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European Quarterly of the European Observatory on Health Systems and Policies EUROHEALTHon Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS European Health Forum Gastein 2019

• Changing the DNA of health care in the • Co-creating policies to tackle

› 2019

A healthy dose of age of Artificial Intelligence obesity |

disruption? • Health innovation: from organisation • Empowering communities to disruption to outcomes value reduce health inequalities

Transformative • Facts. Figures! Fiction? • The global climate crisis: a public Number 3

health emergency change for health and • Transforming financial markets for the good of all • Interview with the European

societal well-being Commissioner for Health :: Special Issue :: Volume 25 EUROHEALTH

Quarterly of the European Observatory on Health Systems and Policies Eurostation (Office 07C020) Place Victor Horta / Victor Hortaplein, 40 / 10 1060 Brussels, Belgium T: +32 2 524 9240 List of Contributors F: +32 2 525 0936 Vytenis Andriukaitis w DG Sante, European Willy Palm w European Observatory on Health Systems Email: [email protected] Commission, Belgium and Policies, Belgium http://www.healthobservatory.eu Clemens Martin Auer w European Health Forum Clare Payne w The University of Melbourne and SENIOR EDITORIAL TEAM Gastein, Austria Tobacco Free Portfolios, Australia Sherry Merkur: +44 20 7955 6194 [email protected] Sherria Ayuandini w University of Amsterdam, Aaron Reeves w Department of Social Policy and David McDaid: +44 20 7955 6381 [email protected] the Netherlands Intervention, University of Oxford, United Kingdom Gemma Williams: + 44 20 7107 5304 [email protected] Ben Barr w Institute of Population Health Sciences, Tanith Rose w Institute of Population Health Sciences, University of Liverpool, United Kingdom University of Liverpool, United Kingdom EDITORIAL ADVISOR Willy Palm: [email protected] Jan-Philipp Beck w EIT Health, Germany Rachel Stancliffe w The Centre for Sustainable Healthcare Chris Brown w World Health Organization European FOUNDING EDITOR Office for Investment for Health and Development, David Stuckler w Department of Social and Political Elias Mossialos: [email protected] Italy Science and Dondena Research Centre, Bocconi University, Italy LSE Health, London School of Economics Jonathan Cylus w European Observatory on Health and Political Science Systems and Policies, United Kingdom Aleksandra Torbica w Department of Social and Political Science, Bocconi University, Italy Houghton Street, London WC2A 2AE, United Kingdom Stefan Eichwalder w Federal Ministry of Labour, Social T: +44 20 7955 6840 Affairs, Health and Consumer Protection, Austria Sarah Thomson w World Health Organization Barcelona F: +44 20 7955 6803 Office, Spain Tamás Evetovits w World Health Organization Barcelona http://www2.lse.ac.uk/LSEHealthAndSocialCare/ Office, Spain Liisa-Maria Voipio-Pulkki w Ministry of Social Affairs aboutUs/LSEHealth/home.aspx and Health, Finland Josep Figueras w European Observatory on Health EDITORIAL ADVISORY BOARD Systems and Policies, Belgium Yuxi Wang w Department of Social and Political Science, Bocconi University, Italy Paul Belcher, Reinhard Busse, Josep Figueras, Scott L. Greer w Department of Health Management Julian Le Grand, Willy Palm, Suszy Lessof, Martin McKee, and Policy, School of Public Health, University of Matthias Wismar w European Observatory on Health Elias Mossialos, Richard B. Saltman, Sarah Thomson Michigan, United States of America Systems and Policies, Belgium

DESIGN EDITOR Johanna Hanefeld w London School of Hygiene Lin Yang w World Health Organization, United States Steve Still: [email protected] & Tropical Medicine, United Kingdom of America Noora Heinonen w Ministry of Finance, Finland PRODUCTION MANAGER Dorli Kahr-Gottlieb w European Health Forum Gastein, Jonathan North: [email protected] Austria CONTENTS SUBSCRIPTIONS MANAGER Stephen K. Klasko w Thomas Jefferson University and Caroline White: [email protected] Jefferson Health, United States of America Knut-Inge Klepp w Norwegian Institute of Public Health, Article Submission Guidelines Norway Available at: http://tinyurl.com/eurohealth Pasi Korhonen w Permanent Representation of Finland Eurohealth is a quarterly publication that provides a forum to the EU, Belgium for researchers, experts and policymakers to express Robert Madelin w Fipra International, Belgium; their views on health policy issues and so contribute Royal College of Physicians of London and to a constructive debate in Europe and beyond. University of Oxford, United Kingdom

The views expressed in Eurohealth are those of the authors Martin McKee w London School of Hygiene & Tropical alone and not necessarily those of the European Observatory Medicine and European Observatory on Health Systems on Health Systems and Policies or any of its partners or and Policies, United Kingdom sponsors. Articles are independently commissioned by the Rachel Melsom w Tobacco Free Portfolios and editors or submitted by authors for consideration. Worthing Hospital, United Kingdom Pasi Mustonen w Permanent Representation of Finland The Observatory is a partnership, hosted by WHO/ to the EU, Belgium Europe, which includes other international organizations (the European Commission, the World Bank); national Margot Neveux w World Obesity Federation, and regional governments (Austria, Belgium, Finland, United Kingdom Ireland, Norway, Slovenia, Spain, Sweden, Switzerland, the United Kingdom and the Veneto Region of Italy); other health system organizations (the French National Union of Health Insurance Funds (UNCAM), the Health Foundation); and academia (the London School of Economics and Political Science (LSE) and the London School of Hygiene & Tropical Medicine (LSHTM)).The Observatory has a secretariat in Brussels and it has hubs in London at LSE and LSHTM) and at the Berlin University of Technology..

© WHO on behalf of European Observatory on Health Systems and Policies 2019. No part of this publication Cartoons in this issue are by Comic House/Floris Oudshoorn may be copied, reproduced, stored in a retrieval system or transmitted in any form without prior permission. Eurohealth is available online at: http://www.euro.who.int/en/about-us/partners/observatory/publications/eurohealth and in hard-copy format. If you want to be alerted when a new publication goes online, please sign up to the Observatory e-bulletin: Design and Production: Steve Still http://www.euro.who.int/en/home/projects/observatory/publications/e-bulletins

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Back issues of Eurohealth are available at: http://www.lse.ac.uk/lsehealthandsocialcare/publications/eurohealth/eurohealth.aspx EUROHEALTH Quarterly of the European Observatory on Health Systems and Policies and Systems Health on Observatory European the of Quarterly societal well-being change for health and Transformative disruption? › A healthy dose of • • • •

the Transforming financial markets for Facts. Figures! Facts. Fiction? disruption to outcomes value innovation:Health from organisation age of Artificial age Intelligence of Artificial Changing the DNA of health care in the

good of all Eur opean on Healt h Sy stem s andP oli cies European Health Forum Gastein 2019 Gastein Forum Health European • • • •

Commissioner for Health with Interview the European health health emergency The global climate crisis: a public reduce health inequalities Empowering communities to obesity policiesCo-creating to tackle RESEARCH • DEBATE • POLICY • NEWS • POLICY • DEBATE • RESEARCH

:: Special Issue :: Volume 25 | Number 3 | 2019 © Gasteinertal Tourismus GmbH CONTENTS 19 16 12 9 5 2 26 23 Systems for change change for Systems innovation Disrupting Issue Special Gastein Future formulas Future

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True change happens outside the comfort zone Our European Health Forum Gastein (EHFG) 2019 conference on “A healthy dose of disruption? Transformative change for health and societal well-being” aims to raise questions which may be uncomfortable to ask, yet need to be addressed if we truly want to counter deadlocks in health systems and move forward.

On the road towards 2030, with the Sustainable exasperated when it comes to issues such as vaccine Development Goals shining a guiding light, we are hesitancy, the nursing crisis or medicine shortages, to at a stalemate in many respects. The EHFG 2019 name but a few examples. While the current system sessions and related articles in this year’s Special might not be broken, it features some severe cracks Eurohealth Gastein edition highlight different and is failing to address many of the most pressing examples of transformative change, some more and issues of our time, with severe implications for health some less disruptive. We invite you to explore key and societal well-being. Clearly, transformative themes related to system change and innovation: change is needed. Now, change comes in many what is disruption? And what can disruption look like forms and with many labels attached. It can come beyond the field of technology and the concept of from within or outside a system, be gradual or abrupt, digitalisation? How do we make sure that in an area be wanted or unasked for. In all cases, the process as vital as health, the human touch is not lost in a swirl of systems change is complex and challenging. To of efficiency and innovation? What can we learn from get us thinking about how complex systems change climate change movements like Fridays for Future or may be cultivated and supported, we will explore Extinction Rebellion, and what part does the health the concept of the Two Loops model at the EHFG, sector play when addressing the climate crisis? which helps to illustrate why old systems may decline and new systems emerge (see overleaf, Box 1).2 An At the EHFG, we are used to lively discussions opening opinion piece in this issue ‘Changing the around the annual main theme in the run up to each DNA of Health Care in the Age of Artificial Intelligence’

EDITORIAL conference. This year, however, we were intrigued by our keynote speaker Stephen Klasko gets us to about just how much room for debate there was, further reflect on how disruptive and transformative

both on the terminology and the moral uncertainties change may occur in health systems specifically. surrounding our theme of disruption. The ambivalent concept of disruption has a promising note to it We then invite you to dive deeper and explore the for some and inspires apprehension and fear in four different EHFG 2019 topic tracks. Clayton M. others. It has by no means a universally accepted Christensen, Professor at the Harvard Business definition, or agreement on whether and in what School, has famously coined the term “disruptive context it is desirable. There is equally no consensus innovation”.3 He maintains that disruption is a process, on whether the more tech-oriented approaches not a product, and uses the analogy of the automobile we know from other sectors are transferable to to make his point clear: the invention of the car was health–an area where the general rules of market not disruptive, because it was a mere luxury good economies do not and should not hold. not able to destroy the market for horse-drawn vehicles. However, when Ford introduced assembly In many areas, the health of Europeans has stagnated, line production and made the car affordable to many, positive trends are reversing, and stalemates are this had a disruptive impact, destroying an old market hardening.1 Decision-makers and citizens alike are

2 Wheatley M, Frieze D. Using Emergence to Take Social Innovation to Scale. The Berkana Institute, 2006. Available at: https://margaretwheatley.com/ articles/using-emergence.pdf 1 OECD/EU. Health at a Glance: Europe 2018: State of Health in the EU Cycle. Paris: OECD Publishing, 2018. Available at: https://ec.europa.eu/health/sites/ 3 Christensen Institute. Disruptive innovations web page. Available at: https:// health/files/state/docs/2018_healthatglance_rep_en.pdf www.christenseninstitute.org/disruptive-innovations/ GUEST

Eurohealth — Vol.25 | No.3 | 2019 Guest Editorial 3

and creating a new one.4 Are we witnessing this kind of disruption With this agenda, we do not aim to answer the question of in health? Should we promote it? The first track on “Disrupting what “true” disruption is. We rather invite you to reflect with innovation” spans topics related to the digital future of health us on the discussions and questions we encountered during care, including Artificial Intelligence (AI), the use and safety of the formation and refinement of the EHFG 2019. Can we, as (Big) Data, and new health care technologies such as cell or part of the same system, be true disruptors, or does disruption gene therapies. A scene setter for this track and touching on always come from an external source? If so, how do we open many of the relevant concerns, from data quality to pushing the the door to usher in a healthy dose of disruption? We hope to reset button on traditional professional profiles, is the article provide you with a lens through which we, as individuals, patients by Jan-Philipp Beck, ‘Are we ready for AI? Why innovation and professionals, as family members and representatives of in tech needs to be matched by investment in people’. institutions, can look at change and rethink the status quo.

This leads us straight to the next thematic block of the EHFG The final Eurohealth Monitoring section of this issue reflects 2019, “Systems for change”, which addresses the oft- on recent European Health Policy. Here, Scott L Greer likens bemoaned slowness of health care systems and the attached Article 168 of the Treaty on the Functioning of the European institutional and political machinery. What could a more Union to a gate with no fence that may appear to provide agile system look like, and how much is cautious diligence obstacles to the development of EU health policy, but can required to ensure prudent decisions? Topics gathered in this instead be ‘opened’ when Member States choose. We are track discuss themes ranging from the optimisation of health delighted to conclude with a farewell interview with Health system governance to cross-national disease preparedness, Commissioner Andriukaitis who reflects on his mandate including the challenges posed by shortages of medicines as European Health and Food Safety Commissioner and or misinformation. The article on fake news – ‘Facts. Figures! provides his thoughts on the future. Enjoy reading about Fiction?’ – by McKee et al., offers a great read on the latter topic. this and much more in the 7th Gastein edition of Eurohealth!

The third track aims to reflect the spirit of a new era for European policymaking in health and beyond, with the appointment of a new EU Commission and new leadership in the World Health Organization Regional Office for Europe. Under the heading Clemens Martin Auer, of “Future formulas”, sessions will be run on a multitude President, of topics, be it the changing power relations between global European Health Forum Gastein industrial players and public actors, or policy design for the advancement of societal well-being. In this track, we challenge you to reflect on what needs to be done and what we want to fight for. A good example of one of the opportunities available to us can be found in an article by Melsom and Payne on ‘Transforming financial markets for the good of all’.

Finally, we want to discuss “Transforming societies”. Dorli Kahr-Gottlieb, As professionals working on health topics, our conference Secretary General, participants and Eurohealth readers will be acutely aware of European Health Forum Gastein just how much health is determined by what happens outside the health sector. This is the reason for the final EHFG 2019 track that aspires to shed light on the societal aspects of copyright: Framez health, with our closing plenary focusing on the climate crisis. From topics like alcohol policies to HIV responses and health literacy, we hope that you will join us in looking at both the Cite this as: Eurohealth 2019; 25(3). structural aspects as well as the personal experiences that make all the difference between simply being and well-being. The important issue of financial hardship incurred by health care is discussed in an article by Thomson et al., asking us to reflect honestly: ‘Can people afford to pay for health care?’

4 The Encyclopedia of Human-Computer Interaction, 2nd Ed. Disruptive innovation web page. Available at: https://www.interaction-design.org/literature/book/the-encyclopedia-of-human- computer-interaction-2nd-ed/disruptive-innovation

Eurohealth — Vol.25 | No.3 | 2019 4 Guest Editorial

Box 1: The Two Loops theory of systems change

It can be difficult to have the bigger picture in mind when making Accordingly, if we want to ease the way for change and help decisions, and systems change is the poster child for just how alternatives prosper from within a community, Wheatley and complex life can get. There have been many attempts to illustrate Frieze identified four components as crucial: systems change in a way that is accessible to our minds, 1. “Name” – recognise pioneers with experiences that are of hearts and business ideas, and which grasps the essence of value to others how transformation happens and how it can be cultivated and 2. “Connect” – make these proponents of the alternative solution nurtured. Among these theories we find the Two Loops model, aware of each other as developed by Margaret Wheatley, Deborah Frieze and others, during their time together at The Berkana Institute. 3. “Nourish” – create the conditions for these individual agents of change to exchange knowledge, learnings and practices The very basis for the Two Loops model is the idea that when a 4. “Illuminate” – make the network visible to itself, going beyond previously dominant system goes into decline, it leaves room for the act of connecting autonomous pioneers, and instead an alternative system to develop. This alternative system is not inviting in a broader community. purposefully constructed but emerges from a growing network of pioneers – proponents of the alternative approach – that become From these actions, a new system may emerge, featuring aware of each other and connect. These local and yet isolated capabilities and capacities that were never found in its hotspots of change spring up while the dominant system is still component parts. In the field of health and healthcare, have we in its prime, and only gain momentum when combined. The witnessed developments in line with the theory proposed above? process of transition from one system to the next is rocky and What will the next big systems change be? These issues and unsettling, for while the new system has not yet reached stability, more will be discussed at the EHFG 2019. the old one is no longer able to fulfil its purpose and a gap emerges that needs to be filled.

Graphic illustrating the Two loops theory

Eurohealth — Vol.25 | No.3 | 2019 Gastein Special Issue 5

IS THERE AN AVATAR IN THE HOUSE? CHANGING THE DNA OF HEALTH CARE IN THE AGE OF ARTIFICIAL INTELLIGENCE

By: Stephen K. Klasko

Summary: Health care is going through a once-in-a-lifetime change that presents an opportunity to make it friendly, equitable and focused on health assurance – if the industry and its leaders embrace transformation. With his extensive experience in medical education, universities and hospital system management, Stephen Klasko has written about change as a good thing for the consumers of care. Transformation can bring “understanding,” not just transparency – understanding both potential costs, and potential outcomes. The author argues that inequities in care apply across numerous nations, where access to care remains difficult despite national differences PIECE

in payment systems.

Keywords: Artificial Intelligence, Disruption, Health Disparities, Social Determinants of Health, Patient Experience

Background 2) Doctors seem to not do well with change and often seem to “want to leave In 1978, when I was a senior medical the status quo as it is.” How do we get student, I was asked to lead a panel about physicians to be more optimistic about what concerned me regarding the future the future? of medicine, as someone who was just starting my career. There were three issues 3) My bank just got an ATM. Why can’t OPINION that I highlighted through my oblivious, health care do cool consumer things naïve, and idealistic lens, but remember, like that? > #EHFG2019 – Opening Plenary: this was 1978: A healthy dose of disruption? Forty-one years later, after delivering 1) There seems to be a huge issue with over 2000 babies and countless numbers of health inequities globally, whether surgeries, and having been the dean of two that is by zip code in Philadelphia, Stephen K. Klasko is President and different medical schools and now leading or between socioeconomic classes in CEO, Thomas Jefferson University one of the fastest growing academic and Jefferson Health, Philadelphia, Asia or southern Africa. Why can’t medical centres in the United States, I am United States of America. Email: we address them? [email protected] sad to say that on the panels I am asked to serve, the same questions come up when

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I’m asked: As a CEO, what concerns you picture” 3 and again it won’t be painful. computers to iPods and digital instruments about the future of health? I am sadder to And this is not just an American (we change the industry) and, with the say that these would be my three answers: problem. I was honoured to serve as the iPhone and iTunes store, he started the American representative for the Centre for global mobile revolution (we change 1) There seems to be a huge issue with Progressive Policy evaluating the current the world). health inequities globally, whether and future state of the National Health that is by zip code in Philadelphia, Service in the United Kingdom. Some Not everyone understood the strategy both or between socioeconomic classes in of the same geometric limitations were within and outside the company. Much has Asia or southern Africa. Why can’t we exhibited there: Access is guaranteed, been written about Gateway (missing the address them? but quality, cost, social determinants and digital computer revolution), Blockbuster 2) Doctors seem to not do well with change patient experience are in need of a healthy (missing the streaming revolution even and burnout is a huge issue globally as dose of disruption. though they initiated it), Kodak (missing physicians feel “incapable” of doing the the digital camera revolution because they work they set out to do. How do we get Is this an insolvable problem? Is health wanted to sell film), or traditional retail physicians to be more optimistic about care doomed to be the global exception megastores underestimating the Amazon the future? to the consumer revolution? I don’t think revolution. so, and I believe that we can look to other 3) Why can I do my holiday shopping in industries to chart a global path. Which brings us to health care. I believe my pyjamas binge-watching Netflix, we are going through a once in a lifetime but if I have a stomach ache I still have disruption from a business-to-business to get on the phone and listen to 11 model to a business-to-consumer model. options to get an appointment three days From physician and administrator as the from now? look to boss to the person-patient as the boss. In other words, a radically new kind of health The reason we haven’t solved any of these other industries experience that actually works as simply three concerns may not be as elusive as and easily as most of our other consumer you think. One of my mentors when I to chart a experiences. And this new model is so was receiving my MBA at the Wharton different from the old one, we can’t even School was William Kissick, MD, DrPH. global path call it health care. That label is too tied to He wrote a book 25 years ago that spelled the past, and isn’t even correct in the first it out. The book was called Medicine’s Disruption in practice place. Anyone in the health care industry Dilemmas: Infinite Needs, Finite The answer became clearer to me as I will tell you that we’re really in a “sick Resources. 1 My interpretation of his book presided over my last commencement care” industry designed primarily to take is summed up by his view of the “iron where John Sculley, former CEO of care of people only after they develop triangle” of access, quality and cost. If Apple, received an honorary degree from health problems. you remember your ninth-grade geometry ‘‘ Thomas Jefferson University. He talked classes, you can only increase one angle about the “business plan” that Steve Jobs I propose a new term that captures if you decrease another. So, if you want to set for Apple at a time when the computer the spirit of what’s developing: health increase access, you have to increase cost industry was stagnating. While Sculley assurance. It is being developed further in or decrease quality, etc. You can change was expecting a consultant-driven, a book I am writing with Hemant Taneja, the geometry only if you are willing to glossy 60 page strategic and financial plan, one of the leading entrepreneurs in Silicon disrupt the system, and disruption is the entire three-year blueprint for strategic Valley, who had previously written a book painful. He once told me, “if anyone says action was on a single page … actually called “Unscaled.” 4 That book highlighted they are going to expand access to all and half a page: companies that disrupted otherwise stale it’s not going to be disruptive or painful, industries: AirBNB, Stripe and Livongo. they are advertently or inadvertently Year 1: We change In our new book we reference easy access skirting the truth.” So, in my country, the Year 2: We change the industry to services and technology aimed at landmark Affordable Care Act (ACA) bill, ensuring we stay well, so we need as little was heralded with this quote, “We are Year 3: We change the world “sick care” as possible. going to increase access for all, increase quality and decrease cost … and it’s not Steve Jobs recognised that the consumer In my role at Jefferson Health, which going to be painful.” 2 computer world was going through a once now encompasses more than 30,000 in a lifetime change from a desktop/laptop colleagues, 14 hospitals, multiple urgent Our current President has promised industry to a digital lifestyle industry. care centres, 100,000 virtual patient visits, that his alternative plan will provide He disrupted how the company selected, we have a simple mission: We improve “health care for everyone and take care paid and motivated their employees lives. Our vision calls for us to meet the of everybody much better than they’re (we change), he diverted dollars from needs of patients to consume their health taken care of now; it will be a beautiful development of PowerBooks and desktop care in the flexible manner in which they

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Figure 1: The patient diamond health care interactions will be at home or unsustainability of health care inequities remote, involving AI or machine cognition and policies that do not address those applications. issues, and the ageing of the millennial generation. Why millennials? Because The iron triangle of cost, access and there is little chance that in the one-click quality (hospital/physician centric) will world in which they were born and grew be replaced by a patient diamond of health up, that they will accept the archaic assurance: namely an ability to thrive and service we provide in health care. There is not have health get in the way, to connect even less chance they will deal with long and have human health relationships when waits in the waiting room, non-transparent needed, to easily navigate one’s own health costs and outcomes and the inability to care on their own terms, and the ability track and manage their own health in to understand options, cost and outcomes the way they have taken over their own (see Figure 1). shopping, travel and every other aspect of their consumer life. That consumer What about the human health care driven disruption will accelerate the provider in the middle of all this? Just pace of change in how health is delivered Source: authors’ own as Steve Jobs recognised he could not globally to the point where our current rebuild Apple with IBM designers, hospital centric construct will seem as consume every other consumer good, and we cannot continue to select medical archaic as having to get money by going to redefine Jefferson Health based on our students based on science GPA (Grade to a bank. The result of this revolution was care and caring rather than our location. Point Average) scores, multiple choice highlighted in my 2018 book, Bless This tests and organic chemistry grades and Mess: A Picture Story of Healthcare. 5 So how do we get from here to there … “hope” that physicians will become more and yes it will be disruptive … and it may empathetic, communicative and creative. “Changing the industry” starts to look like be painful (for some). Or to put it another The ability to choose students based this: Jefferson will offer a subscription way “What would Steve Jobs do?” in an on self-awareness, empathy, cultural service to a technology-plus-human combo industry where technology has advanced competence and communication skills is package that becomes a new first layer of light years for individual patients, but the only way to ensure that the “human in health care, a kind of pre-primary care. health care delivery, patient experience the middle” (provider) is providing value You sign up with Jefferson’s service and and social determinants are still in the to the “human at the centre” of their health give it access to your data, both static data pre-computer age. Well let’s go back to care, the person/patient. It also means (DNA) and real-time data (heart rate from his simple business plan. we need to fundamentally transform the your Apple Watch, sleep patterns from an medical school experience with a heavy app, etc.). The AI gets a baseline of your dose of humanities, population health, health and then watches and learns from quality improvement, communication your patterns. The technology is running we are skills, collaborative negotiations and social in the background, constantly keeping determinants becoming a much larger part an eye on your health. If the AI spots going through a of the curriculum. something unusual, you’re not sleeping, your heart rate is up, or some other once in a lifetime At Jefferson, we are moving from a combination of events, it might send a text two-tiered system (basic and clinical asking some basic questions. Your answers disruption science) to a four-tiered curriculum (basic at first go to an AI bot, and perhaps you science, clinical science, health systems/ figure out that not much is wrong, you’re YEAR 1: WE CHANGE population health science and innovation/ just stressed about a big decision at work. creativity). Also, we have to recognise But if the AI suspects something more, it Technology, AI and genomics will that even though it took us many years to sends the dialogue to a human doctor at fundamentally transform how and where think about interprofessional education Jefferson, a doctor who has enough time to health care is provided. I believe that between doctors and nurses, soon we will talk to you because the AI is taking over by 2020,‘‘ it will be commonplace to need to develop “inter-sentient education” some of the low-level work that used to provide real time genomic-based decision models between humans and non-sentient suck up the doctor’s day. The doctor can support at the time of prescription writing. AI robots! then get on a video call and do a deeper I further believe that by 2022, 20% of exploration. the population with chronic conditions YEAR 2: WE CHANGE THE INDUSTRY will be relying solely or in large part on What that means to us in the health virtual health assistants for wellness and It’s fair to assume that in the next few care ecosystem is as big a change as management. By 2025, 40% of all health years, the “Category Five” disruption moving from being a computer engineer care will be delivered virtually, and leading to these changes will be the to creating digital solutions to complex by 2027, for the first time, the majority of ever-rising global cost of health care, the problems. For one, payment models will

Eurohealth — Vol.25 | No.3 | 2019 8 Gastein Special Issue

reflect these disruptions. The writer just to develop the new MRI or robotic to spark this revolution, we need a call to Upton Sinclair once said, “It’s hard to surgical arm, but to understand what action, not dissimilar to that of climate get someone to understand something populations need to prevent childhood change. The future demands that we take a when their salary depends upon them obesity, eradicate smoking, prevent drug no-limits approach to ensuring that every not understanding it.” 6 In this very near abuse and overuse of opioids, create a individual on the planet has an opportunity future, we will be paid based on quality, clean environment and in essence take a to enjoy a healthy life. And those of us cost, patient experience and outcomes; no limits approach to noncommunicable choosing health care as a profession need hospital stays will be commoditised; our diseases? It is a future where health a new Hippocratic oath that our role is to doctors and nurses will coexist (hopefully policy, population health and personalised work with each individual and population cooperate) with deep learning, machine medicine converge, a future I wrote about as a team to ensure a healthy life for all. cognition entities; we will select and in my 2017 book, We CAN Fix Healthcare, 8 educate humans to be better humans the Future Is Now! References than the robots, not better robots than the robots; and population health, predictive The answer is difficult but not impossible. 1 Kissick W. Medicine’s Dilemmas: Infinite Needs analytics and social determinants will Take food deserts for example. In the Versus Finite Resources. New Haven, CT: Yale University Press, 1994. move to the mainstream of medical past, in low socioeconomic areas in many education and clinical care. countries, food choice meant a market 2 President Obama’s weekly address, 6 June 2009. within walking distance, which often Available at: https://obamawhitehouse.archives.gov/ realitycheck/blog/2009/06/05/weekly-address- And it will not be one technology. We offered highly processed, high sodium, president-obama-calls-real-health-care-reform have to stop talking about “telehealth,” for unhealthy products. But today, with 3 example. We don’t get up in the morning drone shipping technology and healthy Jackson H. 6 Promises Trump has Made About Health Care. Politico, 13 March 2017. Available at: and say “I think I’m going to telebank!” food being farmed and cultivated, a https://www.politico.com/story/2017/03/trump- It’s just that banking has moved from 90% combination of forward-thinking health obamacare-promises-236021 being in the bank to 90% happening at policy and mega-company philanthropy 4 Taneja H, Maney K. Unscaled. Hachette Book home. At Jefferson, we call this disruption, could change that. What if those in Group, 2018. “health care with no address.” government assistance food programs 5 could receive significantly more dollars if Klasko S, Bonner CO, Hoad M. Bless This Mess: A Picture Story of Healthcare in America. Jefferson they agreed to serve their family healthy YEAR 3: WE CHANGE THE WORLD University Press, 2018. food? What if the big tech companies 6 This is the most important part of the pooled their philanthropic efforts for those Sinclair U, Gregory J. I, Candidate For Governor. University of California Press, 1934. strategic plan and the one that will require programs to provide free or near-free the most innovation and discussion. I was delivery? The return on investment from 7 Magnan S. Social Determinants of Health 101 incredibly encouraged as a participant in the decrease of noncommunicable diseases for Health Care: Five Plus Five. NAM Perspectives. Discussion Paper. Washington, DC: National the World Economic Forum at Davos this alone could easily eclipse the initial cost Academy of Medicine, 2017. doi: 10.31478/201710. year by how much attention is being paid and would lead to population health Available at: https://nam.edu/social-determinants-of- to technology as a solution for the social moving from an academic exercise to a health-101-for-health-care-five-plus-five/

and economic determinants of health. It is health policy reality. 8 Klasko S, Shea G, Hoad M. We CAN Fix Healthcare: unacceptable, based on our understanding The 12 Disruptors That Will Create Transformation. of social determinants, that all the money The future is bright and limitless New Rochelle, NY: Mary Ann Liebert Inc. Publishers, we spend on medical care only accounts 2017. for 20% of a person’s health outcomes. 7 As an obstetrician, every baby I deliver Food, education, housing, prevention of should have unlimited potential. That hope chronic conditions, climate change ARE depends on a revolution, not from health health care! They were only an academic care reform to health care transformation, exercise in our former “sick-care” model but to non-incremental health care where the centre of the universe was the disruption. When the ACA was becoming hospital. In the new “health assurance law in the US, I had an opportunity to model” they become THE most important meet with one of its architects. He asked determinant for the team, patients and me what I thought about health care providers. Health care policy, health care reform in America. I answered the way I incentives and salaries are tied to creating answer any expectant mother that asks me an environment that works to prevent what to expect in labour and the birth of chronic conditions starting at home. their baby. I say, “It’s going to be long, it’s going to be painful … and you probably This will be the real test for AI engineers, really won’t know how well you did for technology entrepreneurs and the health about 21 years.” 5 What is true, in both care ecosystem. Can we marshal the cases, is the result is game-changing and trillions of dollars spent in health care not the future is bright and limitless! In order

Eurohealth — Vol.25 | No.3 | 2019 Disrupting innovation 9

ARE WE READY FOR AI? WHY INNOVATION IN TECH NEEDS TO BE MATCHED BY INVESTMENT IN PEOPLE

By: Jan-Philipp Beck

Summary: Artificial Intelligence (AI) promises to deliver transformative impact on health care settings over the next decade. But the health sector faces significant organisational challenges in keeping pace with this fast-moving technology. This article explores some of the very human factors in the implementation of AI and the role of policy in translating improved data into improved care.

Keywords: Artificial Intelligence, Digital Literacy, Health Care Professionals

Introduction changes will need to be made to our systems, operations and infrastructure to AI is perhaps the most divisive issue in keep pace? After all, this technology is health care today. To some, it heralds a entirely dependent on human expertise if shimmering, data-driven future – one it is to realise its potential in health care. in which decisions are made with ever- We may be witnessing exponential growth increasing confidence, and health care is in AI, but let’s not forget that human made ever more accessible. For others, intelligence is also a major growth area; AI highlights deep-seated concerns in the context of an ageing population about the erosion of traditional roles, its and ever greater demands on health implications for data storage, and clinical care systems, McKinsey expects to see accountability. 1 These understandable continued, sustained growth in health care anxieties are rooted in a complex mix of employment. 3 ethics, public trust or simply a very human fear of being out of a job. Ultimately, This growing group of professionals will however, these concerns add up to a simple not be made up of AI ‘users’. Instead, practical question: is health care ready these people will be gatekeepers, for AI? evaluating emerging technology, making sense of its findings and translating them In many networks, as in EIT Health 1, we into real-world benefits for patients. 3 A > #EHFG2019 – Forum 11: see the breakneck pace of innovation in new, data-literate clinician will not emerge AI: It’s not (just) about the technology! AI first-hand (see Box 1). But what about overnight, however. We need investment in the human half of the equation? What people and processes to match investment in the technology itself. This technology Jan-Philipp Beck is CEO, EIT 1 EIT Health is a network that brings together the brightest Health, Munich, Germany. Email: minds from the worlds of business, research and education to will require significant changes to the way [email protected] answer some of our biggest health challenges. EIT Health is supported by the EIT, a body of the European Union.

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people are organised, trained and perhaps in care. Health care professionals are suggestion about how the clinicians of the even the way they identify themselves as able to access individualised feedback, future are trained. The Academy debunked professionals. drawn from metrics from across a health claims that the presence of AI in retinal system – which can improve care while scans and targeted radiotherapy would A culture playing catch-up? reducing costs. reduce the need for medical specialists. Chair of the academy, Professor Carrie We have witnessed a sea change in digital Dr Ahmad is optimistic about overcoming MacEwan, remarked that – if anything – technology in recent years. Advances in some of the infrastructural barriers to the opposite is true, and that AI makes the cloud computing, processing power and adoption. “The conventional wisdom case “for training more doctors in data increasingly sophisticated algorithms is that our hospitals are burdened with science as well as medicine”. 5 have accelerated human decision-making legacy systems, and that our resource- in health care. 3 And yet, just as data constrained public health care will lag As the director of policy at the European legislation in the wider world lags behind behind other industries, but I disagree,” Medical Students’ Association (EMSA), its use in social media, there is a danger he explains. “I see that both frontline Lina Mosch sees a clear appetite for that we in health care will remain on the practitioners and national policymakers exactly this kind of training in the back foot. A major concern from the health are now seeing innovation as a necessity clinicians of tomorrow. A recent EMSA care community is that the regulatory rather than a luxury. If the top and bottom survey 6 found that more than half of environment – particularly in terms of are on board, it may take a little longer for medical students consider their eHealth information governance – is simply not yet management structures to roll out aspects literacy either ‘very poor’, ‘poor’ or ready for these advances. like data sharing agreements, payment ‘acceptable’. Moreover, 85% would like to structures for AI related services and see more eHealth content in the medical open, interoperable systems – but things curriculum. “We identified a huge gap, are changing.” 2 or lag between the lack of awareness of A data- these technologies and the willingness He believes the pitch to concerned of future health care professionals to be literate clinician professionals should hinge on Dr Eric key players in the digitalisation of health Topol’s3 assertion that automation gives care,” Ms Mosch explains.4 “And it’s will not emerge doctors back the ‘gift of time’, and in an also a generational question – health care evidenced common-sense presentation professional organisations on a European overnight of the benefits of these technologies. The level are not really dealing with this topic rate-limiting step, however, sits beyond in-depth. But without a holistic approach, Meanwhile, inconsistent quality of data any individual clinician or setting, Dr it’s not possible to cope with the disruptive means the machines are primed and Ahmad believes. “If Europe wishes to potential of AI.” She notes that only two hungry for information, but we may not continue to keep up in this race, we need European medical associations have know how to feed them. 3 Perhaps most to come to an agreement on sharing data published policies on digital health or importantly, these technologies require a at scale, safely but quickly,” he says. “It’s education. It’s a gap that not only stands shift in‘‘ mindset on the part of clinicians. time to turn the policy and plans into pilots in contrast to students’ appetite for greater A recent opinion piece published by the and partnerships on the ground.” knowledge, but also to a broader structural American Medical Association describes need for a reshaping of clinical roles. the ‘black box’ nature of a technology An intelligent approach to training that generates insights via non-traditional, Health care professionals will likely unobservable methods – which in itself The overwhelming consensus is that become more patient-centric and may be a barrier for uptake by health care only significant and holistic training will relationship-focused as AI absorbs more of professionals. 1 There’s also a perception adequately prepare clinicians (and by the routine work. 1 What’s more, clinicians that AI will only add to the surfeit of extension the environments in which they will need to operate as gatekeepers 3 information and cognitive burden for work) for these technologies. able to bring critical thinking to bear on already overloaded professionals. emerging technology throughout a lengthy Earlier this year, the Academy of Medical career – just as they do with new Dr Umar Naeem Ahmad is ideally Royal Colleges in the United Kingdom medicines today. This new job description placed to comment on these challenges, published The Artificial Intelligence requires no small degree of training being both a clinician and AI pioneer. in Healthcare paper, commissioned – training that sits above the practical He developed a platform which uses by NHS Digital. 4 Amongst its seven operation of the technology (which AI and big data to transform antibiotic recommendations for politicians, would be vulnerable to obsolescence as prescription on an individual basis with policymakers and service providers was a technology changes). EMSA believes this the aim of tackling the ever growing threat of antimicrobial resistance. It provides a 2 Ahmad, Umar Naeem. Telephone interview on behalf of real-time nudge to clinicians so that they EIT Health, August 2019.

become aware of unwarranted variation 3 Founder and Director of the Scripps Research 4 Mosch, Lina. Telephone interview on behalf of EIT Health, Translational Institute. August 2019.

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stakeholders, with medical faculties groundswell of efforts whose cumulative directly involved in its drafting to avoid effect will be transformative over the Box 1: AI is already transforming it being seen as a ‘top-down’ approach. coming decade. infrastructure and outcomes Furthermore, this kind of initiative will only achieve so much at a national level. Policy will be made in an environment of Advanced diagnostics platforms are Cross-border, European-level collaboration enormous possibility – but getting there already shaping the patient pathway is required to ensure we’re learning from will require significant time and effort. in therapy areas such as oncology. our collective successes and failures. It’s a tall order – and one we need to get Products are being developed to started on right now. address the infrastructural problem of bottlenecks in diagnosis. References For prostate cancer diagnosis Machines 1 specifically, a shortage of Maddox TM, Rumsfeld JS, Payne PRO. Questions for Artificial Intelligence in Health Care. Journal of the uropathologists and insufficient are primed and American Medical Association 2018;321:31 – 2. use of available data led to the 2 development of a platform that hungry for infor- Bughin J, Hazan E, Lund S, et al. Skill shift Automation and the future of the workforce. McKinsey combines big data, AI and cloud- Global Institute, Discussion Paper 2018. Available based tech to achieve a number mation but we at: https://www.mckinsey.com/featured-insights/ of advances: i) faster, better future-of-work/skill-shift-automation-and-the-future- and more cost-efficient image may not know of-the-workforce analysis of prostate biopsies; 3 NHS. The Topol Review. Preparing the healthcare and ii) new analytical tools for how to workforce to deliver the digital future. London: Health precision medicine, leading to faster Education England, 2019. Available at: https://topol. treatment and accelerated drug feed them hee.nhs.uk/wp-content/uploads/HEE-Topol-Review- 2019-printable.pdf implementation. ‘‘ 4 Academy of Medical Royal Colleges. Artificial This platform is being trialled in Conclusion Intelligence in Healthcare. London: Academy of hospitals, but these technologies can EIT Health’s great hope for the Medical Royal Colleges, 2019. Available at: https:// also facilitate larger structural shifts, www.aomrc.org.uk/wp-content/uploads/2019/01/ coordinated approach identified by EMSA such as the much longed-for move to Artificial_intelligence_in_healthcare_0119.pdf and others must be to create a generation more patients receiving home care. 5 of health care professionals who are not Downey A. Artificial intelligence ‘won’t solve all healthcare problems’, new report warns. Digitalhealth, The benefits of psychological and simply ‘comfortable using AI’. We need 5 February 2019. Available at: https://www. physical rehabilitation in the home professionals who are far more than end digitalhealth.net/2019/02/artificial-intelligence- setting are self-evident, yet we know users. They must be actively involved in wont-solve-healthcare-problems/

provision is patchy in many countries. the design of AI-enabled technologies, 6 European Health Policy Director 2018/2019 Another new platform aims to pick along with the ethics that surround them. European Medical Students’ Association (EMSA) up where the clinician leaves off and Digital Health–a gap in medical education. operates as an AI companion to Quite rightly, they also need to be satisfied Presentation, June 2019. Available at: https:// emsa-europe.eu/wp-content/uploads/2019/06/ESD- mitigate against feelings of loneliness that data is rigorously regulated, and Deans-Meeting-Rotterdam-2019-1.pdf in people living with chronic excited by the opportunities afforded 7 disease. 7 8 by the ‘gift of time’ in building stronger OECD/EU. Health at a Glance: Europe 2018: State relationships with patients. Part of this of Health in the EU Cycle. Paris: OECD Publishing, 2018. Available at: https://doi.org/10.1787/health_ time will be spent ensuring that patients glance_eur-2018-en themselves are comfortable and confident 8 training should include the fundamentals with this new technology. Tuncay FO, Fertelli T, Mollaoglu M. Effects of loneliness on illness perception in persons with of data analytics, ethical considerations a chronic disease. Journal of Community Nursing and communications skills. Clinicians will also need to be critical 2018;27:e1494–e1500. evaluators of this new technology as it The inherent difficulty, of course, lies in emerges, ready to adopt the innovations the competing interests over curricula, as that will have a lasting impact on patient Ms Mosch identifies: “The speed of digital outcomes. transformation in industry and start-ups is very quick – while in health care there are Clearly, no single innovation will bring a lot of steps to take and lots of opinions. about major structural shifts towards Old professions want to keep their subjects increased self-care or home care. But these in an already-packed programme.” types of innovations are examples of a The solution – at least according to EMSA 6 – is to develop a framework for implementation comprised of different

Eurohealth — Vol.25 | No.3 | 2019 12 Disrupting innovation

HEALTH INNOVATION: FROM ORGANISATION DISRUPTION TO OUTCOMES VALUE

By: Robert Madelin

Summary: Innovation is always a challenge to human conservativism. Innovation is not always truly ‘disruptive’. Nor is innovation always technological in nature: it can be organisational, society-wide or behavioural in a professional class. We need to adopt an innovative mindset if we are to make the most of innovation opportunities for better health, more resilient health systems and better patient outcomes. We must see health as a value system, where all positive outcomes, however created, are sought and welcomed. We also need to ensure that we are resourceful in nudging our systems towards the changes needed, and thoughtful in providing health actors with the

PIECE support necessary to accelerate the adoption of any innovation as

the new normal.

Keywords: Innovation, Mind-set, Nudge, Openness

Medicine since before Hippocrates is a personalised treatments. And it faces risk-taking and innovative endeavour unprecedented disruption, as accelerating demographic ageing and increasing Introduction population movement combine to create less stable health needs, while fiscal Not all innovation is ‘disruptive’. 1 limitations promise a moment of truth for Arguably, the risk-taking attitudes behind health systems. We fear pressures that will ‘do no harm’ get forgotten from time

OPINION likely require change and even threaten the to time. For a century or so, from abandonment or sell-out of the European Nightingale to Crick, via the creation of model of state provision. Patients, their Robert Madelin is an Honorary state-funded universal health services, families and health professionals all feel Fellow of the Royal College of innovation ‘helped doctors do better’, Physicians of London, United disrupted, and not in a good way. Those with some spectacular step-jumps in Kingdom. He is a former Director concerned look back to better times, General of Health at the European outcomes. But it did so without creating feeling disenabled and at risk. Commission. He is currently too directly a challenge to the self-belief both a visiting research fellow on of health elites or the empowerment of technology and global affairs at In uncharted waters and severe weather, the University of Oxford, United the patient population. Kingdom and chairman of public the roads thus far travelled are no reliable point of reference. In health, as elsewhere affairs advisers Fipra International Twenty-first century medicine is arguably in Brussels, Belgium. in life, there is no return, and no forward ever more innovative, notably with the Email: [email protected] grand innovation strategy to be had. move towards using genetic tools and

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What health in Europe needs is rather the neighbourhood. The experience did The experiment was small, cheap and an innovation attitude. 2 While plans not affect her luminous quietness. But, in fast. The intervention was largely a social may founder, an innovative attitude and the health “value network” 3 of a Welsh nudge, 7 showing hard-pressed individuals small-scale tools and trials will create a mining town, that was a net loss. that more was possible, that it produced pro-innovation system in health, and drive more health value and that it eased their value for all concerned. Europe is more tolerant of this practice burden rather than the reverse. Making today. Reimbursement is different. But we a more effective choice an easy choice do need to invest some research effort in requires imagination and a willingness the synergies between Western Medicine to try things. Patients, on the one hand and on the other the assembled wisdoms of Traditional Chinese Appropriating technology – their families Medicine (TCM), Ayurvedic Medicine, Reorganising for genetics and other non-allopathic practice. To its and health credit, the European Union has a modest When cutting edge technology creates new programme doing just this for TCM. 4 At potential, innovation refers NOT to the professionals all the global level meanwhile, the WHO has technology, but to its appropriation by the developed a Traditional Medicine Strategy health system in ways that accelerate and feel disrupted (2014 – 2023) outlining how traditional maximise the creation of value outcomes medicine of proven ‘quality, safety and for people. The whole literature around disruptive efficacy’ can act as a complement to innovation is new, extensive and fast- mainstay health care delivery and help Genomics is a crucial case for Europe growing. It is not summarised here. improve access to care. 5 today. 8 And there is a lot to do. Instead,‘‘ this short text uses four themes to illustrate this approach: More open minds needed? If Hamlet could First, to accept the ‘miracles’ of genetic warn his friends that their philosophies testing more readily than is so far the 1. Open Minds – Grandmother’s Footsteps might not cover all that is to be had in case. None of us notices that we consent 2. Innovation inside – Nudging for the heaven and earth, 6 how much more open to the blood tests our doctor prescribes. Homeless must we be in the Age of Innovation. Not And we need to rather quickly get to to swallow blindfold every assertion, but the same sense of normality for genetic 3. Appropriating technology – to seek more evidence to inform others’ testing. Here, the innovation mindset of Reorganising for genetics ideas of ‘what works’. health professionals is trammelled by 4. A new mindset – Welcoming challenge. all too much red tape. We need a greater Innovation inside – nudging for the sense of political and policy leadership Grandmother’s footsteps homeless to encourage us all to accept genetic tests as the new normal. Of course, I shall start with a heresy, dressed up Much innovation is not ‘new technology’. while encouraging greater adoption as a childhood memory. As national But creating an innovation dynamic inside of genetic testing, the many ethical reimbursement of homeopathy in parts established organisations is far from easy. and legal questions surrounding its of Europe hit the news this year, I thought In the United Kingdom, the National use must be answered and addressed. of my grandmother. Health Service (NHS) offers “start-up For instance, society must ensure that grants” to test new ideas. For £34,000 I do not lose protection and solidarity She was a modest herbal and bone-setting (about €38,000), one such experiment (the (whether state or insurance-funded) just and birthing “healer”, in an age and creation of a single homeless officer in because my genome is better known, and a society where even general practice a big hospital, with 40 hours a week and my privacy rights must keep pace with medicine was beyond the pockets of 90% a smartphone) was enough to shift the medical advances. of her neighbours. For her, the experience attitudes and practice of his fellow health of moving to the big town came with workers. Instead of largely ignoring the Second, to engage while understanding a (male, elite, informal but imperious) high costs, low effectiveness and poor that this IS still new. So the results of a medical and religious instruction to stop humanity of patching up the homeless battery of tests may require more careful doing what she did: Wales no longer and sending them back into the streets, risk-risk analysis than patients and doctors burned witches in the 1900s, but it did the hospital in question (both emergency find easy. Not all BRCA2 variants are yet not like reminders of the past at a time of and acute medical) saw a shift of 20% confidently classified as threats of breast universal exhibitions and the triumph of towards engaging with the need to find cancer or likely benign – in uncertain science. Modest working people did not accommodation and a future perspective cases, where a patient faces an option revolt. Grandmother dialled down her for each homeless patient, and was able to of preventive (‘risk-reducing’) bilateral work, which was not in any case a paid do so without creating longer stay times mastectomy, the patient may decide to occupation, and went on quietly doing in the establishment itself. 7 the bare minimum for difficult births in

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do the operation, and then learn that IWANTGREATCARE.com, instead of References

the variant is no longer uncertain but grumbling at the unethical nature of the 1 Christensen CM, Bohmer RMJ, Kenagy J. Will definitely benign. resulting transparency? Disruptive Innovations Cure Health Care? Harvard Business Review, 2000.

Third, to be patient and yet engaged for the Much of this desirable pressure and insight 2 Madelin R, Ringrose D. Opportunity Now: long term. There are happily increasing will be digitally intermediated. Europe’s Mission to Innovate. The Publications Office numbers of cases where a patient 5 or of the European Union, 2016.

even 20 years ago could not get a clear Doctors are increasingly willing to 3 Allee V. The Future of Knowledge: Increasing genetic diagnosis and yet today has had a use Google themselves to explain to Prosperity through Value Networks. Boston, MA: diagnosis that enables clear treatment to patients what is going on. Hospitals are Butterworth-Heinemann, 2003.

be defined, and can in some cases open increasingly alert to online soft signals 4 European Commission. Good Practice In the path to preventive screening tests for of even ward-specific dissatisfaction Traditional Chinese Medicine Research in the Post- family members. We are all guinea pigs. or overload. genomic Era. CORDIS EU research results, 2013. Available at: https://cordis.europa.eu/project/ Even in the hyper-sensitive field of the rcn/90960/factsheet/en second opinion, digitally-enabled systems 5 World Health Organization. WHO Traditional creating can enable an individual to acquire Medicine Strategy 2014 – 2023. Geneva: WHO, 2013 alternative views of treatment options, 6 Shakespeare W. Hamlet, Prince of Denmark. an innovation in days not months and without travelling (1.5.167 – 8). 2 to distant teaching hospitals . 7 Barrow V, Medcalf P. The introduction of a dynamic inside homeless healthcare team in hospital improves staff Properly embraced, such innovations can knowledge and attitude towards homeless patients. established bring added value into the system, cut the Clinical Medicine 2019:19(4):4294 – 8. costs of repeated improvable treatments, 8 Josephs KS, Berner A, George A, et al. organisations is and improve patient outcomes. Genomics: the power, potential and pitfalls of the new technologies and how they are transforming healthcare. Clinical Medicine 2019:19(4):269 – 72. far from easy Conclusion – Only Connect! 9 European Commission. ERN Collaborative To shape the existing health value system History, if not ethics, seemed in the last Platform web page, 2017. Available at: https:// for all,‘‘ these genetic opportunities is no century to be on the side of the priests and webgate.ec.europa.eu/ern/ mean task. Centres of expertise need doctors who assured my grandmother’s to be established across the continent, charges that a state-funded health service with accessible paths to funded access, would be along shortly. so that (as with the European Reference Networks 9 ) all health professionals can In the current phase of our human health easily get the advice they need for specific journey, things are less clear. With cases. This sort of network must also help unprecedented technological disruption, whole systems to accumulate and use fiscal uncertainty and our demographic (including with Artificial Intelligence and transformation into a grey continent, the Machine Learning) the data generated health value system needs to be more open in exponentially increasing quantity to outside knowledge and pressure. by genomic mapping. Health is a data business, and the fastest progress to new The tools of such openness are themselves value outcomes for patients will come largely data-driven and digital. BUT (in genomics, and elsewhere) from novel they will not be incorporated in a system partnerships between clinics, innovators of health innovation without a positive and data experts 1. and pervasive change in the health community’s mindset. The biggest A new mindset – welcoming challenge new step today could just be to teach “disruption” to first-year medics and How long will it be before all doctors hospital managers. So that young leaders turn towards the patient the computer with innovation mindsets pull into the screen with the patient’s data on it? How health value system all the great potential long before doctors and hospitals pay that is at present “out there”. Health needs for their inclusion in the crowd-sourced innovation inside. benchmarking offered by the likes of

1 In the field of advanced oncology, see one excellent path- 2 For example see: https://www.advance-medical.net/ finder example at: https://www.code-cancer.com/ services/expert-medical-opinion

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Eurohealth — Vol.25 | No.3 | 2019 16 Systems for change

STEER DON’T ROW? BUT HOW TO MOVE THE BOAT TOWARDS THE HARBOUR?

The TAPIC governance framework

By: Scott L. Greer, Matthias Wismar, Stefan Eichwalder and Josep Figueras

Summary: Governance is important but hard to understand or do right. We use the TAPIC framework to shed light on governance’s contribution to policy success and failure via the Transparency, Accountability, Participation, Integrity and Capacity dimensions of governance. Looking at governance this way puts the old “steering versus rowing” debate in a fresh light. Elaborate separations of policy and management or complex public private-private partnerships can overtax governance and choke off valuable information, whether by making decisions opaque, diminishing accountability, or increasing demands on integrity and capacity. Simpler mechanisms can work better. As in boating, to steer is often to row.

Keywords: Governance, Steering, Health Services, TAPIC

Introduction differences (or lack of) between steering > #EHFG2019 – Workshop 1: versus stewardship versus governance, we Steering, not rowing ! The debate on the advantages of ‘steering argue here that this debate is essentially against rowing’ has become ubiquitous in about how to strengthen health sector health policy circles since the early 1990’s governance from the public sector Scott L. Greer is Senior Expert when many governments looked at the perspective. Advisor on Health Governance to application of New Public Management the European Observatory on Health techniques including an increased role Systems and Policies, Brussels, While most commentators, regardless of Belgium, and Professor of Health of the private sector, to health care their political positioning, would agree Management and Policy, Global services. The metaphor implies that some Public Health and Political Science about the importance of governance; are responsible for keeping the course at the University of Michigan, there is far less consensus about ‘how to while others are charged with moving Ann Arbor, USA. Matthias Wismar go about it’ let alone about its definition is Senior Health Policy Analyst the boat. Together, they make progress ‘what is meant by governance’ itself. This and Josep Figueras is Director, towards defined goals. The premise is European Observatory on Health article tackles this challenge by proposing that the public sector should be less in Systems and Policies, Brussels, TAPIC, an effective framework to assess Belgium. Stefan Eichwalder is the business of ‘rowing’, i.e. delivering and strengthen public sector governance, Advisor, Federal Ministry of Labour, health services, and more on to ‘steering’, Social Affairs, Health and Consumer so governments can be as good at steering i.e. providing and ensuring strategic Protection, Vienna, Austria. as they (hopefully) are in rowing. Email: [email protected] guidance and direction. Without going into the thorny issue of the theoretical

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What is governance? ways in governance might endanger a current or possible policy. The first step Governance is often a much-abused term, Box 1: TAPIC Framework of the process is to identify whether the one that can obscure as often as reveal problem is one of governance, as opposed or help. It has been widely used in the Transparency is the extent to which to something else (e.g. lack of resources or literature to mean very different concepts, decisions and the grounds on which a fundamentally flawed policy idea). If the ideas or strategies. they are made are clear and known. problem is in the ways that decisions are made and implemented (“process”) then it Accountability is the extent to At the broadest level, governance can be is probably a governance issue. which actors must account for their defined as the ways in which societies actions to principals in a clear and make and implement decisions. But productive way. beyond this basic understanding of governance there is an impressive degree identify Participation is the extent to which of confusion as different authors and affected parties are consulted in organisations put forward very different decisions relevant to them. propositions. A review of the literature the concrete Integrity is the extent to which shows that governance has been defined organisations have clear rules, by a list of sometimes disparate attributes policy ideas that procedures, and missions, including including democracy, rule of law, anti-corruption and rule of law accountability, transparency, quality, can address measures to clear mandates and control of corruption or formulating policy organisational goals. among many others. the problem Capacity is the extent to which The second step is then to ask what kind Our approach to governance aims to avoid, the system has policy capacity to of governance issue it is. Which of the first, treating governance as a shopping understand the system and the legal, TAPIC components is the problem? Is list of desirable things that may not be economic, political, social and other it, for example, policies that fall afoul of immediately relevant or applicable to ‘‘ challenges in policies. legal challenges because a lack of policy the practical operational needs of health capacity meant they lacked the necessary decision makers; and second endorsing evidence base and process management? 12 a theory of governance that incorporates That would call for a policy capacity Conclusions too many assumptions about how investment. But if the problem is a lack of organisations and systems work. This brings us back to our initial postulate; trust within the system due to capricious this short piece further endorses the need and poorly explained central decisions, We conducted a review of governance for clarity when ‘steering’ rather than then the problem is more likely to be frameworks, synthesising key dimensions ‘rowing’ is needed and when ‘rowing’ transparency and perhaps participation common to the many different frameworks is essential to retain capacity and clout mechanisms. that exist, and then tested with a series of for steering: rowboats and even some case studies in health services, 1 including galleys combine both rowing and steering The third step is to identify the concrete areas such as primary care reform, health indispensably, while other vessels policy ideas that can address the problem: technology assessment and public-private separate them. for example, developing the participatory partnerships, and broader public health 2 mechanisms that build trust and bring including homelessness, 3 trade, 4 climate Yet it also shows the massive better information, or building policy change and pollution, 5 child health, 6 care complexities and difficulties in practice, capacity in order to better anticipate integration 7 and the regulation of new particularly in the face of the perennial problems. There are long lists of such technologies. 8 The basic framework can scarcity in Capacity (the last of our mechanisms 13 and not all mechanisms are be found in a variety of places. 9 10 11 TAPIC dimensions) in many public equally feasible or useful in every case. administrations. We refer here not In this process we developed a framework only about capacity in terms of human The fourth step is to see what can be for understanding the important domains skills and resources; but also, to the learned from the experience in order to of governance where problems and technical, information, legal and political avoid the problem recurring. opportunities for improvement can lie. resources to steer effectively. When There are five of them (see Box 1). this is not the case some government In each case, the question is not how to health administrations may be better off have “good governance” in some abstract going back to the business of rowing to The TAPIC Framework sense but how governance can empower avoid the failures and negative impact of civil society and improve health. 14 15 Put together, these five domains comprise incompetent steering. the core of the “TAPIC framework.” The framework is diagnostic and prospective, designed to be used in identifying the

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References 8 Trump B. Synthetic Biology Regulation and 14 Greer SL, Wismar M, Pastorino G, Kosinska M, Governance: Lessons From Tapic Forthe United eds. Civil Society and Health: Contributions and 1 Greer SL, Wismar M, Figueras J, eds. States, European Union, and Singapore. Health Policy Potential. Brussels: European Observatory on Health Strengthening Health System Governance: 2017;121:1139 – 46. Systems and Policies, 2017. Better Policies, Stronger Performance. Brussels/ Philadelphia: European Observatory on Health 9 Greer SL. Organization and Governance: 15 Greer SL, Lillvis DF. Beyond Leadership: Political Systems and Policies/ Open University Press, 2016. Stewardship and Governance in Health Systems. Strategies for Coordination in Health Policies. In: Levy A, Goring S, Gatsonis C, Sobolev B, van Health Policy 2014;116:12 – 7. 2 Greer SL, Vasev N, Wismar M. Fences and Ginneken E, Busse R, eds. Health Services Evaluation. Ambulances: Intersectoral Governance for Health. Health Services Research. New York, NY: Springer, Health Policy 2017;121:1101 – 4. 2019. 3 Willison C. Shelter From the Storm: Roles, 10 Greer SL, Wismar M, Kosinska M. Towards Responsibilities, and Challenges in United Intersectoral Governance: Lessons Learned From States Housing Policy Governance. Health Policy Health System Governance. Public Health Panorama 2017;121:1113 – 23. 2015;1:128 – 32. 4 Jarman H. Trade Policy Governance: What Health 11 Greer SL, Wismar M, Figueras J, McKee C. Policymakers and Advocates Need to Know. Health Governance: A Framework. In Greer SL, Wismar M, Policy 2017;121:1105 – 12. Figueras J, eds. Strengthening Health System 5 Vasev N. Governing Energy While Neglecting Governance. Open University Press, Maidenhead, Health – the Case of Poland. Health Policy 2016: 27 – 56. 2017;121:1147 – 53. 12 Jarman H. Normalizing Tobacco? The Politics of 6 Wolfe I, Mandeville K, Harrison K, Lingam R. Child Trade, Investment, and Tobacco Control. The Milbank Survival in England: Strengthening Governance for Quarterly 2019;97:449 – 79. Health. Health Policy 2017;121:1131 – 8. 13 Lillvis DF, Greer SL. Strategies for Policy 7 Exworthy M, Powell M, Glasby J. The Governance Success: Achieving ‘Good’ Governance. In Greer SL, of Integrated Health and Social Care in England Wismar M, Figueras J, eds. Strengthening Health Since 2010: Great Expectations Not Met Once Again? System Governance: Better Policies, Stronger Health Policy 2017;121:1124 – 30. Performance. Maidenhead: Open University Press, 2016.

Strengthening health systems with Lithuania and Slovenia which were added to provide broader geographical and policy reach. Part 2, to be published through nursing: Evidence from later in 2019, will provide thematic analysis of important policy 14 European countries issues such as quality of care, workforce planning, ‘Who is a nurse?’ and ‘W elusiv hat is nursing 49 e. This book ?’ seem to be education and training, s explores the imple questio across the variations in ns yet the ans different countries structure and wers are stra academic of Eur organization ngely inter ope. This div of the nursing est. The work ersity, and the workforce health s of nurses has reasons for ystems shift always had it, are of mor Str radically in a critical impac e than eng more important response to t on patient thening . rising deman outcomes. regulation and migration. d, the rol As This e of nurses b book is par ecomes even t of a two-volume health s healt study 52 AM Rafferty, R Busse, B Zander-Jentsch,h systems. T on the co ntributions Edited by: h is is the f tha y irst tim t nur s the Obs e that ses mak tems thr y ervatory Hea the topic of n e to streng lth Policy Se ursing has be thening ough and draw ries. The ai en dealt w m i olic the attention o is to raise th th at length w nur f decision-mak e profile ithin er of nursin sing: Series Part 1 s. g within heal E is a ser th poli vidence fr ies of nat cy Ir ional case stu W Sermeus, L Bruyneel eland, the Ne dies drawn fr The lessons learned from therlands om om , Norw Belgium, Eng chosen ay, P land, 14 Eur Health P as the oland, Spain, Finland, G subject of Sweden, ermany, Gree opean countries a large and Switz ce, were added EU-funded s erland. The to provide br tudy of nursing countries w year oader geogr (RN4Cast) ere , will provide thema aphical and polic . Lithuania and tic analy y reach. Par Slovenia planning, educa sis of important polic t 2, to be publishe tion and tr y issues suc d later this Edited b comparative case-study aining, regulation and migr h as quality o y: The lessons ation. f care, workf learned from orce Anne Marie Raff dime comparative World Health Organizationns ion(acting of the ascase-stud y the host erty Copenhagen: w anal orkforc ysis ratio e. It examines demonstrate Reinhar s; the educa what a nurse wide variation d Busse tion, regulat is; nurse-to- in every workforc ion and issui doctor and n Britta e. While comp ng of creden urse-to-popu Zander analysis demonstrate arative an tials to nu lation -Jentsc it also rev alysis across rses; and th h eals how the countries br e planning o Walt el EU functio ings these di f the er Sermeus ements toge ns as an imp fferences int organization for, and secretariat of, the Europeanther into a mor Observatoryortant ‘bind o sh arp relief e coher ing agen , Luk Br ent whole. t’, drawing t uyneel hese diverse wide variation in every The editors on Health Systems and Policies), 2019 Anne Ma rie R afferty, Professor Care, King’ , Florence Nigh s College, London tingale Faculty o f Nursing, Reinhard Midwifery & P dimension of the workforce. Bu sse, Professo alliative on Hea r, Berlin Univ lth Systems ersity of Tech and Policies nology and Co Brit -Director, Eur ta Zander-J opean Observ entsch, Resea atory Quality and rcher, Berlin U Transparency niversity of Te in Healthcare chnology and 163; 978 92W al890ter S 5174 (I QT3IG) National Inst It examines what a nurse Number of pages: ISBN: e i rmeus tute for ,Professor, Leuv Luk en Institute f Bruyneel,Resear or Healthcare P cher, Leuven Ins olicy, KU Leuv titute for Healthcar en e Polic y, KU Leuven is; nurse-to-doctor and Freely available for download: http://www.euro.who.int/en/ Health Policy Series Series No . 52 nurse-to-population ratios; www.healthobserva about-us/partners/observatory/publications/studies tory .eu the education, regulation ‘Who is a nurse?’ and ‘What is nursing?’ seem to be simple and issuing of credentials to questions yet the answers are strangely elusive. This book nurses; and the planning of the explores the variations in structure and organisation of the workforce. While comparative nursing workforce across the different countries of Europe. analysis across countries This diversity, and the reasons for it, are of more than academic brings these differences into sharp relief, it also reveals how the interest. The work of nurses has always had a critical impact EU functions as an important ‘binding agent’, drawing these on patient outcomes. As health systems shift radically in diverse elements together into a more coherent whole. response to rising demand, the role of nurses becomes even Contents: Foreword; Author affiliations; List of figures and more important. tables; List of abbreviations; Acknowledgements; Introduction; This book (Part 1 of 2) provides a series of national case Belgium; England; Finland; Germany; Greece; Ireland; studies drawn from 12 countries which were chosen as the Lithuania; the Netherlands; Norway; Poland; Slovenia; Spain; subject of a large EU-funded study of nursing (RN4Cast) along Sweden and Switzerland.

Eurohealth — Vol.25 | No.3 | 2019 Systems for change 19

FACTS. FIGURES! FICTION?

By: Martin McKee, Yuxi Wang, Aleksandra Torbica and David Stuckler

Summary: Disinformation, or as we now say fake news, is not new, but the advent of social media now allows it to travel with unprecedented speed to ever larger audiences. It has enormous implications for public health. Some groups pursuing political goals have weaponised issues like vaccine safety. Others have discovered that by tapping into these concerns they can make large amounts of money, using them as clickbait. Health professionals need to understand this changing information environment, understanding the cognitive biases that favour the spread of fake news, proactively tackling its sources, and framing their messages in ways that reduce its impact.

Keywords: Disinformation, Fake News, Anti-vaccination, Backfire Effect, Public Health

The evolution of fake news even if politically important, section of the population. What changed was the In early 2018 former US President Barack technology to distribute disinformation Obama appeared in a video to warn to the masses. The first technological about the dangers of what are termed revolution was the printing press. By “deepfakes”. 1 Originally developed to the 18th century this was being exploited manufacture images of celebrities in by pamphleteers such as those who spread pornographic acts, deepfakes use artificial salacious stories about the alleged sexual intelligence to make it look and sound as adventures of Marie Antoinette. 3 Based > #EHFG2019 – Lunch Workshop 1: if someone is doing or saying something in England, their objective was blackmail Facts. Figures ! Fiction ? they are not. In that particular video, it cut and they succeeded in extracting money away to show that Obama’s words were from Louis XVI. But they also had a being spoken by movie director and actor political impact, encouraging the actions Martin McKee is Professor of Jordan Peele, who has worked with the of revolutionaries who would change the European Public Health at the CEO of Buzzfeed Jonah Peretti to create London School of Hygiene and course of history. Tropical Medicine and Co-Director what was extremely convincing imagery. of the European Observatory on The message was clear. You cannot trust Today, we are in the midst of a series of Health Systems and Policies, anything anymore. London, United Kingdom; technological revolutions, many affecting Yuxi Wang is PhD candidate and what we see, hear, and read. And these The creation of disinformation is not Aleksandra Torbica is Associate have profound consequences for health. Professor at the Centre for new. History has always been written They include the artificial intelligence Research on Health and Social Care, by the victors, or at least by scholars Department of Social and Political application that made possible the fake and dramatists seeking to flatter them. Science, Bocconi University, Italy; video of Obama but also the social media David Stuckler is Professor at the Shakespeare’s plays contain many outlets that allowed it to be disseminated Department of Social and Political examples, made more obvious as his plays Science and Dondena Research rapidly. Collectively, they have given us span the transition between two royal Centre, Bocconi University, Italy. the term, “fake news”. Email: [email protected] dynasties in England. 2 Yet his messages were confined to a relatively small,

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Although this term was first used as long developed by Claire Wardle, and goes involves a number of sophisticated bots, ago as 1925, in a Canadian magazine, 4 it from satire and parody, where there is no mostly run by anti-vaccine groups, but has only become widely used in the past intention to cause harm but some people with many different motives. Some are few years. In Europe, the term took off are still fooled, to fabricated content that is from those who genuinely believe that at the time of the European Union (EU) completely false and is designed to deceive vaccines cause harm. Others are from referendum in the United Kingdom when and to do harm. 10 conspiracy theorists and others who the Leave campaign engaged in a series simply oppose any form of government of illegal activities. 5 One element of their action. Some of these accounts combine strategy involved harvesting data on the automated messaging with human activity, interests and concerns of individuals to making them difficult to detect but there target them with misleading messages, 6 are now quite sophisticated tools using many drawn from the very large number Familiarity with artificial intelligence that can identify of what have been termed Euromyths, now bots with a high degree of certainty. The collected on a website by the European false information third category includes content polluters, Commission. 7 A similar process took again with a variety of motives. Some are place in the United States, where many or, fake news, used to spread malware, knowing that millions of unique and mostly misleading anti-vaccine messages are likely to be advertisements were aimed at individuals increases the disseminated widely. Others attract traffic during Donald Trump’s election to sites that have been monetarized, such campaign. 8 Bizarrely, Trump has now likelihood that it as those with advertisements. taken ownership of the term, using it as a means to attack the mainstream media as will be believed Understanding and changing people’s they seek to hold him to account. ‘‘ views Many aspects of health have been subject What are fake news, misinformation to disinformation but vaccines stand The question then arises as to what and disinformation? out as one of the most frequent targets. can be done about this problem. Just Italy has been one of the countries in as we differentiate misinformation So what is fake news? A recent Europe most severely affected by the from disinformation, it is important Parliamentary enquiry in the United anti-vaccine movement. 11 An analysis to separate out the two reasons why Kingdom concluded that the term is of videos on YouTube aimed at Italians people have incorrect beliefs. They often used with no clear idea of what it found a striking increase in the number can be uninformed or they can be means. 9 The term has taken on a variety of of videos, but especially among those misinformed. If they are uninformed, meanings, including a description of any attacking vaccination. 12 It also provided a then providing the correct information statement that is not liked or agreed with graphic demonstration of what is termed may be effective. There is much evidence by the reader. The Members of Parliament confirmation bias, 13 with videos criticising of the need for misconceptions to be (MPs) recommended that the term fake vaccination more likely to be liked and corrected. Surveys repeatedly show that news should be rejected and replaced to be viewed than those providing an members of the public are wrong on many with agreed definitions of the words objective assessment of the benefits contemporary issues. misinformation and disinformation. of vaccination. Unfortunately, it is often not enough Misinformation is where false or A recent paper from the United States to tell people the truth. In one study, misleading information is provided examined in detail where these messages when individuals were presented with but there is no intent to deceive. are coming from. 14 The authors identified information reporting myths and facts Disinformation is where information three main sources that were tweeting about influenza vaccination, they could is purposely created to deceive people. misleading information on vaccines. The separate the two quite easily if asked In practice, however, it is often quite first was a group of accounts that had immediately afterwards. Yet, only 30 difficult to differentiate them because previously been linked to the Russian minutes later, most were unable to do so. 16 of the difficulty in ascertaining intent. government. They were disseminating For example, some of those spreading messages that were both pro- and anti- The real problem is that many people are anti-vaccination messages genuinely vaccine. The apparent intention was to not so much uninformed but misinformed. do believe what they are saying, even create divisions and polarise opinion, They hold views that are shaped not by if they are completely wrong, but as well as creating confusion. This is a a lack of knowledge but by fundamental there are others who are using it as well-known tactic used in accounts from biases. To understand this, it is necessary an opportunity to undermine trust in this source. For example, they have been to use theories of motivated reasoning. democratic governments. extremely active in spreading messages When people try to find out about in the United States that are both for and something, they are motivated by two Disinformation takes many forms. against the #BlackLivesMatter movement goals. The first is to find the truth, where The most widely used taxonomy was and gun control. 15 The second category they look for and consider carefully all

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of the evidence, so as to reach the best conclusion. The second are partisan, where they look for evidence that will fit their prior beliefs. In practice, everyone pursues both of these goals to some extent. The question is why some people place so much emphasis on the partisan goals at the expense of the accuracy ones.

One of the classic studies in this area involved asking subjects to synthesise evidence that would allow them to explain an issue to someone else. 17 The two issues selected were both known to evoke strong feelings: gun-control and affirmative action. In both cases, the prior positions of the subjects were noted. The computer tracked the information that they searched and the time that they spent reading different arguments, with the material being clearly labelled as to where it came from.

The researchers found evidence of a series of different biases. Subjects regarded evidence that they agreed with as being stronger and more relevant than anything they disagreed with. They actively denigrated evidence they disagreed with while accepting evidence they agreed with at face value. When they were given control over the sources that they looked at, they actively sought out anything that would support their views and avoided anything that would challenge them. Even when people were presented with exactly the same evidence, they could take completely different messages from it.

The same can be seen with vaccines. In one study, while many people were willing to accept evidence of the effectiveness of human papilloma virus vaccine, some incorrect information, surely it would be Observations such as this are went to considerable lengths to undermine possible to provide correction from an manifestations of what has been called the 18 it. These were people who had particular authoritative source? Not necessarily. backfire effect. 16 It takes several forms. views on individual responsibility, traditional gender norms, or who believed In one study, parents were presented with Familiarity with false information or, that this particular vaccine condoned information from the US Centres for fake news, increases the likelihood that it sexual activity. Disease Control. 18 This challenged the will be believed. Quite simply, if a lie is widespread myth that the MMR (measles, repeated often enough, many people will Recognising the backfire effect mumps and rubella) vaccine causes believe that it is true. This is even the case autism. Overall, it did reduce the extent when repeating it simply to challenge it. But surely there is something we can to which the false claims were believed, do. For those of us who live in what we but those who were already opposed to Overkill occurs whenever many different believe to be a rational, evidence informed vaccination said that they were even less reasons are given as to why it is wrong. world, isn’t it possible to engage in a likely to have the child vaccinated. People like simple explanations and dialogue where we challenge false beliefs? multiple counterarguments simply For example, if someone has been given cause confusion.

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Polarised attitudes are important. When it is important to engage seriously with 14 Broniatowski, D.A., et al., Weaponized Health people are given information that is technology companies themselves. They Communication: Twitter Bots and Russian Trolls contrary to their beliefs, they selectively already can decide what is seen and what Amplify the Vaccine Debate. Am J Public Health, 2018. 108(10): p. 1378 – 1384. recall any evidence or arguments that is not seen. It is already possible to install oppose it. In this way, they reinforce the software that will link messages to fact 15 Starbird K. The Surprising Nuance Behind the pre-existing beliefs, no matter how wrong checking sites. Should this not be the Russian Troll Strategy. 2018-10-20; Available from: https://medium.com/s/story/the-trolls-within-how- they are. default setting? It is also possible to deny russian-information-operations-infiltrated-online- advertising revenues to those distributing communities-691fb969b9e4 Finally, messages that cause fear can be hate messages. And even if governments 16 Rossen, I., M.J. Hurlstone, and C. Lawrence, counter-productive, either because they’re fail to act, we should call for action, such Going with the Grain of Cognition: Applying Insights simply not believed or because the activity as boycotts of companies that advertise on from Psychology to Build Support for Childhood in question appeals to people who are websites that peddle lies designed to create Vaccination. Front Psychol, 2016. 7: p. 1483.

attracted to risk-taking. hatred and division. 17 Taber, C.S. and M. Lodge, Motivated skepticism in the evaluation of political beliefs. American Journal of How to best communicate the facts in Reference Political Science, 2006. 50(3): p. 755 – 769. 18 Kahan, D.M., et al., Who fears the HPV vaccine, support of public health 1 Romano A. Jordan Peele’s simulated Obama who doesn’t, and why? An experimental study of the PSA is a double-edged warning against fake news. So what can be done? Many proposed mechanisms of cultural cognition. Law Hum Behav, Vox. 2018-04-18 ; Available at: https://www.vox. 2010. 34(6): p. 501 – 16. solutions respond to the evidence of com/2018/4/18/17252410/jordan-peele-obama- backfire effects. For example, one can deepfake-buzzfeed 19 Virchow, R.C., Report on the typhus epidemic state the facts, and then introduce the in Upper Silesia. 1848. Am J Public Health, 2006. 2 Dickson A. Royal Shakespeare: a playwright 96(12): p. 2102 – 5. myth, rather than the other way round and his king. 2016 Available at: https://www. and then can debunk the myth, ending bl.uk/shakespeare/articles/royal-shakespeare-a- with the scientific fact. A common playwright-and-his-king

recommendation is to avoid repeating 3 Hanrahan J. Blackmail, Scandal, and Revolution: myths. Above all, messages should be London’s French Libellistes, 1758–92. 2008, kept simple. Trying to wear people down Manchester: Manchester University Press.

by multiple counterarguments simply 4 McKernon, E., Sifting fake news from truth. confuses them. In some cases, it may MacLean’s Magazine, 1925 (Nov 15th): p. 32. be better to avoid the facts altogether 5 BBC News. Vote Leave drops appeal against fine. and simply appeal to people’s values 2019; Available from: https://www.bbc.com/news/ and norms. And it is important to avoid uk-politics-47755611 implying that activities that are very rare 6 Cadwalladr, C. Vote Leave faces scrutiny over are actually common. Appeals to fear can £50m football contest. The Guardian 2018-05-20; work, but they need to be used selectively Available from: http://www.theguardian.com/ and with care. politics/2018/may/20/vote-leave-scrutiny-facebook- data-football-contest-brexit

If disinformation is a threat to public 7 European Commission in the UK. Euromyths. health, what can be done more generally? 2017; Available from: https://blogs.ec.europa.eu/ First, the health community must ECintheUK/euromyths-a-z-index/ challenge politicians who lie. Too often 8 Allcott, H. and M. Gentzkow, Social media and we have been reluctant to do so for fear fake news in the 2016 election. Journal of economic of being seen as political. Yet the political perspectives, 2017. 31(2): p. 211 – 36. determinants of health have been clear 9 House of Commons, Disinformation and ‘Fake at least since Virchow called for action News’: Interim Report. 2018, London: Digital, Culture, against the aristocracy, and the church Media, and Sport Committee. that supported them, when he investigated 10 Wardle C. Fake news. It’s complicated. 2018- 12- a typhus epidemic in Silesia in the 19th 10. Available at: https://medium.com/1st-draft/fake- century. 19 If we believe in evidence, news-its-complicated-d0f773766c79 surely it is a natural consequence that we 11 Expert Panel on effective ways of investing will confront those who lie so blatantly, in health, Vaccination Programmes and Health no matter what their position? Second, Systems in the European Union. Brussels: European it is essential to tackle the threat that Commission, 2018. disinformation poses to the democratic 12 Donzelli G. et al., Misinformation on vaccination: process. At the very least, the public A quantitative analysis of YouTube videos. Hum Vaccin should know who pays for political Immunother 2018; 14(7): 1654–1659. advertising and the authorities should be 13 Nickerson, R.S., Confirmation bias: A ubiquitous able to respond to it in real time. Finally, phenomenon in many guises. Review of general psychology, 1998. 2(2): p. 175.

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THE QUEST FOR MORE BALANCED POLICY AND DECISION MAKING – THE ECONOMY OF WELLBEING

By: Liisa-Maria Voipio-Pulkki, Noora Heinonen, Pasi Korhonen and Pasi Mustonen

Summary: The European Union owes its legitimacy to and earns prestige from its commitment to democracy, the rule of law and human rights, environmental sustainability and a strong social dimension. These values are pursued for their own account but they are also a source of economic strength, contributing to Europe’s success as a globally competitive and attractive yet socially and environmentally responsible market economy. Finland’s Presidency of the Council of the European Union is introducing the Economy of Wellbeing as an approach to policy and decision making to address the political, economic and societal challenges of the 2020s.

Keywords: Wellbeing, Economy, Policy making, EU Presidency, Finland

Background Rights, is to ensure respect for human dignity and to promote the wellbeing of Since the 1950s, the European Union (EU) its people. People’s wellbeing is therefore has pursued sustainable peace, improved the responsibility of the EU and its quality of life and advanced social Member States. protection. It has increased the wellbeing of EU citizens by developing the internal The Economy of Wellbeing is a policy > #EHFG2019 – Forum 4: market and promoting macroeconomic orientation and a governance tool with the Towards the Economy of Wellbeing stability. The raison d’être of the EU, as objective to put people and their wellbeing enshrined in the EU Treaties 1 and in the at the centre of policy and decision European Union Charter of Fundamental making. While people’s wellbeing is a Liisa-Maria Voipio-Pulkki is Director General, Ministry of value in itself, the Economy of Wellbeing 1 Respect for human dignity is a central value of the Union Social Affairs and Health, Finland; underlines the mutually reinforcing (Art. 2 TEU) while promoting the wellbeing of its people is Noora Heinonen is Ministerial nature of wellbeing and economic Adviser, Ministry of Finance, a central aim of the Union (Art. 3 TEU). In all its activities, Finland; Pasi Korhonen is the Union shall aim to eliminate inequalities, and to promote growth. Taking wellbeing into account Counsellor for Social Policy and equality between men and women (Art. 8 TFEU). In defining in all policies is vitally important to the Pasi Mustonen is Counsellor and implementing its policies and actions, the Union shall EU’s economic growth, productivity and for Health policy, Permanent take into account requirements linked to the promotion of a fiscal sustainability, as well as to societal Representation of Finland to the EU, high level of employment, the guarantee of adequate social Brussels, Belgium. Email: noora. protection, the fight against social exclusion, and a high stability, democracy and the rule of law. [email protected] level of education, training and protection of human health (Art. 9 TFEU).

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The European Pillar of Social Rights 2 How can we pursue the Economy adapt have never been more important (hereinafter the Pillar) provides a compass of Wellbeing? as the EU Member States are constantly for renewed upward convergence towards challenged to preserve trust and stability. A horizontal approach, overcoming better working and living conditions silos by cross-sectoral collaboration, in the EU. The Pillar has been an is elementary to the realisation of the Social cohesion is vital to economic important milestone in raising the social Economy of Wellbeing. As a multisectoral progress dimension higher on the EU’s policy approach the Economy of Wellbeing agenda and linking the economic and In order to better respond to these touches upon social, gender, health, social dimensions together more closely. developments and to strive for the employment, education and environmental Delivering on the Pillar is a shared objective of the EU becoming the world’s issues and their relation to economic political commitment and responsibility most competitive and socially inclusive growth. The necessity to engage with of the core EU actors and necessitates low-carbon economy, we need to intensify cross-sectoral action is embedded in continuous developments and profound our efforts in promoting the European requirements enacted in the Treaty actions at both EU level and in the Social Model empowering all people by on the Functioning of the EU and in Member States. promoting upward social and economic the European Social Charter, and has convergence. Sustainable and inclusive been brought up as part of Health in All economic growth and resilience can Policies approach in the 2006 Council function as enablers for the wellbeing of Conclusions. 2 Improved people, societies and the planet. The core of the Economy of Wellbeing The balance between economic progress health status concept is to improve the prospects for a and social cohesion is at the core good life based on better cross-sectoral of European integration, but it also contributes to cooperation. It is a horizontal approach, distinguishes the EU globally. It is about which: increased understanding the importance of social, • increases our understanding of how gender equality, health, employment, economic investing in wellbeing enhances education and environmental policy productivity, generates economic aims in relation to economic growth, growth growth, increases employment, and as well as the stability of the economy thus holds promise to reduce public and societies. 3 4 The recent World The Economy of Wellbeing contributes expenditure in the long term; Bank Human Capital index, released in to the aims and implementation of the October 2018 provides results supporting • highlights the importance of wellbeing ‘‘ 5 Pillar in line with the new EU Strategic this thinking. impact assessments, designed to Agenda 2019–2024. The Economy of evaluate how legislative and policy Wellbeing is also at the heart of the Let us take examples. Should women measures affect the wellbeing of people; global 2030 Agenda for Sustainable increase their paid working hours so that and Development, a joint commitment and gender gaps, in both participation and action plan by all governments for people, • underlines wellbeing as a value in itself working hours, disappear completely planet and prosperity, contributing to and as a source of societal resilience by 2040? This would boost the economy integrated and transformative action and to and stability that also benefits business by an additional 15–30% Gross Domestic the fulfilment of agreed targets.3 and investment. Product (GDP) per capita growth in the Nordic countries – an estimation made Public spending on wellbeing, namely by the OECD. 6 Overall, the cost of the social, health, education and employment lower employment rate of women in the expenditure, constitutes a major part of EU is estimated to be around 2.8% of the 2 See the Interinstitutional Proclamation on the European national budgets. Often the dominating EU’s GDP. 7 Improving gender equality Pillar of Social Rights (OJ C 428, 13.12.2017, p. 10) Available tendency in reforms is to cut these would lead to an increase in the EU’s at: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELE expenditures in order to attain fiscal GDP by 6.1% to 9.6% by 2050. 8 Another X%3A32017C1213%2801%29 consolidation in the short-term. On example is the perspective of the ageing 3 It has particular relevance to the following sustainable the other hand, major challenges and population. Longevity is one of the development goals: (1) End poverty in all its forms everywhere, opportunities loom on Europe’s horizon successes of national policies in Europe, (2) End hunger, achieve food security and improved nutrition and promote sustainable agriculture, (3) Ensure healthy lives linked to the changes driven by climate which is strongly and increasingly shaping and promote well-being for all at all ages, (4) Ensure inclusive change, new forms of work, ageing our societies and economies. Ageing of and equitable quality education and promote lifelong learning of the population and changes driven the population has a strong impact on opportunities for all, (5) Achieve gender equality and empower by technological development such as economic growth, productivity, public all women and girls, (8) Promote sustained, inclusive and digitalisation, artificial intelligence and finances and the financial sector, as well sustainable economic growth, full and productive employment and decent work for all, and (10) Reduce inequality within robotics. Resilience and the capacity to as wealth and income distribution. and among countries. Available at: https://www.un.org/ sustainabledevelopment/development-agenda/

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Health is an intrinsic value and should be implemented in a fair manner. the core of the EU’s future strategies as the a prerequisite It is essential to achieve sustainable next step towards a socially, economically growth through measures that benefit both and ecologically sustainable EU. Health is a fundamental human right population wellbeing and the environment, and key factor contributing to wellbeing. but never at their expense. Improved health status contributes to References increased economic growth through 1 European Council. A New Strategic Agenda greater educational attainment, improved 2019–2024, 2019. Available at: https://www. labour market participation and consilium.europa.eu/media/39914/a-new-strategic- higher savings. agenda-2019-2024.pdf 2 Council Conclusions on Health in All Policies On the other hand, ill health imposes a empowering (HiAP) 2767th Employment, Social Policy, Health significant economic burden on society and Consumer Affairs Council meeting, Brussels, and public finances, in addition to its all people by 30 November and 1 December 2006. Available at: http://ec.europa.eu/health/ph_projects/2005/ human toll. For instance, mental health is action1/docs/2005_1_18_frep_a8_en.pdf fast becoming one of the defining global promoting 3 health challenges of the 21st century. The Economy of Well-Being – Executive Summary upward social of the OECD Background Paper on “Creating The total costs of mental ill health are opportunities for people’s well-being and economic estimated at more than 4% of GDP – or growth” (Council of the European Union 10414/19). over €600 billion – across the 28 EU and economic Available at: https://data.consilium.europa.eu/doc/ Member States. Around 550,000 people of convergence document/ST-10414-2019-INIT/en/pdf working age die prematurely every year 4 The Economy of Well-Being – OECD Background across the EU due to non-communicable ‘‘ Paper (Council of the European Union 10414/19 ADD Knowledge-based policy making requires diseases, amounting to 3.4 million 1). Available at: https://data.consilium.europa.eu/ the use of a broad set of indicators and life-years and €115 billion in economic doc/document/ST-10414-2019-ADD-1/en/pdf comprehensive impact assessments potential lost annually. 9 5 World Bank Group. The Human Capital and evaluation of the cost-effectiveness Project. Washington, DC: International Bank for of different policies and actions. It is Reconstruction and Development / The World Bank, The dual pursuits of population widely accepted that GDP alone does 2018. Available at: https://openknowledge.worldbank. wellbeing and sustainable economic not provide a comprehensive picture of org/bitstream/handle/10986/30498/33252. growth people’s wellbeing as stated already by pdf?sequence=5&isAllowed=y the Stiglitz-Sen-Fitoussi Commission. 10 6 OECD. Is the Last Mile the Longest? Economic Population wellbeing and sustainable Therefore, further collaborative efforts gains from gender equality in Nordic countries. economic growth are not contradictory across sectors are required to improve Paris: OECD Publishing, 2018. DOI: https://doi. goals. The Economy of Wellbeing is org/10.1787/9789264300040-en existing instruments, to better use them based on a sound economic policy. It 7 and to build on them for the development Eurofound. The gender employment gap: highlights the importance of investing in of a common approach to measuring the Challenges and solutions. Luxembourg: Publications effective and efficient policy measures Office of the European Union, 2016. Available at: different dimensions of the Economy and structures ensuring access to all to https://www.eurofound.europa.eu/sites/default/ of Wellbeing. public services including health services, files/ef_publication/field_ef_document/ef1638en_1. pdf promotion of health and preventive measures, social protection, and education Inclusive growth is a priority 8 European Institute for Gender Equality, EIGE. and training. It emphasises employment, Economic benefits of gender equality in the EU: Finally, we need to recognise that the Overall economic impacts of gender equality, 2017. active labour market policy and economic growth during past decades doi:10.2839/96823 occupational safety and health as measures has not brought benefits to all people in 9 to guarantee wellbeing at work. It stands OECD. Health at a Glance: Europe 2016 – State of Europe. Though the majority of people in Health in the EU Cycle. Paris: OECD Publishing, 2016. for equal opportunity, gender equality and the EU are wealthier, healthier and more Available at: https://www.oecd-ilibrary.org/social- social inclusion. educated than ever before, the number of issues-migration-health/health-at-a-glance-europe- 2016_9789264265592-en people at risk of exclusion and vulnerable Assessment and monitoring of the 10 groups remains high. Paying attention to Stiglitz JE, Amartya S, Fitoussi J-P. Report long-term consequences of budgetary inclusive growth is, therefore, of utmost by the Commission on the Measurement of policies on both wellbeing and Economic Performance and Social Progress, importance. macroeconomic development are crucial 2009. Available at: https://ec.europa.eu/ for the implementation of the Economy eurostat/documents/118025/118123/ The Economy of Wellbeing approach Fitoussi+Commission+report of Wellbeing concept. In the EU, it is aims at ensuring that no one is left behind vital to understand how wellbeing can in our rapidly changing world and that benefit from and contribute to the internal all people in the EU live in prosperity. market. Climate change will have an Finland’s Presidency aims to incorporate impact on the lives of all people, and the the Economy of Wellbeing approach into transition to a climate-neutral economy

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TRANSFORMING FINANCIAL MARKETS FOR THE GOOD OF ALL

By: Rachel Melsom and Clare Payne

Summary: For the last 50 years, tobacco has been a key investment for many pension funds, insurers, investors and banks. However, investments are no longer viewed solely on financial return and the framework for review is being re-examined in a rapidly changing and transforming investment world. The negative impact of tobacco on health, human rights, environment, corporate governance, reputation, and the clear negative impact on the achievement of the Sustainable Development Goals (SDGs), has been highlighted through the increasing adoption of a framework driven approach, accelerating decisions to divest across the globe.

Keywords: Tobacco, Sustainable, Responsible, Framework, Investment

Introduction Questioning the status quo In the world of global business, the word Tobacco is one of the biggest issues of disruption is usually associated with our time, something well understood by technology companies, maverick Chief the global health community, but less Executive Officers (CEOs) and ‘unicorns’ so in the world of finance. This lack of (privately held start-ups valued at over understanding and the commonly held $1 billion/€0.8 billion). There are well view that tobacco is an individual health known examples of new businesses with choice issue rather than a global financial leaders who think differently, encouraging drain, has seen tobacco promotion us to ride in the cars of strangers (Uber), and investment continue, facilitating sleep in their houses at night (Airbnb) and product uptake at alarming rates in #EHFG2019 – Forum 1: watch a whole season of your favourite emerging nations. Public stewardship & economic show in one sitting (Netflix). Each of these globalisation ‘disruptive’ businesses have flourished The current reality, the status quo, is in a world where finance is available to that many of us are ‘owners’ of tobacco new ideas. Large investments of capital companies through our investment Rachel Melsom is Director UK and flow to businesses set to ‘transform’ our portfolios, most commonly through Europe, Tobacco Free Portfolios, lives whilst providing a handsome return compulsory or corporate pension London, United Kingdom and a Doctor at Worthing Hospital, on investment along the way. But, why is structures. The largest tobacco West Sussex, United Kingdom; it that so little innovative practice seems companies have been considered a Clare Payne is Honorary Fellow, to flow to public health? The good news reliable investment, hence they are The University of Melbourne, Australia and Director of is that this is set to change and financial routinely included in default investment Communications, Tobacco Free markets are transforming, for good. options, meaning that if someone does Portfolios, Sydney, Australia. not explicitly ask for an exclusion, they Email: rm@tobaccofreeportfolios. org

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The rise of responsible investment century because of tobacco use. 4 This combined with the increased pressure story and the implications beyond the Box 1: The three questions on businesses to reduce the negative share price must be told and understood impact of their products on society has by the finance sector in order for a new 1. Can the product that the accelerated us towards a transformation framework for investment to emerge. company makes be used safely? of financial markets. The new framework for investment that is emerging in global 3. Challenging the accepted business With respect to tobacco, the answer financial markets is seeing people’s health model is an unequivocal ‘no’. The only prioritised like never before. There is safe amount of tobacco for human Tobacco is a business, with health still a long way to go; however, the case consumption is zero. Even smoking implications and associated human, of tobacco gives hope that we may yet be an average of less than one cigarette societal and financial costs. The able to address some of the biggest public per day increases the risk of death profitability of tobacco, however, is health issues of our time. from lung cancer nine-fold compared the outcome of a business model that to non-smokers. 12 When used internalises profits and externalises costs. precisely as intended, tobacco will Challenging existing practices to This business model has allowed these result in the early death of two out develop a new framework for our time companies to thrive in financial markets. of three smokers. 13 The evidence Existing practices and rationales have had demonstrating the categorical and However, recent successful litigation has to be challenged in order to introduce a unconditional danger of smoking challenged the business model where the framework for investment that prioritises tobacco is irrefutable. costs of tobacco are borne by society. The people’s health alongside financial criteria. Court of Appeal of Quebec upheld the 2. Is there a UN Treaty regarding ruling for three large tobacco companies the issue? 1. An exception to the practice of to pay C$15.5 billion (€10.6 billion) in ‘engaging for change’ damages 5 – the largest award in Canada’s For tobacco, the answer is ‘yes’. The concept of ‘engagement’, where history. The plaintiffs were Quebec There is the UN Tobacco Control investment professionals encourage smokers who argued that the companies Treaty, the WHO FCTC. 1 companies to improve their practices did not properly warn their customers and 3. Can investors use engagement (usually around environmental, social and failed in their general duty “not to cause with the company as a tool to governance matters) is now commonplace injury to another person.” 5 In May 2019, effect change? across the finance sector. Engagement is Brazil launched a case against two of the considered the preferred practice, allowing largest tobacco companies to recover the As it pertains to tobacco, the answer investors to influence companies to effect cost of treating tobacco related illnesses. 6 is ‘no’. positive change. In the case of tobacco Cases such as these could see significant companies, however, engagement is futile, shifts in the valuations of tobacco as the core product is the problem, and the companies and ultimately a questioning of only acceptable outcome is the cessation of the once accepted business model. are likely to have tobacco stock in their the primary business – tobacco production. investment portfolio. Countries have found 4. Fiduciary duty beyond profit alone themselves invested through Sovereign Dr Vera Da Costa e Silva, Head of Wealth Funds, even when signed to the A fiduciary duty is underpinned by a Secretariat of UN Tobacco Control United Nations (UN) Tobacco Treaty fiduciary relationship, which can be Treaty, has stated, “Engagement with the (WHO Framework Convention on defined as a person having full trust tobacco industry is contrary to the United Tobacco Control, FCTC) that contains and confidence in another to act in their Nations’ systems, objectives, fundamental a provision prohibiting investment in interests rather than out of self-interest. principles and values.” 2 With no levers tobacco companies. 1 Many financial services providers are for change through positive influence, the subject to a statutory obligation to act in case for divestment is strengthened. The global finance community has the ‘best interests’ of their clients. The largely discouraged divestment (the term ‘best interests’ is one of continuing 2. Understanding all the facts removal) of any stocks, instead favouring inquiry as trustees, directors and a ‘diversified’ (i.e. all stocks) portfolio It is over 50 years since the United States fiduciaries attempt to determine the extent to minimise and spread financial risk. (US) Surgeon General announced the of their responsibilities and whether ‘best Due to this attitude towards divestment, unequivocal link between poor health interests’ implies more than the pursuit of even the use of the word divestment can outcomes and tobacco use and yet the true purely financial benefit. According to the meet resistance from the finance sector. extent of the devastation of tobacco is not Fiduciary Duty in the 21st Century Report, Removing tobacco stocks has therefore well understood by the finance sector. The which was published by the UN-backed required the introduction of a new thought facts, the sheer numbers, tend to startle: organisation Principles for Responsible process and framework for investment. seven million people will die prematurely this year 3 and one billion people this

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Investment (PRI), “Fiduciary duty is not Parliament vote in March 2019 paving world’s fifth largest pension fund, based in an obstacle to action on environmental, the way for a ban on single use plastic, to the Netherlands, announced a new policy social and governance (ESG) factors”. 7 reduce pollution in the oceans and to come excluding investment in tobacco 16 based into force by 2021, per SDG 14 ‘Life below on the framework detailed above. It was a The European Parliament and European water’. 9 What is less well known is that signal of the year ahead with the Tobacco- Union (EU) Member States agreed in cigarette butts are the biggest manmade Free Finance Pledge 17 led by Tobacco March 2019 on new rules on disclosure contaminant of the ocean and can take Free Portfolios and launched at the UN in requirements related to sustainable over a decade to decompose. 10 New York during the General Assembly in investments and sustainability risks. 8 The September 2018. UN Environment Programme Finance SDG 17 calls for ‘Partnerships for the Initiative (UNEPFI) outlines that the Goals’, which most clearly articulates the new regulation will provide consistency importance of cross-sector collaboration across EU Member States by clarifying when addressing major global issues and that duties require investors to consider is the philosophy that underpins the new financially material ESG factors in their investment framework. tobacco cannot investment decision-making. It also sets out how financial actors should inform An investment framework specific be considered a beneficiaries about their compliance to tobacco with the integration of ESG risks sustainable and opportunities. This will apply to With the preceding factors understood, private and occupational pension funds, a review framework of three questions investment insurance funds, portfolio management provides a robust investment critique 11 for and investment advisors. This includes all products including tobacco (see Box 1): The initiative was sponsored by the French requirements to disclose the adverse and Australian governments and supported impact of ESG matters. This would be When these questions and answers are in person by Dr Tedros Ghebreyesus, the first regulatory-backed disclosure considered collectively, a clear framework Director-General‘‘ of the WHO, Dr Vera framework for sustainability impact of emerges. As such, applying an exclusion Luiza da Costa e Silva, Head of the investment activity. 8 to investment in tobacco companies can Secretariat UN Tobacco Control Treaty, be viewed as both a rational and pragmatic French and Dutch health ministers, and This evolution of fiduciary duty has option for investment professionals. global finance leaders from across Europe, effectively removed a barrier to the the US, Australia and Canada, all stood divestment of tobacco stock from Viewing this in conjunction with the side-by-side in a public demonstration of investment portfolios, allowing for a financial impact of increased litigation, the finance sector’s desire to play their new investment framework to emerge. regulation, health awareness and part in helping to solve a global health decreasing social acceptability, it is clear issue of monumental proportions. 18 5. Addressing tobacco to achieve that tobacco cannot be considered a a sustainable future sustainable investment. Finance leaders are increasingly willing to use their power to contribute to The Sustainable Development Goals addressing some of the most pressing (SDGs) were formally adopted Financial markets are transforming, issues of our time. Translating these issues by the UN General Assembly in becoming an ally in the fight against into financial reality will be the key. If September 2015, they officially came tobacco this transformation of financial markets into force on 1 January 2016 and are In the United States in 2019, one in four continues, public health will be the increasingly adopted by the finance US dollars is invested under a socially beneficiary, at last. sector to guide and measure their responsible mandate, 14 and BlackRock’s activities. The SDGs have provided a CEO, Larry Fink, who manages one valuable, constructive platform on which References of the biggest investment management to base dialogue regarding tobacco- 1 companies in the world, is calling World Health Organization. WHO Framework free investment. for more. 15 Convention on Tobacco Control. WHO, 2003. Available at: https://www.who.int/fctc/text_ While it is easy to appreciate the download/en/ The removal of tobacco stocks from importance of tobacco control in pursuit 2 investment portfolios is an indication of da Costa e Silva V. Engagement with tobacco of SDG 3, ‘Good Health and Well-Being’, industry conflicting with UN principles and values. financial markets that are transforming for many in the finance sector are becoming Blog post, WHO FCTC Secretariat, July 2017. health and societal well-being. aware that dramatic improvements in Available at: http://www.who.int/fctc/secretariat/ head/statements/2017/ungc-integrity-review- comprehensive tobacco control are vital Momentum around tobacco-free tobacco-industry/en/ for achievement of 13 of the 17 SDGs. investment has grown steadily in the last 3 One of the most recent high-profile World Health Organization. Tobacco. Fact sheets five years. In January 2018, ABP, the 2019. Available at: http://www.who.int/mediacentre/ decisions has been the European factsheets/fs339/en/

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4 World Health Organization. WHO report 10 Ocean Conservancy. Building a Clean Swell. 2017. 16 IPE. Europe’s biggest pension fund to cut on the Global Tobacco Epidemic, 2008 – The Available at: https://oceanconservancy.org/wp- €3.3bn of tobacco, nuclear assets 2018 Available MPOWER package. WHO, 2008. Available content/uploads/2018/07/Building-A-Clean-Swell. at: https://www.ipe.com/countries/netherlands/ at: http://apps.who.int/iris/bitstream/ pdf europes-biggest-pension-fund-to-cut-33bn-of- handle/10665/43818/9789241596282_eng. tobacco-nuclear-assets/www.ipe.com/countries/ 11 Tobacco Free Portfolios. The toolkit, 12th Edition, pdf?sequence=1 netherlands/europes-biggest-pension-fund-to-cut- 2019. Available at: https://tobaccofreeportfolios.org/ 33bn-of-tobacco-nuclear-assets/10022647.fullarticle 5 BBC News. Tobacco firms to pay billions in wp-content/uploads/2019/05/Toolkit-12th-Edition- January 2018. damages in Canada. US and Canada News, June 2015. May-2019-publication-compressed.pdf Available at: http://www.bbc.co.uk/news/world-us- 17 PSI/UNEP. Tobacco Free Finance Pledge, 2018. 12 Inoue-Choi M, Liao L, Reyes-Guzman C, Hartge P, canada-32969338 Available at: https://www.unepfi.org/psi/tobacco- Caporaso N, Freedman N. Association of long-term free-finance/ 6 Reuters. In landmark case, Brazil sues top tobacco low-intensity smoking with all-cause and cause- firms to recover public health costs. Health news specific mortality in the NIH-AARP Diet and Health 18 Tobacco Free Portfolios. Global leaders 2019. Available at: https://www.reuters.com/article/ Study. JAMA Internal Medicine 2016, 1;177(1):87 – 95. launch Tobacco-Free Finance Pledge. News us-brazil-tobacco-lawsuit/in-landmark-case-brazil- report 26th September 2018. Available at: 13 Banks E, Joshy G, Weber M, et al. Tobacco sues-top-tobacco-firms-to-recover-public-health- https://www.globenewswire.com/news- smoking and all-cause mortality in a large Australian costs-idUSKCN1SS2DN release/2018/09/26/1576316/0/en/Global-leaders- cohort study: findings from a mature epidemic with launch-Tobacco-Free-Finance-Pledge.html 7 PRI (Principles for Responsible Investment). current low smoking prevalence. BMC Medicine Fiduciary duty in the 21st century, Page 15, 2015. 2015;13:38. Available at: https://www.unpri.org/fiduciary-duty/ 14 USSIF (The Forum for sustainable and financial fiduciary-duty-in-the-21st-century/244.article investment). What is sustainable, responsible and 8 UNEP Finance Initiative. EU policy makers achieve impact investing?, 2019. Available at: https://www. political agreement on investor disclosures and ESG, ussif.org/sribasics 2019. Available at: https://www.unepfi.org/news/ 15 Fink L. Purpose & Profit. Larry Fink’s 2019 Letter industries/investment/eu-policy-makers-achieve- to CEOs. Blackrock. Available at: https://www. political-agreement-on-investor-disclosures-and-esg/ blackrock.com/corporate/investor-relations/larry- 9 European Parliament. Parliament seals ban on fink-ceo-letter throwaway plastics by 2021. Press Release 27th March 2019. Available at: http://www.europarl. europa.eu/news/en/press-room/20190321IPR32111/ parliament-seals-ban-on-throwaway-plastics- by-2021

Health, the economy & the G20 sector contributes to the economy in the G20 Member States and in the invited guest countries for 2019.

By: National authors, in collaboration with/support from the The series aims to make the contribution of health systems European Observatory on Health Systems and Policies, 2019 to the economy better understood, supporting both health ministers in their negotiations with their finance colleagues Freely available to download: https://www.hspm.org/g20/ and other health advocates so that health systems receive a fair hearing. A compendium of the country assessments will Governments of the world recognise health as a driver of be officially launched at the G20 Health Ministers’ meeting in economic and societal progress in the 2030 Agenda for Japan in October 2019. Sustainable Development (SDG 3). In reality, health systems may face difficulties securing the necessary funding to deliver on their governments’ commitments to move towards Universal Health Coverage. There are a number of reasons health systems do not always receive the funding they need, including How does the JapaneseHow does the Spanish health legitimate concerns about efficiency and value for money in health sector contributesector to contributethe to the How does the Frencheconomy? health economy? health care. It is also clear that health is not the only sector that sector contribute to the matters when it comes to sustainable progress. Acknowledging economy? How does the Argentine all of this, it is equally as important to recognise the growing health sector contribute to the evidence that shows that health is a major contributor and key economy? driver of strong economies and societal well-being.

This new series of country assessments (fiches), authored by national experts with the support of the Observatory, explores the significant part health systems play in the broader economy. The series draws on cross-country comparable data and country-specific analysis to explore how well the health

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YOU(TH) MATTERS – CO- CREATING POLICIES TO TACKLE OBESITY

By: Margot Neveux, Sherria Ayuandini and Knut-Inge Klepp

Summary: In the past two decades, the prevalence of childhood obesity has risen dramatically, and no country has successfully reversed this trend. Current approaches to address the obesity epidemic have focused on influencing individual choices. However, children and adolescents are particularly vulnerable to the influence of the social, physical and economic environments we live in. Given the failure of traditional approaches to provide meaningful results, new innovative ideas are urgently needed. Through CO-CREATE, we will show the value of a participatory approach and co-creation with youth in the establishment of health policy priorities and ultimately in the formulation of policy proposals. #EHFG2019 – Forum 8: Obesity in Europe – time for a new approach? Keywords: Obesity, Youth, Participatory, Policy, Co-creation

Acknowledgement: The CO-CREATE project has Introduction to an increased risk of developing a received funding from the European wide range of diseases, including type- The prevalence of overweight and obesity Union’s Horizon 2020 research 2 diabetes, hypertension, heart disease, and innovation programme under is increasing globally and in 2016, it was psychosocial morbidity and certain types grant agreement No 774210. The estimated that overweight (including content of this document reflects of cancer. Individual-level treatments of obesity) was affecting 340 million school- only the authors’ views and the overweight and obesity, such as bariatric age children. 1 Europe is no exception: European Commission is not liable surgery or weight loss programmes, have for any use that may be made of the in 2013, 4.5 million children between been shown to be either hard to tolerate information it contains. the ages of five and 18 years were living or ineffective in sustaining weight loss with obesity in European Union (EU) over time. 4 To promote the sustainability Member States. 2 Recently, the World of healthy weight, prevention should be Margot Neveux is Policy & Health Organization (WHO) has flagged the prioritised strategy and a strong focus Projects Coordinator, World childhood obesity as “one of the most Obesity Federation, London, United should be placed on adolescents. Kingdom; Sherria Ayuandini serious public health challenges of the 21st is Youth Engagement and century.” 3 As yet, no country has been Current approaches to address the obesity Participatory Research Specialist, successful in reversing this trend, and University of Amsterdam, epidemic have focused on influencing by 2025, the number of children aged five Netherlands; Knut-Inge Klepp is individual choices, but today’s social, to 18 years living with obesity is projected Executive Director, the Norwegian physical and economic environments are Institute of Public Health, Oslo, to reach 4.8 million in the EU. 2 Norway and coordinator of the rather complex and impact on individual CO-CREATE project. Email: decisions in unconscious ways. Obesity Overweight and obesity in youth and [email protected] is driven by several factors, and we need adolescents aged 13 to 18 years is a strong to move towards comprehensive policies predictor of adulthood obesity and leads

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to address the food, physical activity the world by providing the necessary disease. In CO-CREATE, adolescents are systems and environments surrounding us tools, knowledge and infrastructure to not merely the object of an intervention and reshape the context to make healthy adolescents on policies to support making designed by researchers, but are choices the easiest and most widely the healthiest choices the preferred ones. themselves agents for change, able to preferred ones. By politicising the issue of obesity, identify required actions and collaborate the project focuses on fostering multi- to help achieve them. A core concept stakeholder involvement, including underpinning the project is the need academics, policymakers, civil society to move away from single intervention Young organisations, relevant industry and towards the development and investigation market actors, and, most importantly, of systems-based, evidence-informed, people are the adolescents. stakeholder-involved, comprehensive policy interventions. This reinforces the stimulus for Ultimately, CO-CREATE will need to move away from a primary focus demonstrate a new model to identify, on the ‘downstream’ individual-level, change generate, test and support the autonomous and rational choice-based implementation of obesity and energy determinants of nutrition and physical In 2019, young people represent the balance related behaviour (EBRB) activity behaviours and subsequent obesity largest part of the population globally. policies at national, regional and city risk, towards the more ‘upstream’ drivers Increasingly around the world, we are level. Concretely, CO-CREATE will or determinants of these behaviours. A seeing a desire for young people to develop a model on how to involve young key element of CO-CREATE will be have their voices heard, and the recent people in the development of policies the use of a societal systems approach to youth‘‘ strikes on climate change have and priorities for obesity prevention and understand how different societal factors, shown the potential impact of engaged in the range of relevant stakeholders stakeholders and institutions associated youth. Producing long-lasting effects to by providing specific obesity-related with obesity interact at various levels, and positively impact youth health, including policy proposals, and by designing and the implications these have on policy and reducing overweight and obesity, will testing advocacy tools and strategies young people. not only need to include young people’s for implementation and evaluation. It input, perspective and suggestions: the builds movement towards further youth initiative and leadership of young people involvement in policymaking in the themselves should be part of the answer. future, looking beyond obesity to other It builds The Horizon 2020 project “Confronting health issues and has the ambitious goal obesity: Co-creating policy with youth” of involving youth as much as possible movement (CO-CREATE) aims to have young people in the various activities and phases of involved and even leading the process in the project. The focus on adolescents as towards further the development of health policies. the specific target group aims to show the value of harnessing passion from youth Co-creating policy with youth youth in health policy development. They are also at an age where they gain more involvement in Led by 14 research organisations, CO- autonomy in their behavioural choices CREATE (www.co-create.eu) 5 is the and longer-term behavioural habits are policymaking result of a large effort by the EU to established. It is therefore no surprise curb the childhood obesity epidemic. that the empowerment and investment in This complex systems approach underpins Structured in ten work packages (WPs), adolescents as European citizens is the CO-CREATE’s activities and seeks to 6 ‘‘ CO-CREATE engages regional and core vision of the EU Strategy for Youth. highlight the ways different contextual international partners from different It drives the co-creation of apprioritised set and environmental factors are interlinked, policy contexts in Europe (Norway, of policy objectives to tackle the obesity consequently leading to systems that work Netherlands, United Kingdom, Portugal, epidemic using a range of novel tools, and in a dynamic, uncertain and non-linear Belgium and Poland), Australia, South existing approaches adapted and enhanced way. This novel approach encourages Africa and the United States. for this purpose. relevant stakeholders to consider other factors in the development of these With a focus on equity, CO-CREATE CO-CREATE uses an innovative policies, and to look at the process addresses the current gaps in obesity systems approach in synergy rather than in isolation, research by placing adolescents, their through techniques such as group model perspectives and the factors that shape Changing the obesogenic system for – building to create ‘causal loop diagrams’ their health, at the centre of the project. and more importantly, in collaboration (see Figure 1). For these reasons, CO- The main aim of CO-CREATE is to with – adolescents across Europe, appears CREATE adopted a systems approach to prevent overweight and obesity in to be a key strategy to reduce obesity tackling adolescent obesity, looking at the adolescents in Europe and the rest of prevalence and the related burden of bigger picture to deliberately explore the

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Figure 1: A causal loop diagram created using the systems approach. This one was generated by CO-CREATE participants in the UK

Source: 7

complex, ‘messy’ influences on diet and Prevention Policy. Based on participatory facilitated by a CO-CREATE local physical activity that must be considered action research principles, the activities country staff member and a local youth to generate effective public health and conducted in the alliances “involve representative (co-facilitator). other policies. young people constructing knowledge by identifying, researching, and addressing In the alliances, young people will learn social problems through youth-adult about the systemic factors affecting Youth Alliances for Overweight 9 Prevention Policies will be created partnerships.” health-related lifestyles and receive capacity building training to support In line with the community-based system Through regular meetings, the youth will their information collection activities and dynamics approach of CO-CREATE, the design the core activities to support their enable them to refine their policy ideas. project engages adolescents to collaborate goal of creating novel policy ideas in The activities in which young people in system relevant research. In Norway, areas influencing obesity. Young people engage are built on the principles of the United Kingdom, the Netherlands, themselves will oversee the organisation youth-led participatory action research Poland and Portugal, CO-CREATE aims and agenda of their meetings, as well as during which young people are actively to empower adolescents by developing communication and interaction methods. involved throughout the entire process. sustainable and transferable Youth Each of the countries’ alliances consist While CO-CREATE serves as a starting Alliances for Overweight Prevention of a group of young people between 16 point and offers activities for young people Policies. The alliances will bring and 18 years old recruited through schools, to engage in, ultimately, the young people adolescents together, train and co-create existing youth organisations or other themselves decide which activities they with them the most suitable organisational community outlets. They will be would like to pursue and how the alliances form for Alliances for Overweight are to be run. The direct involvement of

Eurohealth — Vol.25 | No.3 | 2019 Future formulas 33

adolescents as project partners will take a education-oriented interventions that References complex system’s approach to enhance our presume rational decision-making, and 1 World Obesity Federation and World Health understanding of how the broad range of high levels of individual autonomy. Rather, Organization. Taking Action on Childhood Obesity. factors at different policy and contextual we need to move towards comprehensive http://s3-eu-west-1.amazonaws.com/wof-files/ levels impacts adolescents’ diet, physical policies addressing the food and physical Report_-_Childhood_Obesity.pdf activity and weight, and identify relevant activity systems and environments within 2 Jackson-Leach R, Montague F, Lobstein T. Obesity policy responses. which children and adolescents live, in Atlas for the European Union: 2017. London. 2016. order to make healthy choices the easiest Available at: www.worldobesity.org The process of building the youth alliances and most widely accepted choices. 3 World Health Organization. Childhood overweight and their activities will be carefully and obesity. Global Strategy on Diet, Physical Activity monitored and evaluated throughout the The CO-CREATE project is a platform and Health, 2017. Available at: https://www.who.int/ project. The policy ideas generated will aiming to build consensus on the dietphysicalactivity/childhood/en/ Published 2017. be shared and discussed with relevant importance of youth-led co-creation in 4 Klebanoff M, Chhatwal J, Nudel J, Corey K, community stakeholders, including policy policymaking among all stakeholders. Kaplan L, Hur C. Cost-effectiveness of Bariatric makers, non-governmental organisations It involves and empowers adolescents Surgery in Adolescents With Obesity. JAMA Surg. 2017;152(2):136 – 141. and private sector representatives in a and youth organisations to foster a series of dialogue forums. The potential participatory process of identifying and 5 CO-CREATE website. Available at: impact of the proposed policy agenda formulating relevant policies, deliberating www.co-create.eu will be predicted applying system such options with other private and 6 European Commission. EU Youth Strategy. dynamics modelling. public actors, thus promoting relevant Available at: https://ec.europa.eu/youth/policy/ policy agendas, tools and strategies youth-strategy_en All tools, methodologies and prototypes for implementation. 7 CO-CREATE EU. CO-CREATE is working with developed as part of the project will be youth to map out the societal obstacles for leading made publicly available and disseminated Young people are the stimulus for change, healthy lives. Available at: https://www.fhi.no/en/ news/2019/co-create-is-working-with-youth/ widely along with the results from both as the inheritors of obesogenic the study. environments and as the democratic 8 Anyon Y, Bender K, Kennedy H, Dechants J. representatives of the future. It is A Systematic Review of Youth Participatory Action Research (YPAR) in the United States: important that we understand the potential Conclusions Methodologies, Youth Outcomes, and Future role of youth in developing health policies Directions. Heal Educ Behav. 2018:1 – 14. If we are to be successful at curbing and as disruptors of the status quo for the obesity epidemic, we need to move positive change. away from a focus on traditional health

Sustainable health financing The analyses find that for countries where the population is comprised of a large share of relatively younger people who are with an ageing population: likely to be active in the labour market, population ageing can implications of different revenue have a positive impact on revenue generation from all funding sources. This leads to the challenge in many country contexts

Cover_Ageing_02.qxp_Layout 1 raising mechanisms and 12/08/2019 11:34 Page 1 of strengthening tax collection mechanisms to take World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, advantage of this Denmark Tel.: +45 39 17 17 17 policy options Fax: +45 39 17 18 18 E-mail: [email protected] The economics of healthy opportunity. However, in web site: www.euro.who.int and active ageing series countries with a large (and

By: J Cylus, T Roubal, P Ong and S BarberThe European Observatory on Health Syst partnership that supports and promotes ems and Policies is a policy-making through comprehens evidence-based health growing) older population, health systems in the European Region.ive and It rigorous analysis of range of policy-makers, academics and pr brings together a wide trends in health reform, drawing on experactitioners to analyse Europe to illuminate policy issues. The Obs SUSTAINABLE World Health Organization (acting as theience from acrosshost relying in particular on social Copenhagen: are available on its web site ( HEALTH ervatory’s products http://www.healthobservatory.eu). FINANCING WITH organization for, and secretariat of, the European Observatory AN contributions generated from AGEING POPULATION on Health Systems and Policies), 2019 Implications of different revenue the labour market to raise raising mechanisms and policy options revenues for health is Number of pages: 34; ISSN: 1997-8065 Jonathan Cylus Tomáš Roubal Paul Ong expected to result in fewer Freely available for download: http://www.euro.who.int/en/ Sarah Barber revenues per person over the about-us/partners/observatory/publications/policy-briefs-and- coming decades. summaries Print ISSN 1997-8065 The authors consider a Web ISSN This brief looks at how health and long-term care systems 1997-8073 number of policy options to are financed and reports on the potential effects of population address potential revenue ageing on countries’ ability to generate sufficient and shortcomings as a result of stable revenues for health from common funding sources population ageing. This brief was produced jointly with the (i.e. income taxes, consumption taxes, property taxes and WHO Centre for Health Development, Kobe, Japan. social contributions) in the future.

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EMPOWERING COMMUNITIES TO REDUCE HEALTH INEQUALITIES IN EUROPE

By: Johanna Hanefeld, Aaron Reeves, Lin Yang, Ben Barr, Tanith Rose and Chris Brown

Summary: The political determinants of health are vital to understanding where we are in addressing health inequities in the European Region. Politics and policies are a product of their environment and context, the way in which political institutions and the distribution of power shape the political process. This includes important questions on who participates, whether processes and decision-makers are accountable and transparent, and if people and communities are genuinely empowered to have voice. These factors all drive the wider processes that determine whether we can make meaningful progress on health equity.

Keywords: Health Inequalities, Political Determinants, Political Voice, Community Empowerment, Accountability

Introduction > #EHFG2019 – Forum 2: Changing the game on health inequalities Closing the gap in health inequities that health inequalities represent social within countries has been slower than injustices, threaten social stability and many had hoped, 1 especially since we represent an unnecessary waste of lives Johanna Hanefeld is Associate Professor, London School of know the policy conditions which can and human potential. It is clear that Hygiene and Tropical Medicine, facilitate progress towards achieving health inequities should be curbed and, United Kingdom, and a Member health equity. 2 The World Health encouragingly, all of the five policy areas of the Scientific Advisory Group for the European Health Equity Organization’s (WHO) recent European so essential for addressing health inequity Status Report; Aaron Reeves is Health Equity Status Report Initiative are modifiable by policy decisions, Associate Professor, Department (HESRi) has outlined five sets of policies which are ostensibly within the control of Social Policy and Intervention, University of Oxford, United that are an essential part of this agenda: of politicians. The puzzle, then, is not Kingdom; Lin Yang is Consultant, 1) access to health services; 2) income why health inequalities are so pervasive, World Health Organization, New security and social protection; 3) safe but rather why there has been such York, USA; Ben Barr is Senior living conditions; 4) social and human slow progress in reducing them and, by Clinical Lecturer and Tanith Rose is Research Associate, Institute capital; and 5) employment and working implication, how can we accelerate action of Population Health Sciences, conditions. 3 However, establishing health on health equity? University of Liverpool, United improving policies across all of these areas Kingdom; Chris Brown is Head of the WHO European Office is not straightforward and countries have Again, the WHO’s European Health for Investment for Health and often struggled to put these policies in Equity Status Report provides invaluable Development, Venice, Italy. Email: place. Moreover, this failure is set against insight. Politicians are not simply free [email protected] a backdrop of widespread agreement to remake societies once they come into

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power because they are constrained in decision-making processes. 4 When tend to have higher quality participation both by the past and by the institutional political institutions systematically exclude and thereby have a greater influence on and societal conditions that make some some groups from decision-making, their policy processes. 7 decisions easier to implement than others. health is likely to suffer because their 5 This is because politics and policies are a interests may be overlooked. Put simply, Empowering communities product of their environment and context, inclusive political institutions incentivise and the way in which political institutions politicians to implement UHC, expand Political institutions can also play a role and the distribution of power shape the social protection, allow the least well-off in how communities get to participate political process. The HESRi stresses the to capture a greater share of economic in decision-making processes. Many centrality of understanding the political growth, or other policies that could people clearly feel disconnected from determinants of health if countries improve well-being. policy decisions which affect their lives are to address health inequities in the and subsequently experience a lack of European Region. 3 control. Moreover, there are inequalities here too, because such feelings are far The job of political institutions is to Political more common among those with little translate the interests of individuals or no education. 3 A lack of control and groups into policies which, in turn, institutions is 11 percentage points higher among men affect life chances. Political institutions with low levels of education than men influence population health because they influence with high levels of education. make politicians more or less responsive to the preferences of citizens and this population health Experiencing lack of control is not just can influence policy decisions (such as about education, however. Women are whether countries implement Universal Lack of political voice frequently follows more likely to experience low levels of Health Coverage–UHC) that impact a clear social gradient. Across the region, empowerment, and this is true of highly health and well-being. In practice, these people with fewer years of education educated women too. In four of the processes are not straightforward because feel less able to influence politics than countries surveyed over 40% of women whether policies are responsive depends those with more education. 3 This sense with the highest level of education on who participates, whether processes of lacking political voice has direct health reported lacking freedom and having little ‘‘ 3 and decision-makers are accountable implications because, as shown in data control over their own lives. Feelings of and transparent, and if people and from the Health Equity Status Report too, empowerment intersect with education, communities are genuinely empowered health inequalities were wider in countries social class, gender, and race and ethnicity, to have voice; these factors all drive the with higher inequalities between those but they are rooted in political institutions wider processes that determine whether who felt able to influence politics. 3 One which shape who has autonomy. we can make meaningful progress on reason is that actual political participation health equity. Just because a country is a tends to be lower among those who believe Empowering communities relies on trust democracy does not mean their politicians they have little or no influence on politics. because collective action and cooperation will implement policies which reduce That is, feeling powerless makes you less are almost impossible in situations where health inequalities if those with the worst likely to exercise what little power you trust is absent. Given this backdrop, it is health are also disenfranchised (either do have. Indeed health inequalities are unsurprising that lack of trust is one of the formally or informally) from decision- wider in countries with greater inequalities primary drivers of health inequities across making processes. In short, the HESRi in voting, a crucial aspect of political Europe, accounting for 28% of health suggests that to scale up action on health decision-making. 6 When some groups do inequities in social and human capital. 3 equity, action needs to be taken on not participate in electoral processes or Trust, of course, may have a direct effect underlying factors driving health equity other forms of deliberative democracy, on health through engendering social and this includes the political determinants their values are too often discounted. support but it is also likely to work through of health. more political mechanisms too, such as Equally, the quality of participation making collective action possible. 3 Who has voice? matters. Where involvement in the policy process signals genuine participation in Empowering communities is also Political institutions, laws and regulations, decision-making, people take ownership concerned with fostering social together with institutional practices (that of policy decisions and participation participation, which reflects the degree is, ways of doing politics, which in turn translates into shared power and to which a population is involved in the are shaped by context and history) govern responsibility with greater accountability. decisions that affect their health. Of who has voice (or who has the right to This differs from the kind of participation course, participation goes beyond that speak) in decision-making processes. in political processes which is ultimately too, it is also concerned with who gets These rules affect policy choices because consultative and which rarely alters to define the problem and then how it is politicians are not compelled to heed the the status quo of power relations. defined. Empowering communities entails voices of those who do not participate Unfortunately, those with more resources creating governance mechanisms that

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raise awareness and recognition of the and transparency will only serve to governance structures where communities rights of those groups with the greatest weaken trust and slow progress toward can become empowered to address their health disadvantage, transforming them health equity. own needs. Paying lip-service to notions from being ‘vulnerable’ into being agents of co-production and participation will of change for their own interests and the Commercial determinants – a spanner not be enough. Instead we must value the interests of their community. Once again, in the works? knowledge of individual and community it is political institutions that determine experiences, maximise the potential of whether communities are empowered The creation of political institutions empowering spaces, such as civic centres or not. that foster ‘responsive, inclusive, and citizens’ assemblies, and explicitly participatory and representative decision- move away from stigmatising narratives 12 Are policymakers accountable? making at all levels’ of our societies of disadvantage. Making this move will is opposed by countervailing forces that not come easily to the health community, While horizontal trust (between citizens do not want to deepen democracy. These and it will mean creating new partners, themselves) is a necessary condition for powerful, organised vested interests may finding new ways of working and taking a well-functioning democracy, it is not work against giving voice to deprived on new challenges. In short, we need a step sufficient. Effective political systems communities and oppose efforts to change in how we build the coalitions that need vertical trust (between citizens and increase accountability. Commercial put power into the hands of those who are policymakers) too. One of the mechanisms entities are one set of actors that have, at most deeply affected by health inequity. for ensuring vertical trust between citizens times, tried to shape public health policy and policymakers is transparency and according to their own priorities, and References accountability, and these are also some in doing so represent the commercial of the underlying drivers of action of determinants of health. 1 Mackenbach JP. The persistence of health health inequalities. When politicians are inequalities in modern welfare states: The explanation of a paradox. Social Science & Medicine 2012; 75: seen to be unaccountable and able to act Clearly not all corporations actively seek 761–9. in their own interests, people become to influence public health policy, and many 2 disenfranchised even if they are formally have the potential to be an active partner Hanefeld, J, Reeves, A, Brown C, Östlin P. Achieving health equity – democracy matters. allowed to participate. Indeed voter in improving population health, but The Lancet, (forthcoming 2019). turnout tends to be lower when trust in public health researchers have uncovered 3 politicians is lower too. 8 numerous examples where corporations WHO Europe. Healthy, prosperous lives for all: the European Health Equity Status Report. Copenhagen, and other vested interests have acted to Denmark: WHO Regional Office for Europe, 2019. Freedom of speech is one way citizens the detriment of population health. 13 Their 4 ensure accountability. Civil society strategies are diverse, sometimes they seek Key VO, Heard A. Southern Politics in State and Nation. Knoxville, TN: University of Tennessee Press, organisations and the media play a to frame the policy agenda (by shaping 1949. crucial role in holding political leaders to what policies are up for debate) while 5 account and when governments curtail at others they try to directly influence Krieger N, Kosheleva A, Waterman PD, Chen JT, Beckfield J, Kiang MV. 50-year trends in US the freedoms of these organisations it legislation (by opposing policy change). socioeconomic inequalities in health: US-born Black weakens their ability to work on behalf of The challenge has always been detecting and White Americans, 1959 – 2008. Int J Epidemiol the communities they serve. Freedom of precisely when and how this influence 2014; 43(4):1294 – 313.

the press, however, has faced a number of works, largely because those who deploy 6 Reeves A, Mackenbach JP. Can inequalities in set-backs across the world in recent years such power want to obscure it. political participation explain health inequalities? and this has coincided with increasing Social Science & Medicine 2019; 234(112371).

levels of distrust of mainstream press Commercial determinants play an 7 Page BI, Bartels LM, Seawright J. Democracy 9 organisations. important role in shaping population and the Policy Preferences of Wealthy Americans. health but the outsized influence of these Perspect Polit 2013; 11: 51–73.

Corruption is often high when vested interests could be curtailed by 8 Hooghe M. Trust and Elections in Uslaner EM (ed.) accountability is weak and there is increasing accountability, empowering The Oxford Handbook of Social and Political Trust. evidence of corruption across the communities, and giving people more New Yory, USA: Oxford University Press, 2018.

European region. In the health sector, voice in political decision-making. 9 Ladd JM. Why Americans Hate the Media and How informal payments, ‘kickbacks’ from It Matters. Princeton, NJ: Princeton University Press, selling access to medical devices, Conclusion 2012. or payments from pharmaceutical 10 Ecorys Nederland B.V. Updated Study on companies to physicians are all too ‘Politics [is] nothing but medicine at a Corruption in the Healthcare Sector. Brussels, common. 10 Beyond health, corruption larger scale’ 14 and public health efforts Belgium: Directorate-General for Migration and Home continues to influence politics, with some to address health inequalities will require Affairs, 2017. think tanks selling access to politicians not just better interventions but more 11 Gornall J. Big tobacco, the new politics, and the for funding. 11 This lack of accountability inclusive political systems. Addressing threat to public health. BMJ 2019; 365: l2164. health inequities rests on changing political and economic systems to create

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12 UN General Assembly. Transforming our world : THE GLOBAL the 2030 Agenda for Sustainable Development. 2015. Available at: https://www.un.org/ga/search/ view_doc.asp?symbol=A/RES/70/1&Lang=E CLIMATE CRISIS: 13 Freudenberg N. Lethal But Legal: Corporations, Consumption, and Protecting Public Health, Reprint edition. New York: Oxford University Press, 2016. A PUBLIC HEALTH 14 Mackenbach JP. Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea. Journal of Epidemiology & Community Health 2009; 63: 181–4. EMERGENCY

By: Rachel Stancliffe

Summary: The climate crisis, the collapse of biodiversity and the widespread pollution of air, water and soil are no longer merely environmental health concerns. They are the biggest public health threats humankind has ever faced. Public health understanding and solutions, not technological fixes, are needed to guide us. Public Health has the skills and tools in research, practice and policy to help the public and government to understand the urgency of the situation and the options for dealing with it. We must now rapidly take that responsibility and work to ensure transformative change is taken to avoid climate catastrophe.

Keywords: Climate, Environment, Emergency, Sustainability, Carbon

Introduction planet in less than 50 years, and humans have accelerated extinction rates up Climate breakdown now poses an to 1000-fold. The prevalence and impacts immediate threat to human health and of plastic pollution have hit the headlines. survival. This is a public health priority. This disruption is not available in a healthy Extinction Rebellion, Greta Thunberg and dose. This disruption is an emergency others have successfully reminded us of happening with what will be a lethal the climate crisis, and the lack of action dose for vast numbers of people. We need to address it: despite the political ‘hot air’, transformative change to avoid climate global greenhouse gas emissions have catastrophe. If we do not achieve rapid more than doubled in less than 40 years, > #EHFG2019 – Closing plenary: transformation, we will see increasing and have been rising at an accelerating The global climate crisis: death tolls within our lifetimes. However, rate in the last three years. 1 They remind a public health emergency if we do, we could witness the emergence us that we face a public health emergency: of much healthier and happier societies. just as for outbreaks of communicable disease, the epidemic has already taken Rachel Stancliffe is Director, The Is society at last waking up? The last year hold, and we must work together to limit Centre for Sustainable Healthcare, or so has seen increased awareness of the Oxford, United Kingdom. further spread and find cures. They impact of humans on the ecosystem upon Email: rachel.stancliffe@ remind our leaders that they have a duty sustainablehealthcare.org.uk which they depend for survival. Over 60% of care to us all. of vertebrates have been lost from our

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Figure 1: Moving towards transformation

HEALTHY PEOPLE PRIMARY CARE SECONDARY CARE

OBESITY, CHRONIC DISEASE HIGH LEVELS RESOURCES USED

30% CARBON REDUCTION

30% REDUCTION IN RESOURCES USED

90% CARBON REDUCTION

90% CARBON REDUCTION RESULTING IN TRANSFORMATION

Source: 9

It was, at least partly, the success of public we have to pass the 1.5ºC mark in 2030. We have health interventions which helped to just 11 years to avert ecological, social and facilitate the rapid increase in the global no time left for public health disaster. population and longevity, which, together with consumerism, support conditions inaction The IPCC reports that avoiding for the current climate crisis. It is public catastrophic climate change requires health that will suffer the most if we Earlier models suggested that global “rapid, far-reaching and unprecedented do not transform urgently. Yet it is also heating up to two degrees above pre- changes in all aspects of society”: the principles and experience of public industrial times might be manageable. transition to 100% renewable energy, health that are best placed to help us to However, the 2018 report of the upgrading housing stock, investment in understand how to re-focus health and Intergovernmental Panel on Climate sustainable transport infrastructure and health care to prioritise how we use our Change (IPCC) spells out the stark impacts a largely vegetarian diet. These changes, precious resources for maximum health. of even a 1.5 degrees increase. 1 Historic designed to protect human health in the emissions‘‘ alone will drive a 1 – 1.2 degree future, will also bring substantial public Is there a climate emergency? ‘fever’ for our planet and heating health benefits now. beyond 1.5ºC will cause drought, crop Over the last 100 years our consumption failure, mass starvation and the collapse These changes are still – just – achievable, of our planet’s resources has grown of many urban civilisations. Beyond this but only with a huge mobilisation of exponentially and the rate at which we we are likely to move through a series political will. are impacting our natural environment of tipping points which break down the continues to accelerate. Despite stability of the climate as we know it. At Dr Hugh Montgomery offers a summary over 40 years of warnings, CO2 levels in the current trajectory, the planet is due of the situation in his presentation the atmosphere have continued to rise, available on YouTube. He jokes that passing 415ppm for the first time in 2019. 1

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‘homo sapiens’ is a disease that is making What can public health do? help people and politicians understand the earth sick, but the disease of ‘homo the scale of the crisis. They must also The core principle of public health– sapiens’ is self-limiting. transform their systems to be fit for the organising and using resources for the future. best health for all people–should guide us Why is the climate emergency also now. What resources are available in this a public health emergency? crucial decade to come, and how must they be deployed? How does this relate Humans are exploiting resources at a to every domain–transport, agriculture, the rate which cannot be sustained: we have energy generation and more? How can drained fossil aquifers and ground water, policymakers support the most vulnerable, biggest known and will soon have destroyed all the who have contributed least to the problem? topsoil on which we can grow crops. 3 How can carbon taxes on fossil fuels (such public health We are destroying the ecosystems upon as those introduced by French President which the very survival of our species Emmanuel Macron) be made equitable and threats depends. 4 Climate change acts as a force palatable to the voting populace? multiplier on such impacts and their health humankind has consequences, whilst increasing bacterial How must the health service transform? growth rates, vector borne diseases, Will we need to prioritise prevention over ever faced oceanic algal blooms and ground level cure, at least in the short term. ozone concentrations. It drives rising 1. Speak out sea levels and more (and more extreme) And what is the role for the public health Health professionals‘‘ are widely respected weather events: heatwaves, wildfires and community in tracking climate change in our society. Use your voice to call for flooding. Such consequences drive direct impacts (e.g. disease surveillance) and in political and institutional action on climate (e.g. water and air pollution) and indirect adapting to such impacts? We may not yet breakdown. Consider supporting the (such as famine, conflict and migration) know the answers to these questions. But work of climate change organisations and health impacts. These are not impacts we have no time left for inaction. We must movements such as Extinction Rebellion which are amenable to ‘simple fixes’. do our best, and now. (https://rebellion.earth) and the calls for declarations of climate emergency (https:// The World Bank predicts that by 2030 Identifying emissions hotspots and climateemergencydeclaration.org/). the changing climate will already have improving surveillance of related diseases reversed global public health gains of the will help to detect and prevent some of 2. Develop environmentally sustainable past 50 years, throwing 100 million people the burden of disease. However, public health care systems back into poverty and causing at least an health practitioners have a much bigger additional 250,000 deaths annually. 5 These Sustainable health care provides role to play. Our skills in systems thinking, may be a very significant underestimation health care for patients today without bio-social relationships, equity and of the scale of mortality, given that we do compromising health and care provision in management must be deployed to help not understand climate tipping points, nor the future. That seems obvious and simple. policymakers in every country design the social and political factors entwined Yet we know that our lifestyles are making equitable transformations to a post- with these. The scale of the 2019 fires in us ill, and our health care practices are carbon world. the Amazon, an increase on 2018 by 84%, 6 using up natural resources far too rapidly, very clearly illustrates this. Increases in leaving more pollution and waste than heatwaves, flooding, infectious diseases, What can all health professionals do? planetary systems can handle, without air pollution and declining food and water consideration for the health care needs of Health professionals dedicate their security may be manageable now, but as tomorrow’s patients. working lives to serve individuals and they increase dramatically over the next populations. Despite the efforts during decade, the social, political and financial So, how do we know what is sustainable? the last decade of organisations including ability to deal with them – even in rich The environmental and social the Global Climate and Health Alliance countries – will decline. sustainability of health care delivery is (climateandhealthalliance.org), Medact as important as the financial viability of (www.medact.org), Healthcare Without The Lancet has supported excellent work services. These three elements together Harm (https://noharm.org) and my own to analyse, interpret, and publicise the are often referred to as the ‘triple bottom organisation, The Centre for Sustainable connections between health and climate line’. Analysing in detail the full resource Healthcare (www.sustainablehealthcare. change, as reported in The Lancet use, or triple bottom line, of all that we are org.uk), the commitment of health Countdown 2018 Report. doing is essential in understanding what professionals to this issue has been far too we should prioritise – we could think of it timid. Health professionals, policymakers as: what gives us the most health for our and their organisations must support and triple bottom buck? learn from the recent schoolchildren’s strikes, finding more effective ways to

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The Centre for Sustainable Healthcare’s time for that – and focus all our efforts available to ensure that transformative four principles of sustainable clinical on working together to save the future of change is achieved to avoid a climate, and practice 8 are: our species. public health catastrophe. • prevention Read more, speak to everyone you know, References • patient empowerment and self-care be humble but brave and generous; begin to act. 1 Intergovernmental Panel on Climate Change. • lean systems Global warming of 1.5 C. IPCC, 2018. Available at: https://www.ipcc.ch/sr15/ • low carbon alternatives Greta Thunberg, the Swedish student who is raising global awareness about the risks 2 YouTube. RCoA ARIES Talk: Climate Change These principles help us to prioritise posed by climate change, speaks bluntly: and Anaesthesia by Hugh Montgomery, 20 April 2017. Available at: https://www.youtube.com/ resource use within health care, and “Why should I be studying for a future watch?v=YMqAkV2yDaU direct us toward upstream spending, that soon will be no more, when no one 3 including preventative care and low carbon is doing anything to save that future? ... Marler J, Wallin J. Nutritional Quality of Harvested Food and Sustainable Farming Systems. Mimeo. interventions. We must change almost everything in our Washington, DC: Nutrition Security Institute, 2006. current societies … Adults keep saying: 4 Sustainable health requires more than a ‘We owe it to the young people to give Living Planet publication index. Available at: http://www.livingplanetindex.org/publications lower carbon version of today’s health them hope.’ But I don’t want your hope. care. It requires transformative investment I don’t want you to be hopeful. I want 5 The World Bank. Climate Change and Health web of resources to keep people healthy, rather you to panic … If you have a child that page. Available at: https://www.worldbank.org/en/ topic/climatechangeandhealth than addressing their illnesses once they is standing in the middle of the road, are sick (see Figure 1). and cars are coming at full speed, you 6 Watts J. Amazon rainforest fires: global leaders don’t look away because it is too hard to urged to divert Brazil from ‘suicide’ path. The Guardian, 23 August 2019. Available at: https:// 3. Connect with others see, you run out and get that child away www.theguardian.com/environment/2019/aug/23/ from there.” 11 It is important to develop contacts with amazon-fires-global-leaders-urged-divert-brazil- suicide-path like-minded individuals to support you The disruption is certainly there. We 7 and to share ideas with. The Centre for YouTube. The Lancet Countdown on Health and certainly need transformative change, Sustainable Healthcare (CSH) offers Climate Change: 2018 report, 28 November 2018. of our health systems and of our whole Available at: https://www.youtube.com/watch?v=mo a range of free networks 9 that you are societies, and more quickly than many YzcYNX1iM&feature=youtu.be welcome to join as do many of our partner of us can comprehend. 8 organisations. Become active on social Mortimer F. The sustainable physician. Clinical Medicine 2010; 10(2):110-1. Available at: http://www. media. clinmed.rcpjournal.org/content/10/2/110.full.pdf OK, now PANIC! 9 4. Support the fossil fuel divestment The Centre for Sustainable Healthcare. Join us The climate crisis, the collapse of web page. Available at: https://sustainablehealthcare. campaign biodiversity and the widespread pollution org.uk/join-in Whether as organisations, or as of air, water and soil are no longer merely 10 Medact. Fossil Fuel Divestment web page. individuals, how we spend our money and environmental health concerns. They Available at: https://www.medact.org/project/ where we keep our money is important. are the biggest known public health divestment/ Switching to renewables starts with our threats humankind has ever faced. As 11 Greta Thunberg speeches web site. Available at: own energy suppliers and then we must professionals who understand the evidence https://www.fridaysforfuture.org/greta-speeches look at where our bank and our pension and its implications, we owe it to our funds are invested. Medact have been children to panic. instrumental in driving a campaign to persuade health care organisations such The time for Public Health to shine as the United Kingdom Royal Colleges to divest from fossil fuels. 10 Public health interventions have supported the population increase and rises in life Don’t panic … expectancy over the past 150 years. Public health understanding and solutions, not Above all, let us not be paralysed simply technological fixes, are now needed to help because we do not have all the answers. respond to the climate emergency. Public Policymakers must work collaboratively Health has the skills and tools in research, with researchers and practitioners to practice and policy to help the public and study the evidence for the best models government understand the urgency of worldwide on options for optimising use the situation and the options for dealing of resources for public health. We must with it. We must now rapidly take that put aside competition – there is really no responsibility and work hard by all means

Eurohealth — Vol.25 | No.3 | 2019 Transforming societies 41

CAN PEOPLE AFFORD TO PAY FOR HEALTH CARE? NEW EVIDENCE ON FINANCIAL PROTECTION IN EUROPE

By: Sarah Thomson, Jonathan Cylus and Tamás Evetovits

Summary: New analysis shows that out-of-pocket payments lead to financial hardship for people using health services, even in high- income countries that cover the whole population. To strengthen financial protection, countries need to focus on the design of health coverage, paying attention to policy on co-payments for outpatient prescriptions – a key determinant of financial hardship, especially in countries where the scope of the publicly financed benefits package is adequate. Learning from a wealth of good practice in Europe, countries can improve co-payment policy by introducing exemptions for poor people, applying annual caps to all co-payments and replacing percentage co-payments with low fixed co-payments.

Keywords: Access, Affordability, Co-payments, Financial Protection, Universal Health Coverage

Out-of-pocket payments undermine budget surveys and analysis of national universal health coverage in Europe policy developments. It reveals that: New evidence from the World Health • between 1% and 9% of households are Organization (WHO) Regional Office for pushed into poverty, or further into > #EHFG2019 – Forum 7: Europe finds that when people have to poverty, as a result of out-of-pocket Can people afford to pay for health care? pay out of pocket for health care, some of payments; them face barriers to access and forego • between 1% and 17% of households treatment due to the cost involved; some experience catastrophic health spending, Sarah Thomson is Senior Health pay and suffer financial hardship; and which may mean they can no longer Financing Specialist and Tamás some experience both unmet need and Evetovits is Head, World Health afford to meet other basic needs such as financial hardship. 1 Organization Barcelona Office for food, housing and heating; Health Systems Strengthening, Barcelona, Spain; Jonathan Cylus The new WHO study draws on • catastrophic health spending is is Economist and London Hub Coordinator, European Observatory contributions from national experts consistently concentrated among the on Health Systems and Policies, in 24 countries in Europe, involving poorest 20% of the population; London, United Kingdom. analysis of microdata from household Email: [email protected] • it is mainly driven by out-of-pocket payments for outpatient medicines; and

Eurohealth — Vol.25 | No.3 | 2019 42 Transforming societies

• the share of people foregoing needed committed to reach by 2030, 2 and a (over 12%). Across Europe, people in the health services, including prescribed priority for WHO (see Box 1). This new poorest quintile are consistently most at medicines, is high in countries where study is the first systematic attempt to risk of catastrophic health spending. financial protection is weak. monitor financial protection in Europe. 3 Outpatient medicines are the main Out-of-pocket payments push people driver of financial hardship into poverty or make them even Financial poorer Out-of-pocket payments incurred by households with catastrophic health protection is a There is wide variation in the incidence spending are mainly due to outpatient of impoverishing health spending among medicines, followed by inpatient care and core dimension European Union (EU) countries and dental care. The share of catastrophic among non-EU countries (see Figure 1). health spending due to outpatient of health system medicines is consistently higher The poorest households are most than average in the poorest quintile performance likely to experience financial hardship (see Figure 3).

Ensuring everyone can use quality health The incidence of catastrophic health Unmet need must be part of the services without experiencing financial spending varies widely among EU analysis hardship – universal health coverage – is countries (see Figure 2). Among non-EU a Sustainable‘‘ Development Goal (SDG countries, the incidence is generally high Financial protection indicators capture targets 3.8.1 and 3.8.2) all countries have financial hardship arising from the use

Box 1: What is financial protection, why does it matter and pocket was already below the poverty line (it was already how is it measured? unable to meet basic needs); it is further impoverished after spending out of pocket. Financial protection is a core dimension of health system • Catastrophic health spending occurs when the amount a performance and central to universal health coverage. 4 household pays out of pocket exceeds a predefined share People experience financial hardship when out-of-pocket of its ability to pay for health care. This may mean the payments are large in relation to their ability to pay for health household can no longer afford to meet other basic needs. care. Small out-of-pocket payments can cause financial Financial protection indicators can be calculated in different hardship for poor households or those who have to pay for ways, using a range of metrics. 5 6 The WHO Regional Office long-term treatment. Large out-of-pocket payments can for Europe has developed new metrics to measure financial lead to financial hardship for rich households as well as poor protection in response to concerns that the method used to households. measure financial protection in the SDGs (SDG target 3.8.2), Where health systems fail to provide financial protection, and other global approaches, pose a challenge for equity and some people may be forced to choose between using health have limited relevance for Europe. 1 Building on established services and meeting other basic needs such as food, housing methods, the metrics used in the new WHO study are less and heating; some may forego health care, resulting in unmet likely to underestimate financial hardship among poorer people need. Lack of financial protection can therefore reduce access than the SDG metrics because they account for differences to health care, undermine health status, deepen poverty and in household capacity to pay for health care. 5 6 The aim is exacerbate health and socioeconomic inequalities. to measure financial protection in a way that is relevant to all countries in Europe, produces actionable evidence for policy Because all health systems involve some out-of-pocket and promotes policies to break the link between ill health payment, financial hardship linked to the use of health services and poverty. can be a problem in any country. All financial protection metrics draw on similar sources of data, Financial protection is measured using two indicators: typically household budget surveys; define out-of-pocket • Impoverishing health spending provides information on the payments in the same internationally standard way as formal impact of out-of-pocket payments on poverty. A household and informal payments made at the time of using any health is impoverished if its consumption is above the poverty line care good or service provided by any type of provider; and before spending out of pocket and below it after spending measure financial protection at the level of the health system, out of pocket (it is no longer able to afford to meet basic not at the level of different types of health care, diseases or needs). A household can also experience impoverishing patient groups. health spending if its consumption before spending out of

Eurohealth — Vol.25 | No.3 | 2019 Transforming societies 43

Figure 1: Share of households with impoverishing health spending, latest year available of health services, but do not indicate whether out-of-pocket payments create 9 a barrier to access, resulting in unmet 8 need. Bringing together data on financial 7 hardship and unmet need reveals the 6 following findings. 5 4 In countries where the incidence of 3 Households (%) catastrophic health spending is very 2 low, unmet need also tends to be 1 low and without significant income 0 1

1 inequality. The incidence of catastrophic 20 1 2013 2014 2015 2016 2015 2015

A health spending and levels of unmet TU 2016 IRE 2016 LV L FR A ALB 2015 ES T PO L AU T SVK 2012 CY P TUR 2014 KGZ 2014 SVN 2015 CZH 2012 UKR 2015 UNK 2014 DEU 2013 GRE 2016 POR 2015 HUN 2015 MD A GEO 2015 CRO 2014 SWE 2012 need are both relatively high in many Further impoverished Impoverished countries, and income inequality in Note: ALB: Albania; AUT; Austria; CRO: Croatia; CYP: Cyprus; CZH: Czechia; DEU: Germany; EST: Estonia; FRA: France; unmet need is also significant, indicating IRE: Ireland; GEO: Georgia; GRE: Greece; HUN: Hungary; KGZ: Kyrgyzstan; LTU: Lithuania; LVA: Latvia; MDA: Republic of Moldova; that health services in these countries POL: Poland; POR: Portugal; SWE: Sweden; SVK: Slovakia; SVN: Slovenia; TUR: Turkey; UKR: Ukraine; UNK: United Kingdom. are not affordable, especially for poorer Source: 1 households.

Figure 2: Share of households with catastrophic health spending by consumption Some health services – notably dental care quintile, latest year available – are a much greater source of financial hardship for richer households than poorer 18 households. This reflects higher levels of 16 unmet need for dental care among poorer 14 households than richer households in 12 most countries. 1 10 8 Unmet need for prescribed medicines

Households (%) 6 is generally higher in countries with a 4 higher incidence of catastrophic health 2 spending, which indicates that out-of- 0

1 pocket payments for medicines lead to 20 1 2013 2014 2015 2016 2015 2015

A both financial hardship and unmet need TU 2016 IRE 2016 LV L FR A ALB 2015 ES T PO L AU T SVK 2012 CY P SVN 2015 CZH 2012 KGZ 2014 TUR 2014 UNK 2014 DEU 2013 UKR 2015 MD A GRE 2016 HUN 2015 POR 2015 GEO 2015 CRO 2014 SWE 2012 for poorer people. 1 Richest 4th 3rd 2nd Poorest

Notes: consumption quintiles are based on per person consumption adjusted for household size and composition using Factors that strengthen financial OECD equivalence scales. The first quintile is labelled “poorest” and the fifth quintile “richest”. protection Source: 1 Health systems with strong financial protection and low levels of unmet need Figure 3: Breakdown of out-of-pocket payments by health service among households share the following features: with catastrophic health spending in the poorest consumption quintile • there are no major gaps in health 100% coverage;

80% • coverage policy – the way in which coverage is implemented and 60% governed – is carefully designed to minimise access barriers and out-of- 40% pocket payments, particularly for poor 20% people and regular users of health

Out-of-pokcet payments (%) services; 0% 1 • public spending on health is high 20 1 2013 2016 2015 2014 2015 2015 A TU 2016 IRE 2016 LV enough to ensure relatively timely L FR A ALB 2015 ES T AU T PO L SVK 2012 CY P SVN 2015 CZH 2012 KGZ 2014 TUR 2014 UNK 2014 DEU 2013 UKR 2015 MD A POR 2015 GRE 2016 HUN 2015 CRO 2014 GEO 2015 SWE 2012 access to a broad range of health Inpatient care Diagnostic tests Dental care Outpatient care Medical products Medicines services without informal payments; and, as a result

Note: countries ranked by incidence of catastrophic health spending from lowest to highest.

Source: 1 Eurohealth — Vol.25 | No.3 | 2019 44 Transforming societies

Figure 4: Incidence of catastrophic health spending and the out-of-pocket payment • out-of-pocket payments are low, share of current spending on health, latest year available accounting for less than or close to 15% of current spending on health. 18 The strong association between the Republic of Moldova (2016) incidence of catastrophic health spending and the out-of-pocket payment share of current spending on health (see Figure 4) 16 suggests that the out-of-pocket payment

Lithuania (2016) share can be used as a proxy indicator for financial protection when data on financial Ukraine (2015) Georgia (2015) protection are lacking.

Latvia (2013) Kyrgyzstan (2014) Better co-payment Albania (2015) 12 Hungary (2015) policy plays an important role in

10 Greece (2016) reducing financial hardship Poland (2014) Portugal (2015) Addressing gaps in coverage to 8 reduce financial hardship

Catastrohpic incidence (%) ‘‘ Estonia (2015) Across countries, public spending on health is shown to be much more effective in reducing out-of-pocket payments than 1 6 voluntary health insurance. Increases in public spending on health or reductions Turkey (2014) Cyprus (2015) in out-of-pocket payments are not enough to improve financial protection in all contexts, however. Coverage policies Croatia (2014) play a key role in determining financial 4 Slovakia (2012) hardship, not just patterns of spending on health.

Austria (2015) Germany (2013) Gaps in coverage arise from weaknesses in the design of three policy areas: 2 France (2011) Sweden (2012) • the basis for population entitlement United Kingdom (2014) Ireland (2016) leaves some people without access to Czechia (2012) publicly financed health services; Slovenia (2015) R 2 = 0.71 • the range of services that is publicly 0 financed – the benefits package – is 0 15 30 45 60 Out-of-pocket payments as a share of current spending on health (%) narrow, or there are issues relating to the availability, quality and timeliness of these services; and Notes: R2: coefficient of determination. Data on out-of-pocket payments are for the same year as data on catastrophic incidence. The association between catastrophic incidence and the out-of-pocket payment share excluding out-of-pocket payments for long- • there are user charges (co-payments) term care is almost identical (R2 = 0.70). in place for services in the benefits Source: 1 package.

Eurohealth — Vol.25 | No.3 | 2019 Transforming societies 45

Figure 5: Catastrophic health spending and the design of co-payments for outpatient prescribed medicines

Percentage co-payments 18 + limited protection 16 Low fixed co-payments mechanisms 14

12 Poor people are exempt from co-payments 10 8 VHI covers Annual cap on co-payments 6 co-payments 4 Catastrophic incidence (%) incidence Catastrophic 2 0 IRE EST LVA LTU SVK ALB FRA CYP GRE POL SVN KGZ AUT POR CZH DEU CRO GEO SWE UNK HUN MDA

Source: 1

Weaknesses in coverage policy undermine countries with strong financial protection References equity and efficiency by creating financial and countries where financial protection is 1 WHO Regional Office for Europe. Can people barriers to access. They also shift the weak overall but steps have been taken to afford to pay for health care? New evidence on financial burden of paying for health protect poor people. 1 financial protection in Europe. Copenhagen: WHO care on to those who can least afford it – Regional Office for Europe, 2019. Available at: http:// poor people and regular users of health www.euro.who.int/en/publications/abstracts/can- Acting on the evidence: progressive people-afford-to-pay-for-health-care-new-evidence- services – and encourage inefficient universalism ensures no one is on-financial-protection-in-europe-2019 patterns of use. left behind 2 United Nations. Transforming our World: the 2030 Agenda for Sustainable Development. New Better co-payment policy plays an Acting on the evidence: better co- York, NY: United Nations, 2015. Available at: payment policy is key important role in reducing financial https://sustainabledevelopment.un.org/post2015/ hardship because it allows the health transformingourworld

The first step to strengthening financial system to target the people most in need 3 Yerramilli P, Fernández O, Thomson S. Financial protection is to identify gaps in coverage of protection. Taking steps to benefit the protection in Europe: a systematic review of the in a given context. The next step is to find most disadvantaged first – an approach literature and mapping of data availability. Health ways of addressing them through a careful known as progressive universalism 7 – is Policy 2018;122(5):493–508. redesign of coverage policy. vital in contexts where public resources 4 World Health Organization. The world health are severely limited. It also offers report. Health systems financing: the path to universal Co-payment policy is a key determinant advantages in countries that do not face a health coverage. Geneva: World Health Organization, of financial protection in European severe budget constraint, enabling them 2010. Available at: https://www.who.int/whr/2010/ en/ health systems (see Figure 5). It is the to meet the challenge of leaving no one most important factor in countries where behind by ensuring that poor people gain 5 Cylus J, Thomson S, Evetovits T. Catastrophic financial hardship is driven by outpatient at least as much as those who are better health spending in Europe: equity and policy implications of different calculation methods. Bull medicines and the scope of the publicly off at every step on the path to universal World Health Organ 2018;96:589–664. financed benefits package is adequate. health coverage. 6 WHO, World Bank. Tracking universal health coverage: 2017 global monitoring report. Geneva: Countries can improve co-payment policy Progressive universalism rests on the World Health Organization, 2017. Available at: https:// by introducing exemptions for poor people, ability to identify the health services most www.who.int/healthinfo/universal_health_coverage/ applying annual caps to all co-payments likely to lead to financial hardship, the report/2017/en/ and replacing percentage co-payments people most likely to be affected and the 7 Gwatkin D, Ergo A. Universal health coverage: with low fixed co-payments. root causes of gaps in coverage. This, friend or foe of health equity. Lancet 2011; in turn, requires indicators and metrics 377:2160–1. There is a wealth of good practice in amenable to equity analysis, like those Europe. Lessons can be learned from developed and used by WHO in Europe. 1 5

Eurohealth — Vol.25 | No.3 | 2019 46 Transforming societies

Can people afford to pay for health care? New evidence on financial protection in Europe Can people afford to pay

By: WHO Regional Office for Europe for health care?

Copenhagen: WHO Regional Office for Europe, 2019 New evidence on financial protection Number of pages: 79; ISBN: 978 92 890 5331 0 in Europe

Freely available for download: http://www.euro.who.int/en/ health-topics/Health-systems/health-systems-financing/ publications/2019/can-people-afford-to-pay-for-health-care- new-evidence-on-financial-protection-in-europe-2019

This new study brings together for the first time data on unmet need and financial hardship to assess whether people living in Europe can afford to pay for health care.

Drawing on contributions from national experts in 24 countries,

the study shows that financial hardship varies widely in Europe, Regional report Regional and that there is room for improvement even in high-income countries.

Through analysis of microdata from household budget surveys and analysis of national policy developments, the study identifies practical steps countries can take to reduce unmet need and financial hardship. It also highlights actions that should be avoided.

Eurohealth — Vol.25 | No.3 | 2019 Eurohealth Monitor 47

EUROPEAN UNION HEALTH POLICY: THE GATE WITH NO FENCE

By: Scott L. Greer

Summary: As the European Union (EU) institutions are gearing up to start a new legislative term, with new Commissioners, new European Parliamentarians and even some new governments, it is perhaps a good moment to remind us how EU health policy is developed and what the scope and constraints are of the health mandate that Member States have attributed to the EU level. This is exactly the idea behind a new publication – or rather a revised edition of a previous “best seller” – called Everything you always wanted to know about European Union health policy but were afraid to ask.

Keywords: Regulation, Internal Market, Fiscal Governance, Public Health, European Semester

Introduction over time. But all of these limiting phrases do not add up to a fence that keeps out Picture this: a freestanding gate in a field EU public health action. Rather, they with no fence on either side. It might be constitute a sturdy gate that can be opened good gate: solid, well-oiled, easy to open when Member State governments choose. and sturdy when closed. But if there is no And they have on several occasions fencing on either side, people and animals decided to open the sturdy gate, over can just go around it. time, with actions including the creation of the European Centre for Disease A gate with no fence on either side is Prevention and Control and invocation an apt description of Article 168 of the of Article 168 in a variety of important Treaty on the Functioning of the European pieces of legislation such as the General Union (TFEU) that lays out the European Food Law of 2002 (Regulation 178/2002) Union’s (EU) public health powers, as and the directive on cross-border patient we argue in our new, completely revised mobility (Directive 2011/24). edition of Everything you wanted to know about European Union health policy but But the gate of Article 168 that Member were afraid to ask. 1 Make no mistake, States so laboriously constructed stands Article 168 is a gate that Member States alone in a field with no fence, and so Scott L. Greer is Senior Expert intend to keep closed most of the time. other dimensions of EU health policy and Advisor on Health Governance to The Article is a virtual lexicon of cautious the European Observatory on Health integration can simply go around it. Systems and Policies, Brussels, phrases and exclusions that constrain, Belgium, and Professor of Health rather than foster, EU action in this field Management and Policy, Global (see Box 1). Walking around the gate with internal Public Health and Political Science at the University of Michigan, market regulation With such a legal base, it might almost Ann Arbor, USA. On one side, there is no fence keeping Email: [email protected] seem miraculous that a considerable body out the massive amount of internal of EU health policy has been developed

Eurohealth — Vol.25 | No.3 | 2019 48 Eurohealth Monitor

the other side. Fiscal governance refers to the rules binding Member States, Box 1: Article 168 of the Treaty on the Functioning of the European Union especially Eurozone Member States, to avoid profligacy that might endanger the “Union action, … shall complement national policies... The Union shall Euro. It was substantially strengthened in complement the Member States’ action... The Union shall encourage the aftermath of the 2008 financial crisis, cooperation … and, if necessary, lend support … improve the which manifested in Europe as a series of complementarity of their health services in cross-border areas...Member States sovereign debt crises starting at the end shall, in liaison with the Commission, … coordinate among themselves their of 2009 and some highly controversial policies and programmes … The Commission may, in close contact with the bailouts. The logic of fiscal governance Member States, take any useful initiative to promote such coordination … is to both punish Member States that run adopt incentive measures designed to protect and improve human health … excessive deficits or macroeconomic excluding any harmonisation of the laws and regulations of the Member imbalances and to preemptively monitor States... and adopt recommendations ... Union action… shall respect the and shape their policies in order to prevent responsibilities of the Member States for the definition of their health policy such bad behaviour. There is an elaborate and for the organisation and delivery of health services and medical care. The coercive set of mechanisms in EU law responsibilities of the Member States shall include the management of now, backed up by an intergovernmental health services and medical care and the allocation of the resources treaty. 7 There is also a complex assigned to them”. mechanism designed to promote good policy and prevent bad policy, justified by Source: Selected excerpts from Article 168(2); boldface added for emphasis. fiscal governance legal bases, called the “European Semester.” 8

market regulation that is the traditional Kohll and Decker decisions and the fallout core of the EU. This is the legislation from those cases. 4 Over two decades, the and policy involved in the ongoing EU European Court of Justice has learned turn project of unification through the market, more about health care, health care actors promoting deregulation in Member States have learned more about operating in the these policies by removing policy that discriminates EU, and the EU has passed legislation on the basis of Member State origin, and which accepts that health care is a service and legal bases replacing it with regulatory floors at the and regulates it as such. That legislation, EU level. The internal market is the basis the 2011 directive, 5 uses internal market to ends that of most EU law, and it certainly is in the law as a jumping off point for cross- case of health. border health systems improvements, promote health such as better interoperability of health Consider the Directive on the application information technology systems and a The European Semester is a year-long of patients’ rights in cross-border health stronger EU role in health technology process of budgetary surveillance, with care, a case of the EU simply walking assessment (with internal market law now complex relationships between EU around the gate on one side. The the basis for a proposed Regulation further institutions’‘‘ evaluations of Member substantive policy impact involved was enhancing it). The case of patient mobility States and Member States’ contribution and remains minor, since people who are showcases it all: 6 to broad EU goals. From its inception, willing to pay out-of-pocket for health the Semester took an interest in health - how court rulings applying internal care services abroad and then claim simply because it is big, expensive and market law simply bypassed the careful reimbursement are not very numerous. publicly funded, and it would be very constricting language of Article 168 For most cases, EU social security strange for a procedure focused on coordination rules, which organise the - how the solution was to accept an EU preventing excessive deficits to ignore exportation of social security rights, role grounded in the internal market such a big and expensive public sector. including the European Health Insurance build better legislation on internal This is irrespective of what Article 168 Card (EHIC), are able to solve the market treaty bases, and might say about Union action respecting key problems of patient mobility. The the “responsibilities of the Member States - how the policies over time actually whole issue of patient mobility is less for the definition of their health policy came to contain potentially valuable and consequential in substantive terms than and for the organisation and delivery supportive health systems policy. the issue of health professionals’ mobility. 3 of health services and medical care” None of that really matters, though, given (point 7). The result was a large number of that the issue of patient mobility in EU law Sidestepping the gate with fiscal recommendations about health services, and politics referred to the assimilation, governance not always with a coherent basis in good by the European courts, of health care to data or understanding of health policy, Next consider fiscal governance, a case internal market law starting with the 1998 such as the puzzling 2015 recommendation of the EU walking around the gate on

Eurohealth — Vol.25 | No.3 | 2019 Eurohealth Monitor 49

that France should reconsider the numerus such as climate change, are all clearly fence. There are good practical reasons for clausus (limiting the number of students) contributors to health where the EU has a farmer to build the gate before the fence. for health professional education. 9 But often taken a leadership role. But the history of EU health policy tells us: again, over time and as with previous EU there will be no fence. The challenge for governance initiatives, the goals began The EU has, further, partially resiled everybody in health is to pay less attention to expand beyond simple budgetary from the austerity and economic focus to that beautiful, sturdy, defensive gate, control and to include an understanding that it adopted immediately after the debt and to pay more attention to the whole of health as desirable in its own right crisis that focus had led to the explicit field and everything in it. There is much and as a social investment. The number and effective devaluation of health in EU policy affecting health. The question is of Country-Specific Recommendations many EU policy areas (such as alcohol, whether there will be EU policy for health. about health produced by the Semester diet, physical activity, and nutrition). increased, but also became more nuanced, The European Pillar of Social Rights References sensitive, and potentially helpful for enumerated 20 rights, including a right health. This reflected, in large part, health to health care and social care as well as 1 Greer SL, Fahy N, Rozenblum S, et al. Everything ministries, experts, Commission officials rights with obvious health dimensions You Always Wanted to Know About European Union Health Policy But Were Afraid to Ask. Second, Revised and advocates who engaged with the such as a right to adequate housing. The Edition. Brussels: European Observatory on Health Semester and made clear the benefits of Commission adopted the United Nations’ Systems and Policies, 2019. health, showing that it was not just a cost, Sustainable Development Goals as its own 2 European Union. Consolidated version of the and argued for subtler and more complex programme, bringing priorities such as Treaty on the Functioning of the European Union – policy recommendations. health, climate change, and equalities into PART THREE: UNION POLICIES AND INTERNAL the Semester and other processes as EU ACTIONS – TITLE XIV: PUBLIC HEALTH – Article 168 (ex Article 152 TEC) OJ C 115, 9 May 2008: 122–124. Using market regulation and fiscal goals. EU Presidencies have argued for a focus on well-being as an explicit goal. Available at: https://eur-lex.europa.eu/legal-content/ policy to promote health EN/TXT/?uri=CELEX%3A12008E168 These initiatives and declarations mark In the cases of both market regulation a shift from the near-exclusive focus on 3 Glinos I. Worrying About the Wrong Thing: Patient and fiscal governance, the opportunity markets and fiscal rigor of a decade ago. Mobility Versus Mobility of Health Care Professionals. J Health Serv Res Policy 2012;17:254 – 6. for health advocates, as well as the most They reflect the work of advocates for effective defensive posture, has been to a broader and healthier EU, and further 4 Greer SL. Uninvited Europeanization: turn these policies and legal bases to ends empower them. Neofunctionalism and the EU in Health Policy. Journal of European Public Policy 2006;13:134 – 52. that promote health. In the case of the 5 European Parliament and of the Council. Directive internal market, much has been done to Conclusions promote health on internal market bases. 2011/24/EU on patients’ rights in cross-border healthcare. Available at: https://eur-lex.europa.eu/ In the case of fiscal governance, what Article 168 might be a beautifully legal-content/EN/TXT/?uri=CELEX%3A32011L0024 began as an often crude and austerity- constructed gate, but without a fence 6 minded intervention has increasingly on either side, its well-oiled hinges and European Parliament and of the Council. Proposal for a Regulation on health technology assessment become supportive of more egalitarian, solid bars have failed to give Member and amending Directive 2011/24/EU. COM(2018) 51. higher quality, and even better funded States control over their health care Available at: https://eur-lex.europa.eu/legal-content/ health systems. The gate did not keep the systems or isolate them from EU policy EN/TXT/?uri=CELEX%3A52018PC0051

EU out, but the entrance of the EU could and law. On one side, internal market 7 European Union. Treaty on Stability, Coordination be turned into something harmless or legal bases underpin EU regulation of and Governance, 2012. Available at: https://www. valuable to health. health care services as well as EU policies consilium.europa.eu/media/20399/st00tscg26_ that affect health in many ways, often en12.pdf That situation is even clearer when we for the better. On the other side, fiscal 8 European Commission. The European Semester remember that Article 168 is not even the governance mechanisms born in 2012 – 13 web site. Available at: https://ec.europa.eu/info/ only Treaty article that explicitly presents were by 2015 producing detailed business-economy-euro/economic-and-fiscal-policy- health as an EU goal. The Treaty chapters recommendations about Member States’ coordination/eu-economic-governance-monitoring- prevention-correction/european-semester_en on Consumer Protection (Art. 169 TFEU), health systems, and by 2019 were being Environment (Art. 191 TFEU), and Social mobilised to support good health policies 9 Council recommendation of 14 July 2015 on the Policy (Arts. 151, 163, 156 TFEU) all in Member States. Given that the Juncker 2015 National Reform Programme of France and delivering a Council opinion on the 2015 Stability call for health as a key goal, above and Commission did not prioritise health Programme of France (2015/C 272/14). beyond the general call in Article 9 of as a goal or a policy area, we might be TFEU for the EU to pursue a “high level impressed by the number of good things of protection of human health.” It is almost for health that happened even in years certain that laws made under these legal when the gate was rarely opened. bases have saved more lives than laws justified by Article 168. Workplace safety, When we see a gate in a field with no work-life balance, and the control of fence, it usually means that somebody potentially existential environmental risks, will come along and build the rest of the

Eurohealth — Vol.25 | No.3 | 2019 50 Eurohealth Monitor

Everything you always wanted to know about European Union health policies but were afraid to ask (Second, revised edition)

By: SL Greer, N Fahy, S Rozenblum, H Jarman, W Palm, HA Elliott and M Wismar 54 page 1 03/09/2019 19:57 Page 1 Copenhagen:Cover_WHO_nr54_REVISED_v3_blue.qxp_Mise World Health en Organization (acting as the host 54 organization for, and secretariat of, the European Observatory EVERYTHING YOU ALWAYS WANTED TO KNOW ABOUT EUROPEAN UNION HEALTH POLICIES BUT WER

can it mean for health? Everything you

Observatory

What does the European Union mean for health? What Series Studies on Health Systems and Policies), 2019 This comprehensively revised second edition answers these questions. It provides a broad reviewes. always wanted to know and analysis of European Union public health policies to mid-2019. It begins by explaining the basic politics of European integration and European policy-making in health, including the basic Freely availablequestion of how for the European download: Union (EU) came http: to have //www.euro.who.int/en/a health policy and what that policy do about European Union Thereafter, it moves on to the three faces of European Union health policy. about-us/partners/observatory/publications/studies The first face is explicit health policy, both public health policy and policies to strengthen healthy, health policies but services and systems in areas such as cancer, and communicable diseases. The second face is internal market building policies, which are often more consequential for health services, but are not made with health as a core objective. These include professional and patient mobilit were afraid to ask What does regulation the ofEuropean insurers and health Unioncare providers, mean and competition for inhealth? health care.iscal They governance,What also include

some of the policies through which the EU has had dramatic and positive health effects, namely can it mean for health? environmental regulation, consumer protection and labour law. The third face is f Scott L. Greer in which the EU institutions police member state decisions, including relating to health. Nick Fahy This comprehensivelyEach face has different revised politics, law, second policy, and health edition effects. Theanswers book provides these a synthesis of Sarah Rozenblum the different faces and the different ways in which they have been used to strengthen or weaken questions. Itpublic provides health and health a comprehensive systems in Europe. It shows thereview many, often and unappreciated, analysis ways that Holly Jarman the EU has worked for health, as well as the opportunities to further strengthen the EU's positive Willy Palm impact on health. of European Union (EU) public health policies to mid-2019. Heather A. Elliott This book is aimed at policy-makers and students of health systems in the EU who seek to Matthias Wismar It covers the understand three howfaces the influence of EU of the health EU on health policy. policy affects After those systemsexplaining and their patients. To ensure that the EU’s impact on health is wholly positive, the wider health community must the basic politics understand of and European engage with the EUintegration in the future—something and thisEuropean book aims to encourage. policymaking in health, including the basic question of how the

EU came to haveThe authors a health policy and what it can do, it moves – University of Michigan School of Public Health and European Observatory on on to the threeScott faces L. Greer of EU health policy. Health Systems and Policies. nd Edition The first face Nickis explicit Fahy – University health of Oxford policy, and European both Observatory public on Health health Systems andpolicy Policies. Sarah Rozenblum – University of Michigan. Revised 2 – University of Michigan. and policies toHolly strengthen Jarman health services and systems in areas such as cancer,Willy and Palm – Europeancommunicable Observatory on Health diseases. Systems and Policies. The second Heather A. Elliott – University of Michigan.

face is internal market building policies, which are often more E AFRAID TO ASK Matthias Wismar – European Observatory on Health Systems and Policies. consequential for health services but are not made with health as a core objective. These include professional and patient mobility, regulation of insurersObservatory and health Studies care Series providers, No. 54 competition in health care. They also include some of the policies through which the EU has had dramatic and positive health effects, namely environmental regulation, consumer protection and labor law. The third face is fiscal governance, in which the EU institutions police Member State decisions including health. Each face has different politics, law, policy, and health effects.

The book provides a synthesis with sources of the different This publication is launched faces and the different ways in which they have been used to strengthen or weaken public health and health systems at the European Health in Europe. It shows the many ways that the EU has worked for health, often unappreciated, as well as the opportunities Forum Gastein 2019 to further strengthen the EU’s positive impact on health. This book is aimed at policymakers and students of health systems in the EU who look to understand how the influence of the EU on health policy affects those systems and their patients. To ensure that the EU’s impact on health is wholly positive, the wider health community must understand and engage with the EU in the future -something this book aims to encourage.

Contents: Introduction; The EU: institutions, processes and powers; EU action for health; The EU market shaping health; Fiscal governance of health; Conclusion; Appendices.

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I AM THE EUROPEAN COMMISSIONER FOR HEALTH, NOT FOR DISEASE!

Farewell interview with Health Commissioner Andriukaitis

Interview by Willy Palm, Senior Adviser, European Observatory on Health Systems and Policies, Brussels, Belgium. Email: [email protected]

With less than two months to go, Vytenis Andriukaitis from his office in Brussels looks back at his mandate as European Health and Food Safety Commissioner and shares his wishes for the future.

Commissioner, thank you for taking the factor approach, empowering our citizens to monitor time to reflect on your experience of the their health, also using new digital technologies Q.last four years. What was your ambition and devices. when you took office in 2014 and how do you assess the state of health in I’m very happy that Finland for its current EU the EU now that your term is nearing Presidency decided to focus on health as part of its end? well-being. This is a big step forward and this broader approach aligns with the concept of Health in All During these past four years my compass has been Policies, which was the focus of the Finnish EU the definition of health as enshrined in the World Presidency back in 2006. Health Organization Constitution, health as “a state of complete physical, mental and social well-being I see a lot of opportunities. Last year we established and not merely the absence of disease or infirmity”. the EU Steering Group on Health Promotion, Disease For me these are not idle words. The prevention Prevention and Management of Non-Communicable and cure of diseases and the fight against their risk Diseases. This group will help to work out new factors is only part of the game. We need to start instruments and concrete proposals to address thinking differently about health. We cannot just the different determinants related to health, not limit ourselves to only talk about healthy food and only disease. more exercise. We need to expand our perspective to “healthiness” and promoting healthy environments: families, schools, work places and cities. Otherwise Looking back, what are you most healthy lifestyle becomes a narrow concept. proud of in terms of successes and Q.achievements? Healthiness implies broadening our tools for keeping I think we did a lot so it is difficult to limit myself to people healthy, both physically and mentally, during only a few. the whole life-course. It requires systematically monitoring the health and well-being of newborns, Perhaps I am most proud of the State of Health in children, adolescents, adults and older people with the EU, the two-year cycle that we put in place to a new set of parameters. If we want to be really describe and monitor the status of health and health serious about healthy ageing, a change of paradigm systems in the EU. From the start of my mandate is needed, moving away from a single disease or risk

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I asked DG SANTE (the Directorate-General for the European Centre for Disease Prevention and Health and Food Safety) to improve our knowledge Control (ECDC), the European Food Safety Authority and capacity to assess the status of health and health (EFSA) and the European Medicines Agency (EMA). reforms in Member States. With the help of the OECD and the European Observatory on Health Systems and During my mandate, we have shown that by working Policies we managed this and it gave a real impetus to together, between services in the Commission but EU health policy. It allowed us to develop constructive also hand in hand with Member States, we can solve recommendations for the European Semester common problems and overcome international crises. process that can help to improve access to care and This is what we did with Ebola at the beginning of prevention, but also to draw the attention of other DGs my term. This is also what we did in the midst of the to the importance of health for the wider economy. migration crisis, providing concrete solutions and coordinating support, such as creating temporary Together with the progress that we made on health records for migrants, monitoring their developing sound methodologies for assessing the health and ensuring access for them to primary performance of health systems and the linkage with care services. the financial instruments, we now have a robust set of tools and instruments to help Member States It probably hasn’t always been an easy in reforming their health systems and achieve ride. You encountered set-backs and better outcomes. Q.push-backs. What has been your biggest disappointment? But it is only just the beginning. So far, the State of Health in the EU cycle has been mainly looking at Probably I’m mostly disappointed by the fact that public health and health care. Again, we will have there is still much misunderstanding about the EU’s to broaden our perspective and look at the health role in health, not only at Member State level but even dimension in other sectors, including education, within the European institutions. transport and environmental protection. All ministers need to take responsibility for health and well-being What people often fail to see is that the Lisbon of the populations they serve. Treaty gives a clear and strong mandate for the EU to act on health. While they keep on referring to In the field of health care, I am particularly proud the principle of subsidiarity, this only relates to the of the European Reference Networks, which were organisation of health services, which clearly is a launched during my mandate, and enable the Member State responsibility where the EU can only exchange of all the available knowledge and expertise coordinate, cooperate and facilitate, like we do in the on rare diseases. This is an absolute miracle and a field of cross-border care. But, when it comes to the clear example of how the EU can be beneficial to its concept of Health in All Policies, this is completely citizens. This is also true for other areas like eHealth enshrined in the Lisbon Treaty and the protection and the digitalization of health care, where the of human health is a responsibility for every Commission’s work on advanced therapies, big data single Commissioner. and the one million genome project is helping to build a new ecosystem for the use of artificial intelligence The Tartu Call for a Healthy Lifestyle made this in health care. very clear. Together with my fellow Commissioners, Tibor Navracsics (Education, Culture, Youth and In the area of pharmaceuticals, we have managed to Sport) and Phil Hogan (Agriculture and Rural put the issue of access high on the political agenda. Development), I signed 15 commitments to promote Our proposal on health technology assessment healthy lifestyles through sport, food, innovation or received the support of the European Parliament. research. This is also why I am so proud of the joint Now it is up to the Council to finalise the work. commitment that the Commission has demonstrated in the implementation of the Sustainable Development We were also very vocal on the importance of Goals (SDGs). Of all 17 SDGs, 14 are related to vaccination and provided tools and strategies for health. An expert team recently concluded that the Member States to improve vaccination coverage most progress has been made on SDG 3 (Ensure rates. Similarly, we pushed the beacons on fighting healthy lives and promote wellbeing for all at all ages). against Antimicrobial Resistance, with a new One Health action plan based on three pillars – We did a lot to act upon the health determinants and agriculture, environment and health care – and a reduce premature death of EU citizens, like in the close collaboration between the three agencies, field of tobacco. Yet, there is so much more that the EU can do: through taxation or regulating marketing practices for instance. Look at our supermarkets and

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how easy it is for people, including children, to get convince people of the added value of the EU. But unhealthy and harmful products, like sugary drinks let’s not fool ourselves, with an EU budget of 1% of and alcohol. Excise duties haven’t changed since 1992 Member States’ GDP this is not going to be enough. because you need unanimity in the Council of Finance Ministers. To conclude, what are your thoughts on the European Health Forum Gastein, Lack of action and political will cost lives. I often which you always faithfully attended? felt alone when calling for bolder action on health Q. promotion, prevention and protection. Our policies Unfortunately, last year I couldn’t attend. But I have to fight against diseases like cancer, diabetes and always been a big fan of the Gastein Health Forum. obesity are weakened by the lack of action on the root Next to health promotion, prevention and protection, causes. I am Commissioner for health, not for disease! I am also convinced of the importance of health You get a lot of support for using the EU’s financial participation, the involvement of citizens and civil instruments to invest in health care infrastructure society. Gastein is a great place to discuss all these or diseases, but less when you want to use them for issues with the wider health community and to join investing in the development of “healthiness valleys” forces in fighting fake news and misinformation in where all people can enjoy good health. health and distrust in science.

During your mandate the EU went through some politically challenging the only Q.times. How do you see the future of the European integration project? sustainable solution I hope the next Commission will continue the work in the same spirit. In my Mission Letter from can come from more Jean-Claude Juncker in 2014 when taking office, he concluded with the words: “We live in a Union with European solidarity a 29th state of unemployed people, many of them young people who feel side-lined. Until this situation and cooperation has changed, this 29th state must be our number one concern, and we have to be very determined and very I wish it could become as big as the World Economic responsible in carrying out our work as Members of Forum in Davos, showing another and more this Commission.” sustainable approach to creating health and well-being for all citizens‘‘ in Europe. Today, 100 million EU citizens still live in poor or very difficult conditions. Certain regions in the EU Let me also tell you, I am grateful for all the support I are abandoned. Progress on closing gaps within and received. I feel I’m part of a broad international team. between Member States is too slow. Fifteen years Together we started changing the narrative on health. after ten Central-European countries joined the EU, Let’s continue our work. people don’t see the convergence between richest and poorest parts. The financial crisis has made a Thank you, Commissioner! What are your plans great part of the European population feel insecure for the future? about the future, especially the younger generation. This feeling has been abused by populist movements First, I want to finish my mandate and pass the ball to and politicians to bedazzle them with simplistic and my successor in the best possible way. After that I will fake solutions. return to Lithuania. I have no concrete plans yet, but I will definitely continue to advocate for health as a For me it’s clear, the only sustainable solution can normal and committed European citizen. come from more European solidarity and cooperation. We need to organise a new debate on strengthening the social component of the EU, and translate the pillar of social rights into reality for all citizens. Only a strong social Europe can help us overcome our other challenges, including climate change. Only through more European integration and concrete cooperation with actors on the ground–in regions, in cities and local communities–can we help solve national and local problems, break the Brussels bubble and

Eurohealth — Vol.25 | No.3 | 2019