HEALTH EQUITY-2020 PROJECT REDUCING HEALTH INEQUALITIES PREPARATION FOR REGIONAL ACTION PLANS
RESULTS OF NEEDS ASSESSMENT AND ACTION PLAN & THE ÉSZAK-ALFÖLD REGIONAL HEALTH INDUSTRY STRATEGY
ÉSZAK-ALFÖLD, HUNGARY
Authors: University of Debrecen
Szinapszis Kft.
15.11.2015
This document arises from the project HEALTH EQUITY-2020 which has received funding from the European Union, in the framework of the Health Programme.
Content Overview ...... 3 PART 1 WHAT DOES THE EVIDENCE for your region SAY? ...... 4 Introduction to Part 1 ...... 4 Phase 1 Carrying out the NEEDS ASSESSMENT ...... 5 1.1 Introduction ...... 5 1.2 Regional profile ...... 5 1.3 Socioeconomic inequalities in health ...... 6 1.4 Socioeconomic inequalities in health determinants ...... 7 Phase 2 Conducting a CAPACITY ASSESSMENT...... 13 Phase 3 Setting the potential ENTRY POINTS for action ...... 19 1.5 Setting priorities ...... 19 1.6 Choosing actions ...... 20 1.7 Translating actions into regional action plans ...... 21 Phase 4 The IMPACT ASSESSMENT ...... 22 1.8 Any other information related information to building your evidence-base ...... 23 PART 2 Action plan to TACKLE HEALTH INEQUALITIES ...... 24 Introduction to Part 2 ...... 24 Translating HE2020 actions into regional action plans ...... 24 2.1 Main questions to answer by an action plan ...... 24 2.2 Recommended key steps...... 25 2.3 Integrated planning ...... 26 2.4 Monitoring and evaluation of the implementation of the Action Plan ...... 26 2.5 Financial appraisal ...... 26 Action Plan ...... 27 2.6 General context ...... 27 2.7 List of partner organisations ...... 27 2.8 List of supporting documents ...... 28 2.9 Action Plan table ...... 29 2.10 Additional support ...... 32 PART 3 DEVELOPING THE ACTION PLAN: the process ...... 33 Introduction to Part 3 ...... 33 3.1 General overview of the process ...... 33 3.2 Using an evidence-based approach ...... 34 3.3 A community & intersectoral approach ...... 34 3.4 Building Support ...... 35 3.5 Typology of the region ...... 35 3.6 Challenges ...... 36 3.7 Validating the regional Action Plan – Integrated planning...... 36 3.8 Financing the Action Plan ...... 36 3.9 Benefits for the region, lessons learnt, good practices ...... 38 3.10 Cascade learning into other regions ...... 38 3.11 Annex – Information on the Regional Action Group...... 39
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Overview This report is summarizing the work of the regions in the framework of the Action Learning and Capacity Building programmes of the HealthEquity-2020 project. This document consists of 3 interrelated parts:
Part 1: Developing the regional action plan. What does the evidence say?
Part 1 summarises the work that has been done in relation to testing the HE2020 Toolkit. The regions went through on different phases to collect the necessary evidence providing step-by-step guidance in designing evidence-based action plans: (i) conducting a needs assessment, (ii) a capacity assessment, (iii) selecting entry points, (iv) carrying out an impact assessment. Based on the Toolkit this template helps the regions summarize the data and information collected during the process of assessing and addressing socioeconomic health inequalities.
Part 2: Regional Action Plan to tackle health inequalities
Part 2 is the main output of the work of the regions. The key activity of the HE2020 project is that participating regions prepare region-specific action plans that are evidence-based and are integrated with regional development plans & that have appraised financial options including ESIF. The provided information and template help develop the regional Action Plan.
Part 3: Developing the regional Action Pan: The process
The HE2020 Action Learning and Capacity building programmes put a strong emphasis on the process of learning, developing, and sharing. Part 3 helps thinking through the action planning process in the project and documenting it. It summarises the context in which the regional team works, the used approach, what has been achieved and how, as well as the opportunities and challenges encountered.
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PART 1 WHAT DOES THE EVIDENCE for your region SAY?
Introduction to Part 1 The aim of the HealthEquity-2020 project was to assist regions in Europe in drawing up evidence-based action plans to address socioeconomic health inequalities. Having an evidence-based approach is important as it provides a rational, rigorous, and systematic approach to: setting up interventions, designing policies, programmes, and projects. The rationale is that well-informed decisions will produce better outcomes.
A key product of the project is the HE2020 Toolkit providing step-by-step guidance in designing evidence based action plans: (i) conducting a needs assessment, (ii) a capacity assessment, (iii) selecting entry points, (iv) carrying an impact assessment. Following the Toolkit structure this template helps regions document the data and information collected during the course of the process of assessing and addressing socioeconomic health inequalities.
Regions are advised to fill in this template as much as possible with the information gathered and assessments made along the development of the project by testing the Toolkit. What is important is providing the best available evidence that can: (i) explain the health gaps between people and the corresponding socio-economic determinants leading to the inequalities; (ii) assess the capacities (existing/missing) to implement actions to address inequalities; (iii) show how the entry points for actions/policies or interventions were chosen; and (iv) assess the policy impact of the interventions chosen.
In practice this summary can serve as an annex to a regional Action Plan or any wider strategy. It can also be used by regions to (i) draw policy makers` attention to a policy issue; (ii) monitor policy implementation; and (iii) evaluate the outcomes of the interventions.
The full HE2020Toolkit is available at this link: https://survey.erasmusmc.nl/he2020/ Additional support for the completion of this template can be found at: http://wiki.euregio3.eu/display/HE2020EU10/Home
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Phase 1 Carrying out the NEEDS ASSESSMENT Assessing the magnitude and determinants of socioeconomic health inequalities
1.1 Introduction
[Insert here a short introduction on why a needs assessment was undertaken. Please describe the overall process: what methods and sources you used to obtain the data, how the data was edited or analysed, was there any action undertaken to improve data availability through conducting additional surveys or improving monitoring of data.]
Needs assessment was undertaken to measure the magnitude and determinants of socioeconomic health inequalities in Észak-Alföld region, Hungary. Different sources were used in this process, mainly Hungarian and international databases, such as Eurostat and OECD Health Data sources. Different publications from Hungarian public health researchers and annual reports of the Budgetary and Financial Department of the Hungarian Health Insurance Fund were also used during the Needs assessment.
1.2 Regional profile [Please provide a short description of the region. You can refer to aspects such as: population size and density, distribution of the population by age and gender, distribution of indicators of socioeconomic position, degree and distribution of urbanity.]
The Észak-Alföld region is located in the East of Hungary and includes three counties: Hajdu- Bihar, Jasz-Nagykun-Szolnok and Szabolcs-Szatmar-Bereg. The region shares external borders with Slovakia and Ukraine on the North and Romania on the East. This provides the possibility for interregional cross-border cooperation between key cities (e.g. Debrecen and Oradea). The Észak-Alföld Region is Hungary’s second largest region in terms of population and area, but population density is below the EU average. It also has a younger-than- average population compared to Hungarian standards. The Észak-Alföld region is among the poorest in the EU, with per capita GDP of 40% of the EU 27 average. The region has undergone significant development, but it still remains below the Hungarian average in terms of industrial production per capita. Lack of infrastructure hinders further development of economic potential in key sectors such as tourism. Research and development, particularly in the fields of life-sciences and innovative technologies are key areas for further development.
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Socioeconomic inequalities in health
Mortality and life-expectancy [Describe here the socioeconomic inequalities in mortality or life expectancy.]
The average life expectancy at birth is 74 years, it lags behind the indicators of the EU Member States in 2009. The region has the country’s second lowest life expectancy rate for both men (68.4 years) and women (77.3 years).
Hungary still ranks among the lowest in Europe with regard to life expectancy at birth, trailing the EU27 average by 5.1 years and the EU15 average by 6.3 years in 2009. Hungary - compared to Western European countries - has very high regional and social differences in mortality. There is multifaceted and complex relationship between the development of sub-regions and demographic characteristics of regions.
SOURCES: Guide to Health Gains from Structural Funds, http://www.healthgain.eu/casestudy/north- great-plain-hungary
Health during life [Also during life, health inequalities can exist. Describe them for a few of the main indicators such as disabilities, prevalence of certain chronic diseases and self-reported health.]
Aside from Hungary lagging behind the EU averages for many health indicators, the persisting geographical and social inequalities in health within Hungary itself are also a matter of concern. For instance, the gap between regions with the highest and lowest healthy life years was 8.1 years for men and 7.7 years for women in 2008. Unfortunately, reliable morbidity and mortality data are not available to describe the health status of the Roma minority but it can be assumed that their health status is considerably worse than the population average (Ádány, 2008). A recent survey comparing the health of people living in Roma settlements to that of the general population found that the self-reported health status of the former group was substantially worse than that of the latter. Moreover, the share of people who indicated that they felt they could do much to promote their own health was 13% to 15% lower among individuals living in Roma settlements than in the general population, also smoking and unhealthy eating habits were 1.5 to 3 times more prevalent than in the lowest income quartile of the general population (Kósa et al., 2007). The highest concentration of Roma in Hungary can be found in the region Northern Great Plain. Unemployment is much higher among this group than among ethnic Hungarians, and many live in slum conditions without running water or sewerage (Kósa, Daragó & Ádány, 2009). Infant mortality rates among the Roma are thought to be high, and life expectancy at birth is presumably far lower than for the rest of the population (Ádány, 2008). RESOURCES:
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Hungary - Health system review (Péter Gaál , Szabolcs Szigeti, Márton Csere, Matthew Gaskins, Dimitra Panteli) Health Systems in Transition Vol. 13 No. 5 2011
Ádány R (2008). A magyar lakosság egészségi állapota, különös tekintettel az ezredforduló utáni időszakra [The health status of the Hungarian population, with special reference to period after the turn of the millennium]. Népegészségügy [Public Health], 86(2):5–20.
Kósa Z et al. (2007). A comparative health survey of the inhabitants of Roma settlements in Hungary. American Journal of Public Health, 97(5):853–859.
Kósa K, Daragó L, Ádány R (2009). Environmental survey of segregated habitats of Roma in Hungary: a way to be empowering and reliable in minority research. European Journal of Public Health, 21(4):463–468.
1.3 Socioeconomic inequalities in health determinants Health behaviours [Describe the socioeconomic inequalities in health behaviours like: smoking, physical inactivity, alcohol consumption or diet.]
Communicable diseases play a subordinate role in Hungary, with the incidence and mortality rates for most childhood infectious diseases continuing to be lower than the EU12 average (WHO Regional Office for Europe, 2010) and the mortality rates for viral hepatitis and HIV remaining lower than the EU15 average (European Commission, 2011). Lifestyle factors – especially the traditionally unhealthy Hungarian diet, alcohol consumption and smoking – still play a very important role in shaping the overall health of the population. According to the European Health Interview Survey (EHIS) conducted in 2009, 21.5% of male respondents and 18.9% of female respondents reported that they were obese (BMI ≥30) and 39.4% and 31.1%, respectively, reported that they were overweight (BMI ≥25 and <30) (HCSO, 2010e). With a 12.5 litre per-capita consumption rate for pure alcohol in 2005 among individuals over the age of 15, Hungary ranked among the countries with the highest rate in the entire EU27. This statistic is backed up by the findings of the 2009 EHIS, in which 4.6% of those who completed the survey – 8.3% of all male and 1% of all female respondents – reported being heavy drinkers (HCSO, 2010e). The consumption of illegally distilled homemade spirits represents an additional risk factor for the development of alcohol- induced cirrhosis and may contribute to the high level of cirrhosis mortality in Hungary (Szucs et al., 2005). In 2009, an estimated 31.4% of the population in Hungary aged 15 years and above were regular daily smokers. Between 2000 and 2009, the share of daily smokers among both men and women decreased in all age groups except for people ≥65 years of age in the total population and for women aged 35 to 64 years. Importantly, the share of the heavy smokers (defined as someone who smokes 20 or more cigarettes per day) reportedly decreased from
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66% to 46% among men, and from 43% to 24% among women between 1994 and 2009 in those aged 15 to 64 years (HCSO, 2010e). In 2009 the death rate from causes related to alcohol and smoking was almost twice as high as the EU27 average and substantially higher than the EU12 average (WHO Regional Office for Europe, 2010).
RESOURCES:
WHO Regional Office for Europe (2010). European Health for All database (HFA-DB). Copenhagen, WHO Regional Office for Europe (http://www.euro.who. int/hfadb)
HCSO (2010e). Statisztikai tükör [Statistical mirror], 27 April, 4(50)
Hungary - Health system review (Péter Gaál , Szabolcs Szigeti, Márton Csere, Matthew Gaskins, Dimitra Panteli) Health Systems in Transition Vol. 13 No. 5 2011
Szucs S et al. (2005). Could the high level of cirrhosis in central and eastern Europe be due partly to the quality of alcohol consumed? An exploratory investigation. Addiction, 100(4):536–542.
Working & living conditions [Present inequalities in social conditions, such as social support and demand-control imbalance, as well as physical conditions, such as housing quality, traffic safety, and exposure to noise.]
We are convinced, that physical conditions, such as noise, traffic possibilities, safety, and housing conditions has a significant impact on health of persons. Health can be influenced also a wide range of housing factors. In Észak-Alföld region, most vulnerable and disadvantaged population are the Roma population. Considerable evidence supports the notion that adequate housing is related to health and that low quality of housing is associated with higher environmental risks and worse health status. The majority of Roma people in Észak-Alföld region have been experiencing great difficulties – among others – in terms of adequate housing due to the high costs of housing relative to their income and the low availability of social support of housing that results in considerably worse living conditions of Roma compared to the average for the country. Improve the quality of housing, traffic and safety should be the first marks on the long road to empower disadvantaged people to improve their health.
The European Statistics of Income and Living Condition (EU-SILC) survey regularly assesses the self-reported health status of the population in the EU. In 2008, 19.2% of respondents in
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Hungary reported that their health status was “bad” or “very bad”, compared to 9.5% in the EU27 as a whole. Conversely, the share of respondents reporting that their health status was “good” or “very good” was 55.2% in Hungary versus 68% in the EU27. There was a marked difference in self-reported health status between men and women in Hungary with 58.9% of men compared to 52% of women reporting that their health status was “good” or “very good” and 17% of men compared to 20.1% of women reporting that their health status was “bad” or “very bad” (European Commission, 2011).
RESOURCES:
Health impact assessment of Roma housing policies in Central and Eastern Europe: A comparative analysis (Ágnes Molnár, Balázs Ádám, Temenujka Antova, Lubos Bosak, Plamen Dimitrov, Hristina Mileva, Jarmila Pekarcikova, Ingrida Zurlyte, Gabriel Gulis, Róza Ádány, Karolina Kósa) Environmental Impact Assessment Review 33 (2012) 7–14
European Commission (2011). Eurostat, Luxembourg, European Commission (http://epp.eurostat.ec.europa.eu/portal/page/portal/eurostat/home)
Hungary - Health system review (Péter Gaál , Szabolcs Szigeti, Márton Csere, Matthew Gaskins, Dimitra Panteli) Health Systems in Transition Vol. 13 No. 5 2011
Access and use of health services [Describe inequalities in access to and use of health care and preventive services such as general practitioners, medical specialists, hospitals, dental care, screening, vaccination programs, and maternal and prenatal care. Consider both the geographical access as well as the financial barriers.]
The basic theoretical principles of the Hungarian healthcare system include accessibility, equality, full care, and ensuring gratuity. It is well known that the expenses of healthcare systems in developed countries grow faster and to a greater extent than the GDP of the particular country. The reasons for this include the dynamic improvement in technology, aging society and the increase in customer awareness and needs of the population. As a result, the sustainability of the healthcare system (while simultaneously ensuring the above principles) represents a significant issue in all countries. Thus, besides the publicly-funded care system, the role of publicly-financed care increases significantly everywhere. The financing of private care can take place in two ways: in all developed countries it appears either as a direct private expense or a savings account in the form of insurance or savings fund scheme. As in Hungary direct private financing dominates, one of the long-term objectives of this study is to assess the long-term opportunities for the development of private insurance in Hungary.
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The Hungarian healthcare system, which is primarily financed (although to a decreasing degree) by public central taxes and targeted contributions, is built on the principle of progressive healthcare. The objective of this is to provide care for the patients at the lowest possible level, where the conditions are already available for the needs of the patients based on their situation. This structure has its roots in the 70’s and its principles have remained unchanged in many respects. The healthcare system itself is based on the system of general practitioners which, depending on the size of the settlement, can be separated into primary care for adults and children. On this level the GP system is complemented by the district nurse system and primary dental care, occupational healthcare and in certain cases with special home care. These elements together make up the Hungarian primary care system and at the same time the first level of the healthcare system. The second level of healthcare is occupied by specialized care, with two different parts, outpatient and inpatient care. The specialized care of outpatients takes place in outpatient clinics, those patients are treated here whose care is not possible due to the lack of professional or technical criteria in primary care. The places for special care are the specialized patient care units operating in the hospitals. The treatment of inpatients takes place within the hospital system in such cases when the condition of patients does not make it possible to treat them as outpatients and/or if the type of care itself requires staying in hospital. The care for inpatients, and to a certain degree that of outpatients as well, can be divided into four levels depending on the level of progressivity: national, regional, county and basic level. On the national level only those special treatments are performed for which specialists, instrumentation and support services should be maintained only at a few places in the country, e.g.: transplantations, rare operations. On the regional level such rare diseases are treated or such rare or other treatments are provided where due to the limitation of professional skills and instrumentation, they are expedient to be installed only in case of the full utilization of instruments; e.g.: neurosurgery, oncology. The county level is a more complex place including almost all special areas, where they are capable of treating almost the full range of diseases. On the basic level¸ i.e. the level of city hospitals, they provide such treatments that are simpler but still require hospital care and which typically affect a lot of patients. On this level typically only a few basic professions are present, such as internal medicine and obstetrics. This organizational principle, of course, is affected by numerous factors, the strongest of which is the issue of financing. As the financing of primary care occurs mostly in the form of a capitation system based on population numbers, those working in primary care do not have an interest in providing final care on the given level. Thus the rate of consultations with specialists and forwarding of patients is really high resulting in the overloading of the middle level, i.e. outpatient care. (specialized outpatient care – very high patient numbers, German example – activity-based financing).
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Inpatient care has Diagnosis Related Group (DRG) based performance financing, which categorizes the same types of diseases into the same group and assigns one value, amount to them. Due to the fact that the budget is closed from the top, this DRG/HUF value is redistributed in the ratio of overall performance. The review of this system was ended and by now the real cost of certain medical procedures does not cover the level of expenses, while there can be such groups as well where due to the decrease of costs the particular treatment can be performed profitably (of course, there are very few of these). An additional basic feature of outpatient care is the performance volume limit. This specifies for a given institution how much the insurer will finance from a particular type of medical procedure. Thus it can happen that there are waiting lists at an institution as over X number of such procedures the insurer does not receive compensation. Thus it does not have an interest in the unlimited care of patients turning to it not even if there are available free capacities. Developed countries specify the structure and tasks of their healthcare systems through legislation. In Hungary, at the time of political transition, the use of healthcare services became subject to insurance coverage based on the obligation of paying contributions. Certain social groups were excluded and there were layers that were simply not included in terms of this obligation. In Hungary Act CLIV of 1997 on Health (Health Act) and Act LXXXIII of 1997 on Mandatory Health Insurance (Health Insurance Act) that fulfil this expectation supplemented and amended by numerous pieces of legislation (government and ministerial decrees).
Economic consequences of health inequalities
Labour related indicators [Describe here labour related consequences of health inequalities (ill health), such as labour participation, sickness leave, and labour productivity.]
In Észak-Alföld region there are several labour-productivity and standard-of-living measures that can be affected by improvements in the health of the labour force (like output per hour worked, output per paid labour hour, output per worker, output per labour force participant). Traditionally, human capital has been interpreted as education and skills. Nowadays, increasing attention has been given to health as a form of human capital. There are a growing awareness that interventions such as promoting healthy lifestyles and reducing stress can result reduced sickness-related absence and health-care costs.
Ill health was related to poor economic outcomes, including reduced labour participation, lower hourly wages, and receipt of more social benefits. Our estimates suggest that the economic impact of socioeconomic inequalities in health is likely to be substantial. While the
[North Great Plain, Hungary] 11 estimates of inequalities-related losses to health as a ‘capital good’ seem to be modest in relative terms, they are large in absolute terms. Just like an adequate level of education, a good health status enables people to engage in formal and informal labour activities and to be productive, and will, through its effects on the production of goods and services, indirectly contribute to people’s happiness or satisfaction.
SOURCE: Economic implications of socio-economic inequalities in health in the European Union (Prof. Dr. Johan (J.P.) Mackenbach, Dr. Willem Jan (W.J.) Meerding, Dr Anton (A.E.) Kunst) Health and Consumer Protection Directorate-General
Direct costs related indicators [Describe here costs of health inequalities (ill health), such as healthcare costs and costs of social security benefits.]
The framework of the financing of the Hungarian healthcare system is well reflected by the composition and cumulative figures of the Health Insurance Fund’s total revenues and expenses. In 2014 the total revenue of the Health Insurance Fund was HUF 1,907,078,423,000 (EUR 6,356,928,077). The total expenses of the Health Insurance Fund for 2014 were HUF 1,907,078,423,000 (EUR 6,356,928,077). Although in the last few years the expenses of the Health Insurance Fund grew in absolute terms, Hungarian healthcare is underfinanced in both absolute and relative terms. The tendency prevalent within the fifteen years between 1993 and 2008 indicates that even in the case of countries with more moderate economic potentials the annual average of growth of healthcare/public healthcare expenses exceeds the average rate of annual growth of GDP in percentage, meaning that the share of healthcare from the GDP continuously increases. Among OECD countries it is only in Hungary that the extent of healthcare expenses falls short of the scale of GDP which indicates the relative decrease in financing (OECD Health Data, OECD Publishing, Paris, 2010a). In Hungary the National Health Insurance Fund provides financing for the running expenses of healthcare providers which, however, does not cover amortization. In the case of healthcare providers, capital expenditure is covered by the owners. The financing of inpatient specialized care is also performance-based, built on the classification system of Diagnosis Related Groups (DRGs).
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Phase 2 Conducting a CAPACITY ASSESSMENT
Introduction [Please describe the overall process of conducting the capacity audit in your region (what data was used, did you conduct interviews, during what period of time?]
Different sources were used in this process, mainly Hungarian and international databases, such as Eurostat and OECD Health Data sources. Annual reports of the Budgetary and Financial Department of the Hungarian Health Insurance Fund were also used in creating Capacity assessment.
Findings [What are the findings with regards to the main domains of the capacity audit? Please refer to weaknesses as well as strengths and opportunities for development.]
The triple helix of the region is of indispensable importance, regarding both the entrepreneurial side and the role in employment, but the educational demand and the entrepreneurial supply should be better synchronized. The helix is build up from the cooperation of industrial, academic and state members. In the industrial field, there is the Pharmapolis Innovative Pharmaceutical Cluster, Pharmapolis Innovative Functional Food Cluster, Thermal Cluster, Silicon Field regional IT Cluster, and LENERG Building-Energy Cluster. In the academic part, the University of Debrecen plays a very significant role, and there is also the Institute of Nuclear Research of the Hungarian Academy of Sciences, the College of Nyíregyháza and the College of Szolnok. Regarding the state representatives, the Municipality of Debrecen, the Regional Development Agency, the Chamber of Industry and Commerce and the Regional Innovation Agency are crucial. Non-scientific stakeholders related to the biotech sector as a whole belong to several groups in accordance with the following: state organizations, government offices, local governments and local governmental institutes, professional associations, chambers, bridging organizations, grant intermediating organizations (including authorities involved in strategic planning). Among the non-governmental organizations the most important players are the large collective forum of state organizations and other undertakings, the chambers. These organizations form groups voluntarily, however in many cases the membership is compulsory and the advantages of this are primarily in the admission to closed communities and the acquaintance with the best practices as well as the application thereof in everyday practice. There are chambers for each profession in healthcare. Although commercial and industrial chambers are not considered as professional organizations, they coordinate a group of entrepreneurs (such as enterprises producing medical prostheses and surgical appliances, manufacturers integrating their research findings into their products). In recent years, in Hungary one of the major tools of national economic policy appeared, these are the corporate groups called clusters. With the cooperation of the University of Debrecen and Richter Gedeon Plc., the Pharmapolis Debrecen Innovative Pharmaceutical Cluster was
[North Great Plain, Hungary] 13 founded in 2008. This cluster has more than 26 members, including SMEs, spin off and start- up companies. The companies participating in the Pharmapolis Cluster perform their research and development activities in cooperation with the University of Debrecen and other research institutes and endeavor to establish a long-term strategic partnership. Other non-scientific organizations include investment supporting organizations, insurance companies, banks, and financial institutes. Identified, non-scientific stakeholders are JEREMIE fund managers, other venture capital companies and business angels. Small, dedicated biotech firms play an important role in almost all fields of biotech applications, especially in healthcare biotech. These small firms are mostly responsible for research and innovation, even though they often depend on external funding. In fact, as firms expand in size, typically they experience a decreasing number of discoveries. For large companies, many discoveries usually represent slight adaptations of existing products rather than the development of brand new ones. In contrast, usually truly inspirational ideas come from smaller dedicated firms located in the clusters. Consequently, it can be concluded that big industry is mostly dependent on small firms. Academic spin-offs are a particularly important type of new companies in the biotechnology sector and that these companies serve as the main vehicles for exploiting biotechnological research. The distribution of employees across different categories is an important criterion, especially when evaluating the total number of employees dedicated to R&D. Since SMEs are mostly involved in R&D and are responsible for the new jobs created, their role in economic development is pivotal. The Észak-Alföld Biotech Cluster was established in 2011 based on the initiative of small and medium-sized enterprises. The Cluster intends to provide better business conditions and opportunities for the SMEs operating in the biotech sector which is one of the main regional economic sectors.
Organizational development [You can talk about: organizational structures, policies and procedures/strategic directions, management support, recognition and reward systems, information systems, quality improvement systems, informal culture.]
Hungary has a great heritage in the health industry (thermal baths, education, pharma industry), although in the past few years tackling the emerging challenges has been in the centre. Traditionally, the Hungarian Health System is social insurance and solidarity based, even if there are some kind of shared responsibilities and functions of the local governments, the state system and the National Health Insurance Fund. However, the reorganization of the health system is happening nowadays, which builds on greater public engagement and the health industry in focus. For today, in Hungary almost all policies are carried out on a national level. Health services are organized on a regional basis. The ultimate goal is to make the regional work effectively enough so that patients could obtain the required level and quality of care and to give greater attention to the health industry, which has of strategic importance for the economic factors. Regions are also statistical regions and were originally established to coordinate developments better within the European Union. Észak-Alföld has great experience based on its research potential and its university in the biotech sector as a whole.
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Biotechnology is essentially relevant to pharmaceutical research and the manufacturing phase. In recent years, in Hungary one of the major tools of national economic policy included the appearance of corporate groups called clusters. The Pharmapolis Debrecen Innovative Pharmaceutical Cluster was established in 2008 with the cooperation of the University of Debrecen and Richter Gedeon Plc. This cluster has over 20 founding members including spin- of enterprises that settled down in the environment of the University.
Resource allocation [You can talk about: financial and human resources, time, access to information, specialist advice, decision making tools and models, administrative support, physical resources.]
There is a need for strengthening the established health and social care system, the development and extension of services available on the local level. These developments aim at the modernization of the services and infrastructural conditions of the institutions as well as the reduction of inequalities of access. The development of primary healthcare is crucial because this level of care must be capable to perform the basic health screenings and health checks and of effectively contributing to the strengthening of the health consciousness of the population. The infrastructural developments in healthcare can contribute to the increase of the number of healthy years of the population, restoration of the ability to work as soon as possible, and with the concentration of resources, to the improvement of the cost efficiency and quality of services. The primary health care of the population is provided by the General Practitioners in all settlements of the county. In the smaller villages primary care is provided on the basis of care contracts or, for example, night or weekend duty is performed by private businesses based on task performance contracts or it is provided simultaneously at several settlements through institutional management associations or district notaries. In 2010 there was some kind of outpatient care in 32 settlements of the county operating with regional task performance obligations. About 81% of the county’s total population could use these services at their own settlement, while in the past decade centralization characterized this area as well. In the period up to 2020 we have to prepare also for the challenges of the aging society, with the development of the related social and healthcare infrastructure as well as the services intertwined to healthcare and with that of primary care.
Workforce development [You can talk about: workforce learning, external courses, professional development opportunities, undergraduate/graduate degrees, professional support and supervision, performance management systems.]
The case of human resource in Hungarian healthcare is in deep crisis and the current system supports change only to a small extent. The human resource supply in the system is in a verifiably bad position. According to data published annually by the Migration and Monitoring Department of the Health Licensing Office1 the number of physicians emigrating
1 www.eekh.hu
[North Great Plain, Hungary] 15 increased continuously until 2011, since then a slow decrease can be seen. With regard to emigration among the other healthcare professionals (dentists, nurses, and pharmacists) the growth did not stop. In 2013 1,850 healthcare professionals left the country, half of them were physicians and one quarter were nurses2. If we consider that in Hungary only approximately 1,000 people get a medical degree annually then the negative trend is clearly visible. The aging society is also a growing problem all over Europe, including Hungary. Technological development can compensate the quantitative problems of human resources but only if the new professionals are appropriately trained with regard to the use of the new technologies. Although the smaller human resource originated by technological development can itself be questioned, for example, in case of imaging diagnostics, there has been exponential growth in the last years, still there is a need for the same number of radiologists as before. The decreased or missing motivation due to the overburdened, expensive and wasteful system is also a disadvantage. The role of clinics and hospitals has become stronger in this respect as local initiatives can turn this worrying trend more positive. The health faculties and clinics of the University of Debrecen have introduced personalized healthcare HR management several years ago. The system is capable to motivate the employees and can also maintain this level. It creates a career plan for everyone for the purposes of predictability; it is cost effective and pays attention to appropriate working conditions. Moreover it guarantees legal protection as well in the case of possible malpractice lawsuits.
Leadership [You can talk about: interpersonal skills, technical skills, personal qualities, strategic visioning, systems thinking, visioning of the future, organizational management.]
Several local and international studies have been published which clearly shed light to threats that can influence the building of successful companies from new enterprises in health industry, where the manager must be competent in several professions. Several programs provide qualifications in economics and finances as well as spread the innovation and management approach in Debrecen. There are two possible ways leading to the training of biomanagers: the financial (further) training of students and researchers interested in the business approach from the fields of medical and health sciences, life sciences, agricultural sciences, or the other way around, the health science education of people with qualifications in economics, finance. The former approach is generally accepted and can be realized more easily, it can be adapted successfully even with minor changes in the system. The knowledge of business should be integrated systematically in the above mentioned health industry- related study programs and all such self-motivated forms of education should be supported that aim to strengthen the business knowledge of the population. It was the need for the training of healthcare managers and their supply that resulted in the creation of the
2 http://www.vg.hu/vallalatok/egeszsegugy/itt-vannak-a-legfrissebb-migracios-adatok-420038
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Department of Health Systems Management and Quality Management for Healthcare at the Faculty of Public Health at the University of Debrecen in 20123. The aim of the training programs offered by the Department is to help professionals participating in the program to effectively meet the requirements they have to face in the public, business, governmental, and non-profit sectors as well. The health industry depends on all the actors in the triple or quadruple helix, thus from the regulatory bodies as well. The aim of the local government is to support, educate, and prioritize those managers in the organizational structure, who have management skills, international experience, and knowledge of foreign languages. It is the joint innovative education development program (supporting the development of the economy) of the Municipality of Debrecen and the University of Debrecen to establish a Healthcare Management Training Centre at the Faculty of Public Health and to provide the necessary conditions for it. The University of Debrecen, as the Research University and University of National Excellence of the Észak-Alföld region as well as that of the Észak- Magyarország twin region, has a clear social and professional policy responsibility with regard to providing future managers who are adequately qualified and have appropriate management competencies. With the establishment of the manager training centre, the framework is created for demand-based HR planning, system-level competence development, managerial talent management, management brand development, while the continuous expert support of managers and their further training also receives attention. The target groups of the training programs offered by the centre are the civil servants, public employees (healthcare, public and higher education) and the health industry sector. Besides this, the centre, in cooperation with the multinational companies, SMEs of the region, also provides internal training programs customized to the needs of the business sphere. Together with the management, it could provide continuous support for the managers and employees in the business/public sector with individual career planning and competence development, and with the involvement of managers it facilitates the harmonization of individual objectives with the organizational ones. It supports the process of talent management as a partner either through finding talents from the outside (recruiting) or with the identification and special training of hopeful talents within the company with the appropriate methodology. Besides all these, the Centre supports the definition of the company’s strategic objectives with a methodology based on scientific research findings as well as the completion of the processes related to management of changes in company culture necessary for the realization of the strategic objectives. The direct participation of TEVA Gyógyszeripari Zrt. in the educational program of the University of Debrecen is also a good example for the importance of the proper training among future professionals. There are two departments operating within the university with the support of TEVA; these are the External Pharmaceutical Industry Department (Faculty of Science) and the External Pharmaceutical Manufacturing Department (Department of
3 http://emmt.unideb.hu
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Pharmacy). The experts of TEVA also participate in the educational work of these external departments starting from elaborating the curriculum to teaching. Moreover, the practical experience of students is also strengthened by the company with visits to the factory, the modernization of the department’s infrastructure, and by providing summer internship positions. Specialists of TEVA are also open to work with graduating students as advisors to their theses. This relationship, however, has two sides: the specialists working at TEVA also apply to the doctoral school of the university, who this way can acquire a doctoral degree while contributing to the up-to-date range of programs of the doctoral schools with their practical experience. Those students graduating from the external departments can find a job more easily within the pharmaceutical industry, the majority is employed already before they receive their diploma.
Partnerships [You can talk about: shared goals, relationships, planning, implementation, evaluation, sustained outcomes.]
The lack of an adequate financial background, information sharing and adequate practical sector specific knowledge are the main obstacles of innovation, therefore the formation of an effective and supportive environment is indispensable. There is also a lack of innovation awareness, with a lack of cooperation. The sharing of innovation knowledge is not very common, although there are some good examples for joint R&D programs and research platforms. Involving an external advisor or mediator organization would help a lot in the whole process. Relevant intellectual property and technology transfer activities are required for the better exploitation of research results. Regional biotech companies do not really feel the need for management consultancy services; they try to solve these issues within the company. They rather need outside help in terms of patent issues. Those services which are to help map and build up potential relationships also aroused their interest. They would welcome opportunities which could take them to bigger partners. Therefore the development of an innovation system is a key, interconnecting the supply and demand side of innovation on the regional level, exploiting the potential local capacities. At present, the size of the companies – besides the time and money shortage - is the biggest hindrance in the prosperity of the companies (economies of scale) rather than the fact that they are not able to reach the potential companies, customers. In some cases they cannot afford the needed services due to financial limitations. Therefore, encouraging the involvement of venture capital and private equity, co-financing methods are essential. Companies do not use external help because they consider themselves too small to enter into it alone. They see several opportunities in the clusters. The co-operation with the members of the sector, relationship building may help getting into bigger projects or even participation in professional events can become easier. A supporting organization would give a great opportunity to organize information coming from different sources. The role of the University of Debrecen is prominent in the region’s innovation (among external research services used by the companies), and also the participation of the Hungarian Investment and Trade Agency, the Knowledge and Technology
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Transfer Office of the University and the Regional Innovation Agency (INNOVA). They provide information about different events and possibilities and give help in the realization of projects and research. Common research groups, projects were formed between the University and the companies, and this worked very well in providing help mutually. However, it is sometimes difficult to find the appropriate partner in research services. Regarding management consultancy services, companies try to solve these issues mainly themselves, employing indoor specialists, meanwhile other companies think that different financial, sales and HR tasks have to be handled within the company. Smaller companies think that outsiders cannot get involved in the operation of the company to such extent that they would be able to help. Contact building (possibilities, available services, and mediator organization) is considered to be one of the main business issues. The role of clusters is also very important (regarding common projects, cooperation, participation in conferences, representation), but clusters do not operate the same way in Hungary as abroad, they are more heterogeneous and have fewer members. Participating in an international biocluster would open up broader perspectives to the members.
Phase 3 Setting the potential ENTRY POINTS for action
1.4 Setting priorities [What are the health inequalities that raised concerns in your region? Why? How did you choose a/ between priorities? Explain it by taking into account factors like: impact, changeability, acceptability, resource feasibility. Talk about European regional priority setting! European Structural and Investment Funds are a potential source for funding actions but they also set up the political agenda in terms of developing priorities. Have you managed to relate your priorities set up for your region/country to the European level?]
In order to realize the sectoral and regional objectives included in the Hajdú-Bihar county Regional Development Concept, those priorities have been specified within which the particular measures (as developmental tools for the execution of the concept) will be implemented. Development priorities of Észak-Alföld region for 2014-2020: 1. Sustainable Environment 2. Complex Development of the County’s Agriculture 3. Competitive Economy 4. Improvement of Accessibility in Hajdú-Bihar County 5. Intelligent Society 6. Healthy and Caring Society 7. The Development of a Supportive Environment for Innovative Economy in Debrecen
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1.5 Choosing actions [What are the actions you can take to address this health inequality? Talk about the mechanism chosen! (e.g. (a) reducing the inequalities in socioeconomic position itself (education, income, or wealth); (b) improving health determinants prevalent among lower socioeconomic groups (living and working conditions, health behaviours, accessibility to and quality of health care and preventive services) ; (c) reducing the negative social and economic effects of ill health (school drop-out, lost job opportunities and reduced income) Talk about the strategy chosen: e.g. (a) a targeted approach; (b) a whole population approach; (c) a life-course perspective; (d) tackling wider social determinants of health. Have these interventions already been proved successful in reducing inequalities in other regions or studies?]
To address health inequalities we decided to improve health determinants prevalent among lower socioeconomic groups (living and working conditions, health behaviours, accessibility and quality of health care and preventive services). In order to achieve this, Faculty of Public Health at the University of Debrecen promote awareness, political commitment and action on the adverse social conditions (including poverty and social exclusion) that make certain groups (such as Roma and other ethnic minorities) vulnerable to ill health. Health status assessment among disadvantaged people is evaluated in a yearly basis. These assessments are also analysed by specialists of University of Debrecen Faculty of Public Health. According to these assessments, we are able to determine action that should be taken in order to reduce socioeconomic health inequalities.
Another key weakness and focus area in the Észak-Alföld region occurs in the regulatory framework. The biggest problem is the lack of capital in the diffusion of innovation. The overly rigid and inflexible legal background makes the system also very complicated. The regulatory framework and the business infrastructure can be characterized by the lack of structural solutions for authorities to address regulatory market and financial risks raised by new bio products, sometimes there are heavy administrative burdens too. The majority of research and development is conducted at universities or institutes and collaboration with the industry is limited. Therefore, the lack of entrepreneurial experience in public research institutes and administration is also a great obstacle of development. Regarding the financial background, it can be contested that the risk-sharing mechanism is not designed for entrepreneurs. The process for funding applications is relatively uncoordinated. There is a lack of business advice for start-ups. Venture capital investment is limited, there is only pre- seed funding. There are no available local financial sources for biotech companies, only national and international opportunities. Research is mainly related to higher education and public funds. The reasons behind this – which have to be changed - are the risk-averse culture in the financial and risk sharing structures, the lack of international culture and of entrepreneurship recognition and the lack of communication on role model entrepreneurs and on reward of their success. Therefore, knowledge and technology transfer platforms are welcomed. The availability of professional and business advice is increasing, but remains
[North Great Plain, Hungary] 20 expensive for most of the SMEs. Forming a supportive development environment is essential, where mediator organizations and adequate external advisors can play more explicit role. The importance of the innovative approach has to be understood by the companies, the public and the private sphere as well in practice, via workshops, good examples, municipal and governmental incentives. In order to create better funding, it is indispensable to better understand the needs of people. Development and service has to be offered for them, because as for today, they have and they provide most of the sources. Customers, clients, patients, we can call them in many different ways.
1.6 Translating actions into regional action plans [For the actions chosen did you think about? (a) the reach of the action (the intended target population)?, (b) effectiveness/ efficacy of the action (the desired effect of the action) ?; (c) who will adopt the action?; (d) who should implement the action? (e) what type of maintenance of the action was required?]
As part of the planning process we choose to define overall objectives and strategic objectives. We identified three overall and three strategic area objectives:
Overall objective 1 Economic development based on the natural features, traditions and research potential of Hajdú-Bihar county, which increases employment and strengthens the function of the county as the innovation centre of Eastern Hungary
Overall objective 2 The strengthening of service and administrative functions for reducing poverty and social exclusion and to increase the marketable skills of the working-age population
Overall objective 3 Effective water and energy management and the establishment and development of the conditions for sustainable environmental management in order to reduce the negative effects of climate change in the Northern-Great-Plain’s TransTisza region
Strategic area objective 1 Debrecen, the Vital City, as the capital of health and innovation in the Carpathian Basin
Strategic area objective 2 District centres and the district-level small towns as centres of cooperation for local communities
Strategic area objective 3
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Small settlements as the scenes of livable rural communities
Phase 4 The IMPACT ASSESSMENT Assessing the potential impact of actions on health and health inequalities
Screening [Is the policy/ intervention likely to impact health/ determinants of health considerably? Which populations are currently relatively disadvantaged in the context of this policy or intervention? Does the policy enhance equity or increase inequity? What might be the unintended consequences?] The intervention is likely to impact health determinants. We are able to determine action that should be taken in order to reduce socioeconomic health inequalities between the most vulnerable groups, like Roma population.
Scoping [Which health outcomes or determinants of health outcomes does this impact assessment focus on? How was it carried out (literature reviews, quantitative modelling, qualitative analysis- expert consultations, interviews, focus groups)? What evidence was used to show how the health equity impact was identified?]
University of Debrecen Faculty of Public Health have been participating many research programs, resulting many publications in this field. We are able to draw up evidence-based action plans to address socioeconomic health inequalities. After identifying problems and evaluation of the situation the first step of the actions clearly is realignment of vulnerable groups.
Impact assessment [Quantify or describe potential, important health and health equity impacts.]
With regard to the specific circumstances of the Észak-Alföld Region, the main characteristics are: population’s poor state of health (e.g. high number of people with disabilities, alcohol and drug problems), unsatisfactory health care (i.e. absence of prevention and protection centres, lack of rehabilitation institutions) and uneven territorial distribution of healthcare services. In order to address these difficulties the region needs to curb territorial imbalances and adjust health care services to local needs. Improving the institutional framework for rehabilitation and developing outpatient care are crucial to achieve these objectives. Evidence-based action plan to address socioeconomic health inequalities is also based on these main characteristics.
Decision making [Provide recommendations to improve policy (evidence-based, practical, realistic and
[North Great Plain, Hungary] 22 achievable measures that would reduce the negative and enhance the positive health equity impacts of the policy).]
Thanks to strong political support, the region is determined in focusing health inequality problems. For example during the design of operative programs regarding Hungary, Ministry of Human Resources continuously consulting with Hajdú Bihar County concerning health issues. In decision making process we tried to involve all actors which are able to influence and improve policies.
Monitoring & evaluation [Talk about: the process evaluation (Was the impact assessment carried out successfully? Were there challenges or barriers?); the impact evaluation (will the recommendations of the impact assessment be adopted/implemented?); the outcome evaluation (How will you know if health inequities have been reduced in real life?)]
Impact assessment and evaluation was necessary in order to get appropriate feedback. We experienced challenges in coordination and cooperation of all relevant actors.
1.7 Any other information related information to building your evidence-base [If you had any difficulties with regards to the data collection and interpretation, please describe it here.]
There were negligible number of difficulties regarding data collections and interpretation.
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PART 2 Action plan to TACKLE HEALTH INEQUALITIES
Introduction to Part 2 The key outputs of the Action Learning and Capacity Building programmes are the evidence- based regional Action Plans to address socioeconomic health inequalities.
There are many different types of action plans in practice: from simple to more complex. Ideally action plans are linked to a wider strategical plan and can be developed annually, biannually.
The HealthEquity-2020 project did not plan to introduce a particular action plan format as there are many factors in practice that can influence their particular design and content. The regions themselves are also differing in their priorities and objectives they want to focus on and achieve, their stakeholders and their institutional background, their political context, the mandate or role to be played as a strategic document for the region.
Nonetheless, this document aims to present the key characteristics of an action plan and provides some guidance on the most important elements that should be considered together with providing a simple template.
The regions are kindly asked to fill in this template based on their work, or use any other format that is also in line with the basic characteristics of an action plan and with the characteristics of their own local/national policy planning/action planning processes.
Whichever way the region chooses, the main point is to build the Action Plan on the data and knowledge gathered via the action learning process documented in Part 1.
Translating HE2020 actions into regional action plans
2.1 Main questions to answer by an action plan
An action plan is detailed plan related to a strategic document outlining:
1. What will be done (the steps or actions to be taken) and by whom (which organisation). 2. Time horizon: when will it be done (when the actions/steps will be done) 3. Resource allocation: what specific funds are available for specific activities.
In practice we can find various different kinds of documents that are called Action Plans with elements like vision, mission, aims, objectives, goals built on each other, and actions etc., but these documents are more likely should be considered as Strategies.
Within the HealthEquity-2020 project the idea was to look for (to develop) action plans to be integrated into regional development plans, national reform programmes etc. These
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Action Plans should be aligned to these existing strategical documents’ vision, mission, objectives etc.
2.2 Recommended key steps Considering the special context of the HE2020 project and the steps already taken as part of the HE2020 Actin Learning programme, the following key steps are recommended to be taken to finalize your regional Action Plan.
2.2.1 Bring together the different people/organizations/sectors to be involved in developing the Action Plan to get various views in the planning work. This group is ideally the Regional Action Group. While action planning can take place within single departments, organizations and sectors, the HealthEquity-2020 project encouraged cross-sectoral action planning.
2.2.2 Review your data and information that you have collected with the help of the Toolkit. Regions assessed the magnitude and determinants of health inequalities in their region by conducting a needs assessment, assessed the capacities, formulated entry points, and some of them have taken to the impact assessment phase. Please review what you have learned about health inequalities, and what capacities you have to tackle that. Examine again the selected priorities based on the data, and the possible actions by which you can address the assessed inequalities. Critically evaluate the chosen strategy to tackle the problem. If data exist evaluate the potential impact of possible actions on health and health inequalities.
This information and careful analysis should provide the background and basis of your action plan; it is going to be the so called evidence-base of the Action Plan.
2.2.3 Develop the action plan by
3.1 Presenting the general context under which the action plan was developed. a) Explain why actions are needed, make a reference to the evidence collected by briefly summarizing the results of the health inequality assessment (key considerations, why these priorities/objectives have been selected) b) Briefly explain how this plan was developed c) Explain how the action plan fits within or linked to a wider development strategy or other document(s) (Operational Program/National Reform/Health or Social Strategy etc.)
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3.2 Filling in the action plan table by identifying a) the key actions of the priority area/identified objective (you can also chose to prioritize actions if you want to bring focus on certain issues (essential; high; medium; low) b) the output/deliverable of the action c) the responsible parties d) other parties to involve e) the timeline f) key outcome indicators to measure success g) financial resources.
3.3 Listing the partner organisations contributing to the development of the Action Plan
3.4 Listing the supporting documents as annexes of the action plan (e.g. a more detailed review of the determinants of socioeconomic health inequalities in your region).
2.3 Integrated planning A key element in the HealthEquity-2020 project is that the developed Action Plans should be integrated into regional development plans. Please describe in the General context to which regional or national strategical document your Action Plan can be linked to and how.
2.4 Monitoring and evaluation of the implementation of the Action Plan Monitoring and evaluation is a key to demonstrate the results achieved to policy makers/ policy entrepreneurs/ decision makers/supporters/stakeholders and to generate financial or political/institutional support further on during/after the implementation stages of the action plan. However, building a monitoring and evaluation system requires special expertise, thus here you can focus only on listing a few key indicators measuring outcomes.
2.5 Financial appraisal Getting financed the action plan is crucial for implementation. HE2020 puts an emphasis on the use of the European Structural and Investment Funds (ESIF) as an important source of funding for actions related to the inequalities area.
Please make a financial appraisal. A few points for consideration:
- What are the funds available for your region? - Consult the Operational Program(s) that cover your region. Can you make a match with its priorities that can support the Action Plan? Are you eligible to apply for funding?
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- Can you build synergies/partnerships with your stakeholders, officials, industry representatives and NGOs from your Regional Action Group to increase your profile? - When the Calls for Proposals are organized and how does that fit with the implementation stages of the Action Plan? - Funds are allocated to those projects that can demonstrate their ability to achieve the results in a measurable way relevant to the priorities mentioned in the Operational Programs. Can the evidence you collected in your assessments support this approach? - Other sources of funding might also be available at national/regional level or within other frameworks (regional, national, or other international funds e.g. the Norwegian Grant). Have you considered them?
Action Plan
2.6 General context [Please (i) Explain why actions are needed, (ii) Make a reference to the evidence collected by briefly summarizing the results of the health inequality assessment (key considerations, why these priorities/objectives have been selected), (iii) Briefly explain how this plan was developed, (iv) Explain how the Action Plan fits within or linked to a wider development strategy or other document(s) (Operational Program/National Reform/Health or Social Strategy etc.)]
Hajdú-Bihar county is to preserve its natural values by 2020 and building on the cooperation, capabilities, and traditions of local communities, it will be a liveable, sustainable, balanced, rural environment with quality life available for its population and utilizing the beneficial effects of the position of Debrecen as the health centre of the Carpathian Basin and the competitive centre for innovation on the economy and jobs.
2.7 List of partner organisations [Please list the partner organisations contributing to the development of the Action Plan.]
Pharmaceutical Industry SMEs in medical devices, medical appliances and (including eHealth, mHealth) Healthcare service providers (Clinical Centre of the University of Debrecen, Kenézy Gyula Hospital and Outpatient Clinic) Medical Tourism providers Biotech companies Functional and healthy food companies Bioinformatics companies
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2.8 List of supporting documents [Please list the supporting documents as annexes of the action plan (e.g. a more detailed review of the determinants of socioeconomic health inequalities in your region).]
Health Industry strategy for 2014-2020, Debrecen
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2.9 Action Plan table Others to Output/ Responsible involve to Actions Timeline Indicators Financial resources Deliverables party complete action
Priority area/Objective
Overall objective 1 growing municipalities, university 2020 numbers of re- government resources, EU Economic development based employment educational employed funds, on the natural features, rate centers citizens traditions and research reduction of potential of Hajdú-Bihar unemployement county, which increases rate (relative employment and strengthens and absolute) the function of the county as the innovation centre of Eastern Hungary
Overall objective 2 organizing educational university 2020 numbers of government resources, EU The strengthening of service trainings centers education, funds and administrative functions vocational for reducing poverty and social trainings, exclusion and to increase the number of marketable skills of the participants working-age population
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Overall objective 3 water and municipalities infrastructural 2020 water and government resources, EU Effective water and energy energy providers energy funds management and the management management establishment and feasibility report feasibility report development of the conditions for sustainable environmental management in order to reduce the negative effects of climate change in the Northern-Great-Plain region
Strategic area objective 1 capital of health municipalities university 2020 capital of health government resources, Debrecen, the Vital City, as the and innovation and innovation local tenders capital of health and report report innovation in the Carpathian Basin
Strategic area objective 2 specific needs municipalities, university 2020 local survey government resources District centres and the assessment research results district-level small towns as among the organizations centres of cooperation for local citizens communities
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Others to Output/ Responsible involve to Actions Timeline Indicators Financial resources Deliverables party complete action
Priority area/Objective
Strategic area objective 3 liveable rural municipalities 2020 liveable rural government resources, Small settlements as the scenes communities communities local tenders of liveable rural communities report, surveys report
Please add further rows as necessary.
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2.10 Additional support Additional support for different types and models of action plans can be found on the HE2020 Wiki Page under the section “Action Plans Examples”. These documents can be used as a source of inspiration and adapted according to the needs of the regions. http://wiki.euregio3.eu/display/HE2020EU10/Action+Plans+Examples
Regions can also consult other sources or documentation on action planning like: http://ctb.ku.edu/en/table-of-contents/structure/strategic-planning https://www.hitpages.com/doc/6289108800372736/1 http://www.open.edu/openlearnworks/mod/oucontent/view.php?id=53774§ion=1.4 ]
For further information you can also consult:
The HE2020 Policy Matrix link at HE2020 wiki
The Regional Development Agency in your region: http://ec.europa.eu/regional_policy/index.cfm/en/atlas/managing-authorities
A large database with successful projects available for review for the past period that can serve as inspiration: http://ec.europa.eu/regional_policy/projects/stories/index_en.cfm
Other potentially relevant websites: http://ec.europa.eu/regional_policy/en/checklist/ http://ec.europa.eu/regional_policy/en/atlas/ http://ec.europa.eu/health/health_structural_funds/used_for_health/index_en.htm http://www.esifforhealth.eu/ http://fundsforhealth.eu/
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PART 3 DEVELOPING THE ACTION PLAN: the process
Introduction to Part 3 Regions have different starting points in the action planning process and they also have region-specific development scenarios depending on their organizational background, institutional, political, and cultural context. The regions differ in their policy making processes, problem perceptions, and problem solving practices, as well as they work with various stakeholders.
This template helps thinking through the action planning process in the project and helps documenting it. It summarises the context in which the regional team works, the used approach, what has been achieved and how, as well as the opportunities and challenges encountered.
3.1 General overview of the process [Please describe the overall process of developing the action plan throughout the HE2020 project. Please define the context. How the process has started? Have you had dealt with the topic of health equity before within your region/country (in a direct or indirect way)? Have you built your work in the project on any earlier regional work/developments related to the inequities field? Have health/health equity/social determinants of health issues had been on the discussion table of policy makers before? How did this have an effect on the general process of developing the Action Plan as part of the project?]
University of Debrecen Faculty of Public Health together with the Municipality of Debrecen are very enthusiastic in reducing socioeconomic health inequalities, regarding the city of Debrecen as well as the Észak-Alföld region. Special program of Faculty of Public Health aims at catching up underprivileged citizens (e.g. Roma population) regarding health status assessments and health conditions. In 2012 WHO has designated the Department of Preventive Medicine in the Faculty of Public Health, at the University of Debrecen, Hungary, as a WHO Collaborating Centre on Vulnerability and Health. Life expectancy among marginalized Roma communities is considerably lower than the average for the WHO European Region. The Centre will promote awareness, political commitment and action on the adverse social conditions (including poverty and social exclusion) that make certain groups (such as Roma and other ethnic minorities) vulnerable to ill health. Health status assessment among disadvantaged people is evaluated in a yearly basis. These assessments are also analysed by a specialist of University of Debrecen Faculty of Public Health. According to these assessments, we are able to determine action that should be taken in order to reduce socioeconomic health inequalities.
[Észak-Alföld, Hungary] 33
Faculty of Public Health have been participating many research programs according to these evaluations, resulting many publications in this field. We are able to draw up evidence-based action plans to address socioeconomic health inequalities. After identifying problems and evaluation of the situation the first step of the actions clearly is realignment of vulnerable groups.
3.2 Using an evidence-based approach [How much does evidence usually matter in decision making? Are strategies usually evidence-based in your region? Were there enough available (regional) data on health status, social determinants of health to conduct the necessary needs assessments for designing this action plan? Have you managed to build your Action Plan on the collected evidence? To what extent did the evidence gathered influenced: setting the priorities; choosing actions and interventions?]
According to the assessments mentioned in previous section, we are able to determine action that should be taken in order to reduce socioeconomic health inequalities. Evidence- based researches have been conducted like “A comparative health survey of the inhabitants of Roma settlements in Hungary” by Karolina Kósa, “Studying vulnerable populations: lessons from the Roma minority” by Karolina Kósa and Róza Ádány.
City of Debrecen is engaged in reducing health inequalities among underprivileged people. Revision of previous health status assessment reports is currently in progress.
3.3 A community & intersectoral approach [Health inequalities is a cross-cutting issue. In dealing with health inequalities, it is important to implement a community/intersectoral approach to develop action. For this reason regions were encouraged to set up a Regional Action Group with stakeholders from various sectors/organizations who either directly or indirectly are dealing with the inequity problem. Please describe how you managed to set up the Regional Action Group. Please list the member organisations of your RAG in the Annex of this part of the document. Have you had already used an intersectoral approach before? Is this something that is part of your institutional/working culture or quite the opposite? If it was not possible to set up a Regional Action Group, please explain why not (e.g. no interest or support, reluctance in sharing information or competencies).]
Regional Health Council has been working, but their work is discontinued. There is no other organization which is able to take over its role and activities. HealthEquity 2020 project drew attention to the need of the reorganization of such institution.
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European Union grants allocation is interpreted locally, that means there are different operative programs. In Észak Alföld region regional development operative program is coordinated by Hajdú-Bihar County. The region is determined in focusing health inequality problems.
3.4 Building Support [How would you describe the political/institutional support that you have received during your pursuit of developing an action plan to tackle health equity (either in the framework of a RAG discussed above or in any other forms)? Have key decision-making bodies (municipalities, local/regional governments, Ministry of Health, other professional bodies at the health and social field, European Structural and Investment Funds Managing Authorities, etc.) been involved in drafting/adopting/implementing the action plan? Have they been supportive?]
As mentioned in previous section European Union grants allocation is interpreted locally. Regional development operative program is coordinated by Hajdú-Bihar County. Thanks to strong political support, the region is engaged focusing on health inequality problems. During the design of operative programs regarding Hungary, Ministry of Human Resources continuously consulting with Hajdú-Bihar County concerning health issues (e.g. which operative problems should focus on inpatient and outpatient care).
Regional organizations are constantly consulting with Ministry of Human Resources and Medical Chambers and managing authorities. Solutions for health conditions problems are made locally. Regional cooperation between these institutions is necessary in order to get funding from operative programs.
3.5 Typology of the region [The characteristics of a region can have a strong influence on the process of developing an action plan at the local level. Is your region only an administrative/statistical reporting unit or an autonomous region with higher competences in designing policies at local level? What are the opportunities usually to develop actions for health/health equity at a regional level? ]
The Észak-Alföld regional development operative program is coordinated by Hajdú-Bihar County. By comparing regions in Hungary Észak-Alföld is the least developed region and has the worst indicators in health issues. The region has a better competence in realizing problems concerning health inequalities. Thanks to strong political support, the region is engaged focusing on health inequality problems.
[Észak-Alföld, Hungary] 35
3.6 Challenges [Describe the major challenges you encountered in the process of attaining your goals during the course of the action learning process (e.g. changes within the institutional context, lack of support from higher level authorities, weak collaboration or partnership with others sectors/stakeholders, lack of data to make the case of health inequalities, lack of financing or capacities to take forward actions)?]
There might be two major challenges in the process of attaining our regions’ goal.
Challenge 1: Regional Health Council is abolished. There is a need for a same organization in order to coordinate cooperation between the actors of the region and the country.
Challenge 2: Vulnerable groups, disadvantaged people are hard to reach therefore it is complicated to ensure their participation. This results many inadequate assessments.
3.7 Validating the regional Action Plan – Integrated planning [One guarantee of successful implementation of actions is taking an integrated approach by incorporating specific, health inequality focused action plans into wider regional and/or national development plans in order to promote and ensure synergies in decision making and funding. This means that higher-level decision-making processes can validate regional plans. However, getting those priorities integrated into a regional or even a national planning cycle is one of the biggest challenges in this work. What preparations have you made through your RAG or any other way to have the Action Plan join a more powerful process (regional planning, regional masterplan, national reform programme, etc.) or what opportunities exist for this?]
Partners participating in the implementation of our action plan should be involved in planning processes, commentaries, and research. University of Debrecen Faculty of Public Health is ready to participate in these activities and to disseminate outcomes in local, regional and national level.
3.8 Financing the Action Plan [Do you think you (your region) have enough knowledge about using European Structural and Investment Funds (ESIF) in your own country? How do you get the information? If no, why? What investment opportunities have been identified for your region under ESIF? Are health/health equity issues compatible with them? Or are any of them health related? Have your region had any opportunities to influence the drafting of the Operational Programs or the overall programming process?
[Észak-Alföld, Hungary] 36
What about your stakeholders? Do you have the possibility/competences/know- how/resources to access this type of funding? If you think about the financial aspect of the developed action pan, what future actions are you planning to take to finance it? What resources do you have available for implementing the Action Plan? What resources do you think will be available in the future? Is there an opportunity to fund the Action Plan from ESIF? Please add into details that are not explained in the Action Plan.]
Észak-Alföld region has access to knowledge about using European Structural and Investment Funds. There are several regional development agencies that help the appropriate use of funds. Recently formed organization of the Municipality of Debrecen is named EDC Debrecen Urban and Economic Development Centre. The centre’s aim is to help the region in using European Structural and Investment Funds. The EDC also designs comments and influences the drafting for Operational Programs.
Municipality of Debrecen is the centre of the region. The city designed a Health Industry Strategy for 2014-2020, determining actions and financing opportunities for actions. These actions have also a huge regional impact.
[Észak-Alföld, Hungary] 37
3.9 Benefits for the region, lessons learnt, good practices [What do you think are the major achievements of your planning process? What main lessons your team learned during the course of developing/adopting the action plan? What are the main influencing factors and drivers for your success? What good practices or recommendations would you like to share with other regions? What helped you overcome some of your challenges, problems?]
While developing the action plan made the chance to realize HealthEquity 2020 project was a great opportunity to examine our region potential. We also had the chance to get an insight to other European regions planning processes. We discovered that there is a room for improvement. In order to achieve our goals we need to make policy makers and universities cooperate, because problems just can be identified and solved together.
3.10 Cascade learning into other regions [On of the objectives of HE2020 project is to cascade learning from HE2020 project into other regions. Have you managed to share your learning and experiences from the project with other regions (in your own country or with any other regions in the EU)? How important do you think for your region is to build working relationships nationally or internationally with other regions in order to exchange experiences and learn from each other?]
Due to the HealthEquity 2020 project we had the chance to participate in a work based on knowledge-sharing. We are ready to participate in similar project in the future as partner instiution. We experienced there is professional expertise by HealthEquity 2020 partners in different health related fields that we understand as a good practice we could use and apply.
[Észak-Alföld, Hungary] 38
3.11 Annex – Information on the Regional Action Group Official name of the group:
List of member organisations of the Regional Action Group
1. Municipality of Debrecen 2. Clinical Centre of University of Debrecen 3. University of Debrecen
[Any other information concerning the work of the RAG (e.g. working method, who is coordinating the group, responsibilities etc.)]
Clinical Centre of University of Debrecen is responsible for coordinating the group.
[Észak-Alföld, Hungary] 39
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