 576,924 1,138,000 Asylum applications 202,834 476,649 396,947 In several Federal States, migrants who are only entitled to a limited scope of care
Source: Ref. 1 – 4 have to present an authorisation from the responsible authority to the health care adequate number of doctors and medical in some of the Federal States authorities provider. This authorisation, which is equipment for the first health checks, were lagging behind in paying hospitals issued by a civil servant of the authority, the governments of the Federal States for their support. is subject to criticism as nonmedical staff are contracting with third parties, e.g. are is required to decide on the urgency hospitals or doctors in hospitals, using a Hospitals’ role in migrants’ of treatment. Additionally, this entails a number of different arrangements. In some health care bureaucratic burden and may cause longer Federal States, refugees are brought to waiting times for migrants. Despite this, hospitals and get checked there, whereas Apart from their involvement in the first it is considered to be an adequate means in other Federal States hospital doctors are health check, hospitals also provide health of control and cost containment for the asked to conduct the first health checks care to migrants. As soon as migrants responsible authorities. in premises belonging to public health leave the first admission centres and are services or in first health check centres admitted by and housed in cities and The experience of hospitals in the that are in or near first admission centres municipalities, the provision of health Federal States where this system of prior where migrants are housed during the first care is organised by the latter. The legal authorisation applies has been mixed. In weeks of their stay. In yet other Federal basis for migrants’ claims to treatment is some of them the cooperation between States, first health checks are organised at the “code on services for asylum seekers” health care providers and the responsible first admission centres and are conducted (Asylbewerberleistungsgesetz), along with authorities works well as patients show up by hospital doctors. As in 2015 and at the the relevant rules in the Federal States. with the entitling document and hospitals beginning of 2016, the number of arriving The cities and municipalities in which the get reimbursed shortly after invoicing migrants became overwhelmingly large newly arrived migrants have their “usual for the treatment. However, in some and rose faster than the official structures domicile” are also charged with paying other Federal States hospitals reported available. This meant that a lot of hospitals for medical care. problems concerning the fulfilment of and hospital doctors worked in a honorary formal prerequisites as well as timely capacity as a personal contribution, often Only limited access to care for reimbursement. This applies particularly without receiving pay for their services. migrants in the numerous cases when patients show up at the emergency department or without Reports from hospitals and the The scope of the health care basket for prior authorisation. Robert-Koch-Institute showed that the migrants is defined by the “code on vaccination status of arrivals was in services for asylum seekers”. For those High risk of default for hospitals many cases insufficient or non-existent, who have been in Germany for at least thus endangering themselves and other fifteen months as official asylum seekers, Hospitals are legally bound to deliver migrants at overcrowded first admission no restrictions apply in comparison to the health care and rejecting a patient may centres. At the same time, experts were normal scope of the health care basket. For subject them to criminal prosecution. concerned about a possible threat to the migrants who have not yet completed this German hospitals completely fulfil their health of the resident population. Some waiting period and for foreigners who are responsibility. At the same time, the cases of infectious tuberculosis were officially bound to leave Germany, only default risk for assuming the treatment detected, as well as cases of some other a limited scope of health care services is costs of migrants is borne by hospitals diseases, e.g. scabies, 5 which were non- made available, i.e., only acute care or pain as securing reimbursement from the existent in Germany. relief as part of necessary medical care responsible authorities is difficult for or dental care are provided for this group. practical and legal reasons. On the The financing of these support services Thus, treatments which cannot be delayed one hand, claims from the hospital for was also problematic, especially during the because of suddenly occurring cases of medical assistance provided at emergency second half of 2015. Contracts with service illness, as well as medicines necessary departments to patients in urgent need, providers were consequently negotiated for healing and curing are covered. This but without any entitling documents, are by the responsible authorities, setting the is also valid for chronic diseases, e.g. in the first instance transferred to the somewhat spontaneous cooperation on a hypertonia or diabetes, if the omission of patients and can only be further settled more reliable footing. Nonetheless, at least care were to lead to an acute status and with their cooperation. On the other would endanger the patient. Pregnant
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hand, linguistic and cultural barriers as After the Asylum Process Accelerating code on the card for migrants, thus well as time constraints in emergency Act was passed, a further six Federal enabling the hospital to know that only departments can make it problematic for States made use of this new opportunity the limited scope of the health care basket a hospital to fulfil the legally-imposed (Berlin, Brandenburg, Niedersachsen, applies for this patient. This distinction burden of proof. This problem becomes Nordrhein-Westfalen, Schleswig-Holstein, has been possible from the beginning extremely relevant for migrants who are Rheinland-Pfalz) and contracted with their of 2016 and helps to prevent hospitals from not registered as there is no responsible regional statutory health insurance funds having to pay back parts of invoices for authority for them and thus, hospitals have in late 2015 and early 2016. Their eight the delivery of services for which a patient only a very limited chance of obtaining agreements differ with regard to claims for was not entitled to. reimbursement for their treatment. benefits and also with regard to the added service fee for the funds, which in the Extra-budgetary accounting An (unpublished) survey, conducted case of Nordrhein-Westfalen reached 8% of migrants by the German Hospital Federation in of treatment costs without any ceiling. In late 2015/early 2016, found that at the end the case of Nordrhein-Westfalen this was Knowing the residence permit status of 2015 a total of €50 million was owed considered unacceptable by the responsible of patients is not the only relevant to clinics/hospitals for health care to authorities and led to the health insurers information that hospitals need when migrants and for required extra services, refusing to opt-into the contract provided determining what health care basket e.g. translation services. However, the by the regional government. Finally, at applies in each case. They also have to figures are not completely reliable as it least in the larger Federal States, the prove that patients were treated under the remains unclear whether the amounts health insurance card for migrants is not special regime of the “code on services were still pending payments or whether used in a comprehensive manner, creating for asylum seekers” as special financing they were lost completely. The ratio of confusion for hospitals and problems in rules apply for these groups: hospitals claims considered to be depreciated is 10% obtaining reimbursement. are allowed, for accounting purposes, to higher for ambulatory services (compared count them as “extra-budgetary”, even to inpatient services) and 20% higher for Regardless of having a migrant health retroactively for the whole of 2015. This non-registered migrants (compared to card, no progress has been made on clearly political opportunity was provided to registered migrants). defining the limited services that new hospitals in order to prevent them from migrants (i.e., those who have been in losing out during price cuts based on Migrants’ health card does not solve the country for less than fifteen months) the Hospital Structure Reform Act that the problems are entitled to. The Asylum Process came into force at the beginning of 2016 Accelerating Act required the federal in response to the extraordinary rise As an alternative to the system of prior associations of cities and municipalities of cases †. authorisation, migrants in some Federal and the statutory health insurance funds States can present a “migrants’ health to negotiate a framework agreement to Conclusions card” that entitles them to the limited define the scope of the health care basket version of the health care basket during for migrants, to harmonise invoicing The enormous influx of migrants since the first fifteen months. With the Asylum and scrutiny procedures, as well as late 2014 has created the need for several Process Accelerating Act passed in reimbursement for the expenses of the additional efforts in the German health late 2015, regional governments were health insurance funds. The negotiations care system. From early on, hospitals have given the opportunity to contract with led to the signing of an agreement at the taken their full responsibility, as evidenced statutory health funds in their region end of May 2016 but left open a number of by their pragmatic approach to the many in order to provide migrants with their questions on which the negotiators could organisational challenges, as well as by own health insurance card. With this not reach consensus. Thus, a catalogue of the personal commitment of hospital staff card, migrants can attend the health care health care services that are guaranteed in a lot of cases, where many provide provider directly without first having to migrants who have not been in the their services for free. Although problems to obtain prior authorisation from the country for more than fifteen months still regarding the provision of care do not responsible authority. After treatment, the does not exist, either as a positive or as a occur nationwide, lack of financing and health care provider directly invoices the negative list. 6 personal capacities are severe challenges health insurance fund issuing the relevant in some regions. card and gets reimbursed. Finally, the Another problem has been that since it is health insurance funds get the money back not possible to visually mark the health Migration continues to increase due to from the responsible authority, including insurance cards for migrants issued under global political, economic and climate an added service fee. This arrangement this regime, hospitals needed certainty developments. This has caused many is called the “Bremer Modell” as this about the legal status of the patient kind of cooperation was invented in the showing the card when attending. Thus, Federal State of Bremen and implemented a technical marker was agreed upon by † Several mechanisms are in place to restrictively steer the development of the number of cases. Hospitals have to accept since 2005, joined by the Free State of the “Gematik” (the society for telematics relevant price cuts for every case delivered beyond a ceiling in Hamburg since 2012. applications), providing a special technical the budget negotiations. Additionally, fixed costs are deducted for a special group of cases.
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people to search for shelter and a better life References 5 Beerman S, Rexroth U, Kirchner M, Kuhne A, Vygen S, Gilsdorf A. Overview about epidemiologic abroad. UNHCR estimates that 65 million 1 Statistisches Bundesamt (Federal statistics relevant infectious diseases. Available at: http://edoc. people actually are displaced from agency) External migration of foreign persons – rki.de/oa/articles/reoqYEk1fm2/PDF/25d2DtldjKhxo. 7 2014 and 2015 sorted by Federal States. Available their homes. According to projections pdf presented by the Federal Government, at: https://www.destatis.de/DE/ZahlenFakten/ 6 approximately 200 million migrants are GesellschaftStaat/Bevoelkerung/Wanderungen/ Federal framework agreement on the acceptance Tabellen/Aussenwanderung.html of health care for non-insured persons for estimated to reside in third countries, payment after § 264 paragraph 1 of Social Code 2 Bundesamt für Migration und Flüchtlinge and a large part of them might come to book Number 5 (for recipients of health care (Federal agency for migration and refugees) Asylum Europe and to Germany. 8 Thus, migration services after §§ 4 and 6 of code on services processes statistics 12/2014. Available at: http:// for asylum seekers). Available at: https://www. most probably will become a permanent www.bamf.de/SharedDocs/Anlagen/DE/Downloads/ gkv-spitzenverband.de/media/dokumente/ challenge for health systems. The special Infothek/Statistik/Asyl/201412-statistik-anlage-asyl- presse/presse_themen/asylbewerber/20160527_ geschaeftsbericht.html responsibility of hospitals requires a Bundesrahmenempfehlung_Asylsuchende_264_ political and legal acknowledgement 3 Bundesamt für Migration und Flüchtlinge Abs_1_SGB_V.pdf by politicians and systematic, adequate (Federal agency for migration and refugees) Asylum 7 UNHCR report. Global trends – forced processes statistics 12/2015. Available at: http:// financing for delivering these services, displacement in 2015. Available at: http://www.unhcr. www.bamf.de/SharedDocs/Anlagen/DE/Downloads/ which in general are the responsibility of org/576408cd7 the whole of society. Infothek/Statistik/Asyl/201512-statistik-anlage-asyl- geschaeftsbericht.pdf?__blob=publicationFile 8 Frankfurter Allgemeine Zeitung. Federal Government expects 200 Million climate refugees. 4 Bundesamt für Migration und Flüchtlinge Available at: http://www.faz.net/aktuell/wissen/ (Federal agency for migration and refugees) Asylum klima/regierung-fuerchtet-200-millionen- processes statistics 6/2016. Available at: http:// klimafluechtlinge-13029062.html www.bamf.de/SharedDocs/Anlagen/DE/Downloads/ Infothek/Statistik/Asyl/201606-statistik-anlage-asyl- geschaeftsbericht.pdf?__blob=publicationFile
Professorship in competence and a strong track record in and local developments influenced by knowledge of the intersection of Health globalisation and regionalisation. Global Health and and Social Sciences. A higher education The appointed professor will participate degree is required in Public Health or Development in inter- and transdisciplinary education. Medicine (licentiate, medical doctor) or In the area of research, s/he will be able Social Sciences, and formal studies or Job description to continue and expand her/his research demonstrated strong knowledge in the field interests in so far as they contribute The University of Tampere (Finland) other two fields. An appropriate doctoral to Global Wellbeing. Examples of is seeking applicants for a new degree is essential. The professorship will potential themes include: professorship in in Global Health be filled on a permanent basis, starting and Development. By global health as soon as possible (to be negotiated). • Global and Regional Policies; we mean a system-based and Socially Fit Health Technology Background transdisciplinary approach to education, • Urbanisation and segregation; research, and practice. This field places University of Tampere will merge Forced Migration priority on improving wellbeing, health by 2018 with Tampere University of • Global Environmental Health and equity worldwide. It emphasises Technology and Tampere University • Impacts of Globalisation on Health complex transnational issues and the of Applied Sciences. The profile of the and Health systems search for sustainable solutions. It new University will build on three major • Human Rights and Bioethics; involves many disciplines and engages areas of focus: Society, Technology Global Governance. with a wide range of stakeholders. and Health. Within the focus, Global The university is seeking a visionary Wellbeing will play a major role. As The successful candidate is required person, who is able to utilise the a hub, including Global Health and to have broad experience in the field potentials outlined, and shares the vision Development, it is envisioned that it of researching Global Health, and of Global Wellbeing. will enhance joint activities of disciplines especially expertise and promise in in different faculties, such as Social For further information, please contact: inter- or transdisciplinary study of the and Health Sciences, Medicine and Anneli Milen, Professor, Global Health interaction between global phenomena, Life Sciences, Technical Sciences, and Development. health and human wellbeing. Candidates Educational Sciences, Economics, and from a diverse disciplinary background Email: [email protected] Management. The hub will facilitate are considered and invited, but previous Tel. +358 50 318 7770 or innovative education and transdisciplinary work and degrees must show both formal +358 40 552 1337, Skype AnneliMi research on global issues and on national
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BIG DATA FOR HEALTH SERVICE RESEARCH: BALANCING POTENTIALS AND CHALLENGES
By: Anna-Theresa Renner, Julia Bobek and Herwig Ostermann
Summary: Big data, and digitised information in general, is of high importance and already widely used in most sectors and research fields, including health. Purposeful application of health data can contribute to better population health and more efficient health service provision. Nevertheless, precautions need to be taken, as individual health data is highly sensitive and misuse can have significant negative effects on the individual (e.g. on the labour market). This article explores the potentials and pitfalls of using big data in health service research. Furthermore, it highlights the necessity for governance of the interests of different stakeholders in accessing health data.
Keywords: Big Data, Health Service Research, Health Data, Data Governance
Introduction volume, velocity, and variety; it has been further suggested to add value and Digitisation of everyday life and veracity as fourth and fifth “Vs”. 2 3 Other technological advancements in the authors have proposed to define big data storage of collected data (server sizes) with respect to the sample population have led to the increasing relevance which equals the whole basic population. 4 of data for research and business. As Although there is currently no definition the processing power of conventional of big data in health, the importance of the Anna-Theresa Renner is a computers has steadily increased and the topic has been recognised by the European researcher in health economics at public mind-set has turned towards data the Austrian Public Health Institute Commission and its Directorate General driven information over recent decades, (Gesundheit Österreich GmbH) for Health and Food Safety (DG SANTE), and a doctoral candidate at the the term “big data” is frequently used in which is currently developing policy Vienna University of Economics and scientific and non-scientific discussions. Business, Austria; Julia Bobek is recommendations for big data in public Even though there is no single definition a researcher in health economics health, telemedicine and health care*. at the Austrian Public Health of big data, the term usually refers to very Institute and a PhD candidate at large amounts of data that are routinely the University of Maastricht, The or automatically collected and stored. Potentials and pitfalls of big data Netherlands; Herwig Ostermann Data can be structured or unstructured is director of the Austrian Public Health data are collected at different Health Institute and associate (e.g. pictures) and can be mined for service levels of the health care sector professor of health policy and information, whereas the insights of administration at the University (e.g. in hospitals, primary care or for Health Sciences, Medical conventional inductive statistical inquiries Informatics and Technology, are fairly limited for big data. 1 Hall/Tyrol, Austria. * The full “Study on Big Data in Public Health, Telemedicine Email: [email protected] Quite often big data is defined by three and Healthcare” written by the Gesundheit Österreich characteristics, known as the “3Vs”: Forschungs- und Planungs GmbH and SOGETI will be published later in 2016. Eurohealth — Vol.22 | No.3 | 2016 Eurohealth SYSTEMS AND POLICIES 47
pharmacies), but also outside the health of the procedures […] in the health group that will develop guidelines for care sector (e.g. via mHealth-Apps or insurance system, or for […] scientific or assessing the quality of data collected via social media), and for different purposes, historical research purposes or statistical health apps. such as reimbursement and insurance purposes”. 6 This means that big data for claims, or for epidemiological reasons (e.g. health service research is in principle Other data sources and datasets comprise registries). Other (secondary) uses of these allowed, but only when its benefit for the some intricacies as well. For example, data sources can be utilised for further public is substantiated. diagnostic data that are collected in applications such as health economic, hospitals for reimbursement purposes, health system or health service research, Another pitfall that is related to data are generally regarded as high quality, and of course clinical research (e.g. protection is the secondary use of data. but might be prone to up-coding, or a bias with genomic data). Data content ranges Quite often data are collected for a stemming from different coding routines from genomic data to socioeconomic specific purpose (e.g. a clinical study) in different hospitals. Being aware of data, including, among others, data on to which the patient or any other data these possible biases and using statistical pharmaceuticals, treatment processes, subject (e.g. a health care provider) has methods to control for them is essential insurance claims, telemedicine, and on consented to. In some countries, use for health service research to produce wellbeing and behaviours. of these data for any other purposes, robust results that eventually lead to more including research, needs further approval informed and evidence-based political The possibilities of analysing these data of the data subject. 7 This presents a severe decision-making. are numerous, and possible research barrier for scientific research. In some questions that can be answered increase other countries, access to health data is Besides shortcomings in data quality, even more when linking different datasets. permitted for research if it is done in the the quality of the data analysis is also Moreover, the costs of using big data for public interest, and the individual-level key to the valuable utilisation of big research are relatively low compared to data are anonymised or pseudonymised. data. In analysing big data, researchers data collected in clinical trials, but yield Under the GDPR the processing of health should be aware that the probability of similar robust results due to the sheer data without consent of the data subject spurious correlations rise with the size volume. 5 Utilising this potential of big is possible under the condition that the of the available datasets. It is therefore data can benefit the single patient when rights and freedoms of natural persons imperative for the analysis of big data for used for research on effectiveness, quality, are protected by suitable and specific health service research that analytical and safety of treatments and prevention, measures. The GDPR is generally seen skills are paired with knowledge of the but also the whole population for as a step in the right direction to align field. To exhaust the potentials of big data example by using it for infectious disease European national legislation, but critics in health, researchers have to be able to monitoring. Furthermore, accessible big have raised the concern that there is too identify, within the abundance of data, data facilitates comparative effectiveness much room for interpretation on how what information is crucial to answer a research which will ultimately lead to it should be implemented in the EU specific and relevant research question. cost-containment and more effective Member States. Even though some EU distribution of resources in the health care Member States already have stricter data Using big data for research sector or the whole economy. and privacy protection laws in place, the implementation of the GDPR, especially Several projects in various EU Member There are also some pitfalls related to big the appointment of a Data Protection States aim to facilitate health service data in health that must not be neglected. Officer in each country, is feared to research by linking relevant datasets. These are mainly related to the fact that increase administrative burden and to The Austrian project DEXHELPP (www. health data are not only individual-level require a high level of human resources. dexhelpp.at), which is co-funded by data, but also highly sensitive, as misuse two ministries and the city of Vienna, can negatively affect the individual, for Another important issue that could uses existing health care data to develop example on the labour market or with mitigate the benefits of big data in health methods, models and technologies for regard to insurance payments. This is the service research is the quality of the supporting decisions in health policy and reason why health data cannot be treated data and the data analysis. To derive planning. The project is coordinated by in the same way as data from other areas valid conclusions from quantitative the Vienna University of Technology and of life, but need special regulations. The analyses, researchers need to be aware carried out together with private and public European Parliament and the Council of the quality of their analysed data. partners, such as the Main Association of have recognised this fact in their recently Accuracy, completeness, consistency, the Austrian Social Security Institutions ratified “General Data Protection reliability, timeliness, and validity are (“Hauptverband der österreichischen Regulation” (GDPR), where health data are frequently named as indicators of data Sozialversicherungsträger”) and mentioned as one of the “special categories quality. Especially the quality of data the Austrian Public Health Institute of personal data” [6, Article 9]. The GDPR from mHealth apps is often unclear, but (“Gesundheit Österreich GmbH”). By allows for derogation from a prohibition highly relevant when linking these data developing methods for linking different on processing these special categories of with e.g. routinely collected health care datasets, analyses of the current status personal data, only if its purpose is in the records. To tackle this issue, the European but also models for forecasting and interest of the public, which includes to Commission has set up a working for comparative evaluations can be “ensure the quality and cost-effectiveness carried out. Eurohealth — Vol.22 | No.3 | 2016 48 Eurohealth SYSTEMS AND POLICIES
One of the main achievements of this EPR/EHR usable for research was not a For health service research it is crucial project so far has been the development primary goal of the epSOS. Nevertheless, that the process of accessing data (and big of a secure research server for all project aligning national eHealth structures, data in particular) for research purposes is partners, where highly heterogeneous or at least defining a minimum level of transparent, and equal for all researchers. datasets can be safely stored and analysed. technical and content-wise standardisation, Therefore, data governance is a key issue This server is the basis for other research will not only improve cross-border health in utilising the full potential of big data areas of DEXHELPP, such as estimating care, but also enable cross-country analysis. Data governance includes clear the burden of disease with computer comparisons for health service research. guidelines on what data can be used, simulation models or the comparison of in what form (pseudonymised, level of different health care interventions and Governance of stakeholder interests aggregation etc.) and by whom. This payment systems. Many other European not only encompasses (public) health countries have implemented similar Reservations against the widespread use researchers but also state institutions projects (e.g. UK Clinical Practice of big data, especially of big health data, in their role of planning and organising Research Datalink, Italian ARNO should be taken seriously, especially when (public) health service provision. This Observatory, Swedish ICT eHealth). Even coming from the data subjects (i.e. patients way, big data governance can substantially though, the fields of application of these or health care providers). Communicating contribute to accountability, not only of projects vary, the common objective is the potential benefits of big data to citizens individual health care providers, but also to make data available for research in the and stakeholders will be crucial, and has of the state as a regulator for the provision public interest. to be done in a measured way. It will of health and social services, hence, not be enough to highlight the benefits, shaping a more equal relationship between The aforementioned research projects but it must be made clear under which the state and its citizens. Therefore, usually include data from electronic circumstances the analysis of big data the value of big data for health service patient records or health records (EPR/ sets has an advantage over other methods research are not reflected in the sheer EHR) and electronic prescription systems. of evidence generation. Furthermore, the amount of available and accessible data, The aim of such eHealth systems is to fears of the data subjects regarding privacy but in the sensible use of these data to improve patient care pathways by enabling need to be addressed openly, which generate high level evidence that can be a secure exchange of the collected patient includes informing them about existing used for (better) policy making targeted at level data between health care providers. legal frameworks, as well as other data the welfare of the population. In Austria, the electronic health care protection policies to reduce possible data record (“Elektronische Gesundeitsakte” – breaches or data abuse to a minimum. References ELGA) (www.elga.gv.at), which includes an eMedication application, is currently Big data not only offers potential 1 De Mauro A, Greco M, Grimaldi M. What is being piloted in several regions. Other opportunities for individuals and big data? A consensual definition and a review of key research topics. AIP Converence Preceedings European countries are further ahead in public health, but is also a big business 2015;1644:97 – 104. the implementation of eHealth structures, opportunity for companies in the 2 such as the Netherlands (AORTA), health care sector. European industrial Dijcks J. Big Data for the Enterprise. The Oracle White Paper, 2013. Denmark (Shared Care Platform) and stakeholders have raised concerns that the Estonia (E-Estonia national identity relatively high data protection standards 3 Schroeck M, Shockley R, Smart J, Romero- scheme). in the EU compared to other parts of the Morales D, Tufano P. Analytics: The real-world use of big data – How innovative enterprises extract value world, might shift business opportunities from uncertain data. IBM Institute for Business Value, There is currently no common to countries outside the EU. Contrary 2012. understanding or guideline at the to this fear, the European Commission 4 European Commission. The Use of Big Data in European level on which applications hopes to attract business by increasing Public Health Policy and Research. Brussels: DG for should be incorporated in a national the trust of its citizens, which in turn Health and Consumers, 2014. eHealth structure or what the content of enables companies to establish sustainable 5 Hansen M, Miron-Shatz T, Lau A, Paton C. Big an EPR/EHR should be. However, efforts relationships with their clients. Moreover, Data in Science and Healthcare: A Review of Recent on this issue have been made by the the EU rules on data protection and Literature and Perspectives. Contribution of the IMIA European Union and its Member States, privacy apply to all companies, including Social Media Working Group. Yearbook of Medical by co-funding the European Patient Smart those from non-EU countries, which Informatics 2014;9:21 – 6. 8 Open Services (epSOS) project (www. operate in an EU Member State. Whether 6 European Parliament. Regulation on the protection epsos.eu), with the objective of improving these efforts will yield the expected of natural persons with regard to the processing of the interoperability of eHealth systems results, or whether business opportunities personal data on the free movement of such data to facilitate cross-border health care in will accelerate elsewhere, remains to be (General Data Protection Regulation), 2016/679. Brussels: Office Journal of the European Union, 2016. Europe. epSOS focused on technical and seen. Independent of these developments, semantic aspects, but also on legal and business considerations, unless they 7 OECD. Health Data Governance: Privacy, organisational frameworks, and developed are in the interest of the general public, Monitoring and Research, in OECD Health Policy Studies. Paris: OECD, 2015. recommendations for supporting should not compromise the privacy rights further developments in cross-border of citizens. 8 European Commission. The EU Data Protection interoperability. Making cross-border Reform and Big Data (Factsheet). Brussels: DG for Justice and Consumers, 2016.
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NEW PUBLICATIONS
Voluntary health insurance in Europe: Voluntary health insurance in Europe: role and regulation country experience
By: Anna Sagan and Sarah Thomson By: Anna Sagan and Sarah Thomson
Copenhagen: World Health Organization, 2016 Observatory Copenhagen: World Health Organization, 2016 Observatory Studies Series No. 43 Studies Series No. 42
Number of pages: xvii+ 122 pages; ISBN: 978 92 890 5038 8 Number of pages: xiv + 161 pages; ISBN: 978 92 890 5037 1
Freely available for download at: Freely available for download at: http://www.euro.who.int/__data/assets/pdf_file/0005/310838/ http://www.euro.who.int/__data/assets/pdf_file/0011/310799/ Voluntary-health-insurance-Europe-role-regulation.pdf?ua=1 Voluntary-health-insurance-Europe-country-experience.pdf?ua=1
If public resources were unlimited, there would be no gaps in No two markets for voluntary health insurance (VHI) are identical. health coverage and no real need for voluntary health insurance All differ in some way because they are heavily shaped by the (VHI). Most health systems face fiscal constraints, however, and nature and performance of publicly financed health systems and VHI is often seen as a way to address these pressures. This study by the contexts in which they have evolved. draws from the experiences of 34 countries to assess VHI's This volume contains short, structured contribution to health spending and to profiles of markets for VHI in 34 understand its role in Europe and in countries in the WHO European relation to publicly financed coverage. Region. These are drawn from It looks at who sells VHI, who European Union Member States plus purchases it and why. It also reviews Armenia, Iceland, Georgia, Norway, public policy on VHI at the national the Russian Federation, Switzerland and EU levels and the related national and Ukraine. The book is aimed policy debates. at policy-makers and researchers The analysis shows that, while the interested in knowing more about markets for VHI vary considerably how VHI works in practice in a wide in size, operation and regulation, range of contexts. the vast majority are small. The study suggests that VHI is normally Each profile, written by one a better way of meeting the population's health or more local experts, identifies gaps in needs than out-of-pocket payments. VHI can contribute to publicly financed health coverage, describes the role VHI plays, financial protection, especially where it plays a substitutive and outlines how the market for VHI operates, summarises public complementary role covering co-payments. Nevertheless, it is a policy towards VHI, including major developments over time, and complex, challenging and highly context-specific policy instrument highlights national debates and challenges. that may undermine other health-system goals, including equitable Contents: Introduction; 34 country profiles. access, efficiency, transparency and accountability, even where markets are well regulated. Contents: Introduction; VHI at a glance; Why do people buy VHI?; Who buys VHI?; How do markets for VHI work? Public policy towards VHI.
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NEWS
International in communicating with both policy-makers in addition to coordinating this network, and the public about the urgent nature of provides technical, regulatory and Conference on health and climate sets climate change, with its severe and growing scientific support. European priorities health risks. The aim of EU rules on pharmacovigilance Delegates also emphasised the importance is to monitor the safety of medicines so that The Second Global Conference on Health of providing authoritative and evidence regulators can take action to reduce the and Climate took place in Paris, France based guidance on health risks and risks and increase the benefits of medicines on 7– 8 July. Hosted by the Government of benefits associated with different climate for human use. The role of individual EU France, holder of the Presidency of mitigation policies and about best buy countries is to monitor medicine safety the 21st session of the Conference of the options for climate and health. This, they data, assess signals of possible emerging Parties (COP21) to the United Nations noted, will require a more systematic side effects, and analyse the data when a Framework Convention on Climate Change, analysis of the health effects of a range of safety issue is identified at European level. the Conference was held to define an actions from specific technology choices, action agenda to implement the Paris The report describes the activities of the such as for energy provision, to broader Agreement on climate change. This action EU system for monitoring and managing interventions such as carbon pricing. This agenda will contribute to the 22nd session the safety of human medicines from the should include estimates of the burden of of the Conference of the Parties (COP22), time the new pharmacovigilance legislation disease and economic costs and benefits to be held in November 2016 in Marrakesh, came into effect in July 2012, until for health services and the wider economy, under the Presidency of the Government July 2015. It highlights that closer alongside estimates of effects on of Morocco. collaboration between the EMA, the carbon emissions. European Commission and the EU Member The Paris Agreement, adopted During the conference the World Health States, enabled by the new European on 12 December 2015 emphasised that Organization (WHO) and the Climate and pharmacovigilance legislation, has “the right to health”, will be central to the Clean Air Coalition launched the global enhanced the monitoring of the safety of actions to be taken. The Agreement not Breathe Life campaign. It aims to raise human medicines throughout their life cycle only sets ambitious aims to curb awareness about the health risks of for the benefit of patients. greenhouse gas emissions to keep global short-lived climate pollutants such as black warming well below 2°C, it also commits In particular it notes that the creation of carbon, ozone and methane, which countries to strengthen adaptation. This a dedicated scientific committee for the contribute significantly to climate change includes implementing plans that should safety management of medicines, and air pollution. protect human health from the worst the Pharmacovigilance Risk Assessment impacts of climate change, such as air More on the Breathe Life campaign at: http:// Committee (PRAC), and the regulatory pollution, heat waves, floods and droughts, www.who.int/sustainable-development/ tools made available under the revised and the ongoing degradation of water news-events/breath-life/en/ legislation, allow for a more proactive resources and food security. It commits approach to ensuring medicine safety. For Detailed information on the conference countries to finance clean and resilient all medicines, pharmacovigilance activities is available at: http://www.who.int/ futures in the most vulnerable countries. are planned early on in the medicine globalchange/mediacentre/events/climate- It is hoped that through monitoring and development so that each medicine comes health-conference/en/ revision of national contributions every to the market with a comprehensive plan to five years, the world will begin to see gather more information on its benefits and improvements not only in the environment, risks. The analysis shows that the new European Commission publishes but also in health, including reductions in system has been successful at detecting three-year report on implementation the more than seven million deaths safety issues more quickly, thus enabling of pharmacovigilance legislation worldwide that are attributed to air regulators to take rapid action when pollution every year. needed and provide advice and warnings On August 8 the European Commission to users of medicines. This system The second Paris conference brought published its three year review on the effectively engages patients and health together more than 300 government pharmacovigilance activities of the care professionals, who report suspected ministers, health experts and practitioners, European medicines regulatory network. side effects, contribute to the decision- nongovernmental organisations and This is a closely-coordinated regulatory making process in case of safety concerns experts in climate change and sustainable network of national competent authorities and add the invaluable perspective of the development. Political will they noted needs in the Member States of the European people most affected by diseases and to be mobilised to scale up action; they Economic Area (EEA) working together their treatment. also highlighted the importance of the with the European Medicines Agency (EMA) health sector providing strong leadership and the European Commission. The EMA,
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Some specific achievements noted in the • Around 200 pharmacovigilance Commission. These expert-driven, review include: inspections have been carried out analytical documents will provide • Risk management plans, which every year. complementary data and indicators, and emphasise the particular characteristics identify the studies and risk minimisation A clearer focus was put on medication and challenges of each Member State. measures required to manage important errors through the provision of new known or potential risks, are an integral guidance. Side-effect reports related 3. November 2017: a Commission analysis part of proactive safety management. to medication errors increased from accompanying the 28 country health The PRAC assesses around 600 risk around 4,500 in 2012 to over 7,000 in 2014, profiles, giving Member States a succinct management plans each year for centrally in part because of increased awareness overview of the information provided in authorised medicines, while over the and a clearer legal basis for reporting. the first two products, linking them to the reporting period some 20,000 risk broader EU agenda and emphasising Work is also underway on improving the management plans have been submitted cross-cutting policy implications. to the Member States for nationally system’s infrastructure, and on simplifying authorised medicines. and streamlining existing processes where 4. From December 2017: exchanges possible, to minimise the administrative between individual EU countries and the • Reporting of side-effects has burden for all stakeholders. Ongoing Commission, the OECD and the improved; in particular direct reports from research in regulatory science will also Observatory, to discuss concrete patients have increased by 50%. Reporting support future improvements. implications of country findings and help of side effects by all stakeholders is an Member States make the best use of essential element for gathering more The report is available at: http://ec.europa. gathered evidence. information on the benefits and risks of eu/health/files/pharmacovigilance/ medicines in real life. pharmacovigilance-report-2012-2014_ en.pdf • Nearly 200 safety signals (information Countries commit to keep Europe about new or changing safety issues malaria-free potentially caused by a medicine) were State of Health in the EU initiative investigated by the PRAC up to the end Countries in the WHO European Region of 2014. Half of the confirmed signals led at risk of malaria have reaffirmed their In June 2016 at the Employment, Social to updates of the product information, commitment to keep the Region malaria- Policy, Health and Consumer Affairs and a further quarter to other regulatory free. The European Region is the first in (EPSCO) Health Council in Luxembourg, measures. Through rapid detection and the world to have interrupted indigenous European Commissioner for Health and management of safety signals, the malaria transmission. The number of cases Food Safety, Vytenis Andriukaitis, EU pharmacovigilance system is delivering dropped from 90,712 in 1995 to zero cases announced the State of Health in the advice on the safe and effective use of in 2015. On 21–22 July 2016, Armenia, EU initiative for 2016 – 17. The initiative will medicines more quickly to patients and Azerbaijan, Georgia, Kazakhstan, bring together internationally recognised healthcare professionals. Kyrgyzstan, the Russian Federation, expertise to provide Member States with • Regular re-assessment of the benefit- Tajikistan and Turkmenistan met in evidence on health that is relevant to their risk balance of marketed medicines is being Ashgabat in Turkmenistan at the first specific country context and that can help carried out via submission of periodic high-level consultation on the prevention maximise the effectiveness, accessibility safety update reports (PSURs) for of malaria reintroduction. and resilience of their health systems. assessment by regulators. Member States The 50 participants unanimously: evaluated over 12,000 PSURs for purely The State of Health in the EU comprises nationally authorised medicines. In four components with the • recognised the need to sustain their addition, PRAC reviewed and finalised following timeline: political commitment and vigilance and over 900 assessments for centrally invest in strengthening health systems in 1. November 2016: publication of the authorised medicines, or for active order to control importation of malaria, “Health at a Glance: Europe 2016” substances found in both centrally and prevent re-establishment of local report prepared by the Organisation for nationally authorised medicines. Because transmission of the disease and rapidly Economic Co-operation and PSURs can lead to directly-binding contain any resurgence; Development (OECD) in cooperation with changes to product information this delivers • stressed the need to continue the Commission. The structure of this faster safety warnings to patients. collaborating across borders and mobilising report will be aligned to the objectives of resources to support countries in need; • The PRAC led 31 safety-related the 2014 Communication on and referrals. This type of review procedure effectiveness, accessibility and resilience allows assessment of the safety or of health systems. • called upon WHO/Europe to continue benefit-risk balance of a medicine or a supporting countries in their efforts. class of medicines by the PRAC leading 2. November 2017: a set of 28 individual The consultation was convened by the to a recommendation for a harmonised country health profiles developed by the WHO Regional Office for Europe in position across the EU. OECD and the European Observatory on Health Systems and Policies collaboration with the Government (Observatory) in cooperation with the of Turkmenistan.
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Country news The report is available at: http://www. to eat better and move more. This scheme hrb.ie/publications/hrb-publication/ will be taken into account during official Ireland: rates of alcoholic liver publications//710/ school inspections, while guidelines will be disease treble developed to provide more healthy meals in schools and nurseries. A report published in June by the Health England: Government publishes plan The scheme has though been criticised Research Board (HRB) in Ireland examines for action on childhood obesity by some public health organisations who national findings on the patterns and would have liked to have seen a ban on effects of alcohol consumption and how it On 18 August the UK government price-cutting promotions of junk food in is impacting Irish individuals and society. published a plan which it hopes will reduce supermarkets, as well as the promotion of According to Dr Deirdre Mongan, lead England’s rate of childhood obesity within unhealthy food to children in restaurants, author and Research Officer at the HRB, the next 10 years by encouraging industry cafes and takeaways. There were also calls the report “highlights that the rate of to cut the amount of sugar in food and for advertising restrictions of unhealthy food alcoholic liver disease trebled drinks and getting primary school children high in salt, fat and sugar to children during between 1995 and 2013. The fact the to eat more healthily and stay active. At a prime time television schedules when highest rate of increase was found UK wide level a soft drinks levy will be children may be watching popular television in 15 – 34 year olds is a real public health introduced. In England, the revenue from programmes such as reality talent shows concern as alcoholic liver disease usually the levy will be invested in programmes to and soaps. develops after a number of years of harmful reduce obesity and encourage physical drinking, and as a result it is normally seen activity and balanced diets for school age The plan can be viewed at: https://www.gov. in older people. However, these increases children. This includes doubling additional uk/government/publications/childhood- would reflect the high occurrence of physical education and sport premium obesity-a-plan-for-action harmful drinking patterns that have been funding that primary schools receive and observed in numerous Irish surveys over putting a further £10 million a year into the past decade.” school healthy breakfast clubs to give more Germany: Cabinet approves draft law on children a healthier start to their day. mental health service reform The report noted that in 2013, alcohol- Northern Ireland, Scotland and Wales will related discharges accounted for 160,211 make their own decisions on how to spend On 3 August the German Cabinet approved bed days in public hospitals, that is 3.6% of their share of the levy. a new law intended to improve the quality all bed days that year; compared to 56,264 of mental health services. The new bed days or 1.7% of the total number of Another key element of the plan is a measures abandon the previous intention bed days in 1995. €1.5 billion is the cost to voluntary structured sugar reduction to move to single set of national prices for the tax-payer for alcohol-related discharges programme to remove sugar from the mental health services. These prices will from hospital. That is equal to €1 for every products children eat most. All sectors of now be the subject of local negotiation. €10 spent on public health in 2012. This the food and drinks industry will be New requirements on minimum staffing excludes the cost of emergency cases, challenged to reduce overall sugar levels quality are also being set out. The GP visits, psychiatric admissions and across a range of products that contribute reimbursement system is also being alcohol treatment services. Moreover, to children’s sugar intakes by at least 20% reformed so that home treatments can, for an estimated 5,315 people registered by 2020, including a 5% reduction in year reimbursement purposes, be considered unemployed in November 2013 had lost one. This can be achieved through as a hospital service so as to promote their job due to alcohol use, while the cost reduction of sugar levels in products, continuity of care and encourage the of alcohol-related absenteeism was more reducing portion size or shifting purchasing provision of more services outside of the than €41 million in 2013. towards lower sugar alternatives. hospital setting. The new law will take effect It is not just what Irish people drink, but the To ensure that the achievement matches from 2017. way they drink that causes harm. In 2013 expectations, progress will be reviewed by More on the new law (in German) at: the HRB Alcohol Diary survey showed that Public Health England who will publish http://www.bmg.bund.de/ministerium/ more than 50% of Irish drinkers consumed interim reports on progress every six meldungen/2016/psychvvg-kabinett/faqs- alcohol in a harmful manner – too much months. This will include reviewing psychvvg.html alcohol in one sitting and more than the reductions achieved through analysis of recommended number of standard drinks sales and food composition data, along in a week. In 2012 Ireland had the fourth with plans for further reductions. If Additional materials supplied by: highest alcohol consumption level insufficient progress is made then the EuroHealthNet Office among 36 OECD countries after Estonia, government have said that they may take 67 rue de la Loi, B-1040 Brussels France and Lithuania. Current per capita addition steps to achieve the same aims. Tel: + 32 2 235 03 20 consumption is 21% higher than the Other steps include a new voluntary healthy Fax: + 32 2 235 03 39 Department of Health alcohol steering rating scheme for primary schools to Email: [email protected] group’s target which sets out to reduce per recognise and encourage their contribution capita consumption, from 11.0 litres of pure to preventing obesity by helping children alcohol per person to 9.1 litres.
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