Quarterly of the European Observatory on Health Systems and Policies EUROHEALTH European incorporating Euro Observer
on Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS European Health Forum Gastein 2014
❚ Health and European integration • Caring about multimorbidity
› Electing health: 2014
❚ Telemedicine • Leadership in public health |
the Europe we want ❚ Strengthening Europe’s health system • Austria: Strengthening primary care ❚ Health system performance Number 3
• Former Soviet States: Health | ❚ Post-2015 agenda system trends • Germany: Inpatient care quality :: Special Issue :: Volume 20 1356 ISSN Still Steve Production: and Design permission. prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of part No 2014. Policies and Systems Health on Observatory European of behalf on © WHO Medicine. &Tropical Hygiene of School London the and Science Political and Economics of School London Funds), Insurance Health of Union National (French UNCAM Bank, World the Commission, European the Italy, of Region Veneto the and Kingdom United the Sweden, Slovenia, Norway, Ireland, Finland, Belgium, Austria, of Governments the Europe, for Office Regional Organization Health World the between apartnership is Policies and Systems Health on Observatory European The consideration. for authors by submitted or editors the by commissioned independently are Articles sponsors. or partners its of any or Policies and Systems Health on Observatory European the of those necessarily not and alone authors in expressed views The beyond. and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for Eurohealth at: Available Guidelines Submission Article White: Caroline MANAGER SUBSCRIPTIONS North: Jonathan MANAGER PRODUCTION Still: Steve EDITOR DESIGN B. Richard Mossialos, Elias McKee, Martin Lessof, Suszy Palm, Willy Grand, Le Julian Holland, Walter Figueras, Josep Busse, Reinhard Belcher, Paul BOARD ADVISORY EDITORIAL aboutUs/LSEHealth/home.aspx http://www2.lse.ac.uk/LSEHealthAndSocialCare/ 6803 7955 20 +44 F: 6840 7955 20 T: +44 UK 2AE, WC2A London Street, Houghton Science Political and Economics of School London Health, LSE Mossialos: Elias EDITOR FOUNDING Palm: Willy ADVISOR EDITORIAL 6381 7955 20 +44 McDaid: David Maresso: Anna 6194 7955 20 +44 Merkur: Sherry TEAM EDITORIAL SENIOR http://www.healthobservatory.eu [email protected] Email: 0936 2525 +32 F: 9240 2524 T: +32 Belgium Brussels, 1060 Horta Victor Place 07C020) (Office Eurostation Policies and Systems Health on Observatory European the of Quarterly EUROHEALTH is a quarterly publication that provides a forum aforum provides that publication aquarterly is Saltman, Sarah Thomson Thomson Sarah Saltman, – [email protected] [email protected] 1030 http://tinyurl.com/eurohealth [email protected] [email protected] [email protected] [email protected] / 40 Hortaplein, Victor Eurohealth [email protected] are those of the the of those are [email protected]
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CONTENTS 1
List of Contributors
Wolfgang Ballensiefen w Project Management Agency, German Aerospace EDITORIAL – Josep Figueras and Dorli Kahr-Gottlieb Centre (PT DLR), Germany. 2 Miriam Blümel w Berlin University of Technology. Angela Brand w Maastricht University, The Netherlands. Helmut Brand w International Forum Eurohealth Observer Gastein and Maastricht University, The Netherlands. HEALTH AND EUROPEAN INTEGRATION: PART OF THE Reinhard Busse w Berlin University 5 PROBLEM OR PART OF THE SOLUTION? – Helmut Brand of Technology, Germany. Ulrike Bußhoff w Project Management and Willy Palm Agency, German Aerospace Centre (PT DLR), Germany. BUILDING EU HEALTH POLICY FOR THE FUTURE – Katarzyna Czabanowska w Maastricht University, The Netherlands. Artur Furtado, Georgina Georgiou and Patricia Nelissen 11 w Thomas Czypionka Institute for Advanced Studies, Austria. TELEMEDICINE: THE TIME TO HESITATE IS OVER! – Inger Ekman w University of Gothenburg, 14 Terje Peetso Sweden. Nedret Emiroglu w WHO Regional Office for Europe, Denmark. IN HEALTH, EUROPE MUST BE IN THE BUSINESS OF Nick Fahy w independent consultant and 17 CHANGE AND MEAN BUSINESS – Tamsin Rose PhD student, Queen Mary University of London, United Kingdom. Josep Figueras w European Observatory WHAT IS THE EU’S CONTRIBUTION TO HEALTH SYSTEM on Health Systems and Policies, Belgium. 20 PERFORMANCE? – Matthias Wismar, Scott L Greer and Artur Furtado w Directorate-General for Health and Consumers, European Nick Fahy Commission, Belgium. Georgina Georgiou w Directorate- General for Health and Consumers, European Commission, Belgium. Scott L. Greer w University of Eurohealth International Michigan School of Public Health, Ann Arbor, Michigan, USA and European CONTENTS Observatory on Health Systems and FROM MILLENNIUM DEVELOPMENT GOALS TO THE POST Policies, Belgium. 24 2015 DEVELOPMENT AGENDA – Nedret Emiroglu and Erica Hackenitz w Netherlands Evis Kasapi Organisation for Health Research and Development (ZonMw), The Netherlands. Dennis Horgan w European Alliance for LEADERSHIP IN PUBLIC HEALTH: REDUCING INEQUALITIES Personalised Medicine (EAPM), Belgium. 28 AND IMPROVING HEALTH – Katarzyna Czabanowska Anneli Hujala w University of Eastern Finland. Dorli Kahr-Gottlieb w European Health WE CARE: COORDINATING THE DEVELOPMENT OF AN R&D Forum Gastein 32 ROADMAP – Inger Ekman, Karl Swedberg, Reinhard Busse Evis Kasapi w WHO Regional Office for and Ewout van Ginneken on behalf of the WE CARE partners Europe, Denmark. Lada Leyens w Maastricht University, The Netherlands. CARING FOR PEOPLE WITH MULTIPLE CHRONIC Martin McKee w London School of 35 CONDITIONS IN EUROPE – Verena Struckmann, Hygiene & Tropical Medicine, and Sanne Snoeijs, Maria Gabriella Melchiorre, Anneli Hujala, European Observatory on Health Systems and Policies, United Kingdom. Mieke Rijken, Wilm Quentin and Ewout van Ginneken Maria Gabriella Melchiorre w Italian National Institute of Health and Science CSA PERMED: EUROPE’S COMMITMENT TO on Aging (INRCA), Italy. Patricia Nelissen w Directorate-General 41 PERSONALISED MEDICINE – Lada Leyens, Erica for Health and Consumers, European Hackenitz, Denis Horgan, Etienne Richer, Angela Brand, Commission, Belgium. Ulrike Bußhoff and Wolfgang Ballensiefen on behalf of the Willy Palm w European Observatory on Quarterly of the European Observatory on Health Systems and Policies Health Systems and Policies, Belgium. EUROHEALTH PerMed consortium European incorporating Euro Observer Dimitra Panteli w Berlin University on Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS European Health Forum Gastein 2014 of Technology. Terje Peetso w Directorate-General for Communications Networks, Content & Technology (DG CONNECT), European Commission, Belgium. Wilm Quentin w Berlin University of Technology, Germany. ❚ Health and European integration • Caring for multimorbidity
› Electing health: 2014
❚ Telemedicine • Leadership in public health |
the Europe we want ❚ Strengthening Europe’s health system • Austria: Strengthening primary care ❚ Health system performance Number 3
• FSU: Health system trends | ❚ Post-2015 agenda • Germany: Inpatient care quality :: Special Issue :: Volume 20 © Michael Wolf – Fotolia
Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 2
Eurohealth Systems and Policies List of Contributors
SOLVING THE CONUNDRUM: HOW TO BALANCE CARE Bernd Rechel w European Observatory on Health Systems and Policies, London 45 COORDINATION AND PATIENT CHOICE IN AUSTRIA? – School of Hygiene & Tropical Medicine, Thomas Czypionka United Kingdom. Erica Richardson w European Observatory on Health Systems and HEALTH SYSTEM TRENDS IN THE FORMER SOVIET Policies, London School of Hygiene & 49 COUNTRIES – Bernd Rechel, Erica Richardson and Tropical Medicine, United Kingdom. Martin McKee Etienne Richer w Canadian Institute of Health Research (CIHR), Canada. Mieke Rijken w Netherlands Institute ASSURING QUALITY OF INPATIENT CARE IN GERMANY: for Health Services Research (NIVEL), 52 EXISTING AND NEW APPROACHES – Miriam Blümel, The Netherlands. Sanne Snoeijs w Netherlands Institute Dimitra Panteli and Ewout van Ginneken for Health Services Research (NIVEL), The Netherlands. Verena Struckmann w Berlin University of Technology, Germany. Karl Swedberg w University of Gothenburg and Imperial College, Eurohealth Monitor London, United Kingdom. NEWS Ewout van Ginneken w Berlin University of Technology, Germany. 56 Matthias Wismar w European Observatory on Health Systems and Policies, Belgium. CONTENTS
Featuring viewpoints on the future challenges for health care policy in Europe from:
Alois Stöger, Federal Minister of Health, Austria
Tonio Borg, EU Commissioner for Health and Consumer Policy
Zsuzsanna Jakab, Regional Director of the WHO Regional Office for Europe
Martin McKee, Professor of European Public Health at the London School of Hygiene and Tropical Medicine
Nicola Bedlington, Executive Director of the European Patients Forum (EPF)
Richard Bergström, Director General of the European Federation of Pharmaceutical Industries and Associations (EFPIA)
Louis Ide, MEP (since 2014), European Conservatives and Reformists Group, Belgium
Karin Kadenbach, MEP (since 2009), Group of the Progressive Alliance of Socialists and Democrats in the European Parliament, Austria
John Bowis, former MEP (1999-2009), Group of the European People's Party, United Kingdom EDITORIAL
Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 3
Editorial This second special Gastein edition of Eurohealth marks an important step in the long-standing collaboration between the European Observatory on Health Systems and Policies and the European Health Forum Gastein in an effort to promote a constructive European health policy debate.
With this year’s topic ‘Electing Health –The Europe i.e., what policy frameworks and instruments are We Want!’ the EHFG speaks to the very core of EU needed for the EU to fulfil this new role; and, chiefly, health politics. Debating the EU health mandate how the EU can contribute, in practice, to improving is no stranger to the pages of this journal nor is it the performance of health systems in Member States. a new theme for the EHFG. On the contrary, year after year the Forum has succeeded in providing The main bulk of the articles in this special issue a unique platform for exploring policy innovations of Eurohealth reflect on the themes of the EHFG and legal developments and for fostering forward 2014 parallel forum sessions and provide us with thinking and decision making among key health policy some very insightful responses. In the lead article constituencies in the EU. At the risk of sounding ‘Health and European integration: part of the too optimistic, there is now a sizeable window of problem or part of the solution?’, Brand and Palm opportunity to adopt a stronger health policy agenda address the central question of this year’s Forum in Europe. While besieged by many challenges, no by placing health at the centre of the Europe 2020 less by the increasing euro-scepticism in politics growth strategy, with the trinity of wealth, economic or by the threats posed by the financial crisis to the growth and budget sustainability making up its European social model, we believe that many of these constituent dimensions. Without quibbling about challenges can be converted into opportunities. the ‘holiness’ of such a Trinity, we do agree with For instance, we can reassert the uniqueness of the authors that the role of the EU in health is solidarity as a core European value or demonstrate much broader than that given by the public health the centrality of health as an engine for societal article in the Treaty. Yet, this should not stop policy cohesion and economic growth. In the same way, makers from seeking ways to strengthen the health the EU counts on an increasing arsenal of legislation, mandate and/or implementing it more effectively, policy strategies and instruments to make this such as by championing ‘Health in all EU policies’. possible, such as those arising from Europe 2020, the European Semester cycle for economic and The ‘European Voices’ section provides an fiscal policy coordination, the Cross-border Care appetiser for responses from a selected panel of key Directive or, more recently, the Commission’s stakeholders in European health policy representing Communication on effective, accessible and resilient the four constituent pillars of the Forum. Notably, with health systems. While most, if not all, are born out the exception of Professor Martin McKee, who shows of ‘economic union’ policies with a main objective a healthy dose of academic scepticism, all other of fostering economic growth, strengthening the stakeholders including the European Commission, internal market and supporting financial sustainability, World Health Organization (WHO) and the Austrian they may not offer the sole but perhaps the Minister of Health, as well as patients and industry best chance to boost an EU health agenda. representatives, seem to share a fairly positive outlook on the future of health in the EU and agree Similar to last year’s edition, the EHFG 2014 poses on many of the policies that need to be put in place. four challenging but very policy-relevant questions to The “Voices from Parliament” heard in this issue its delegates. In a nutshell, we are asking delegates echo that sense of hope and optimism regarding to gaze into the crystal ball and share our ‘vision’ the role of health in European policy-making and the of: the future of the European social model and its priority it deserves in the course of the next term – core values; the EU’s future role in health and health not least for its impact on economic performance. systems; the ‘nuts and bolts’ of implementation EDITORIAL
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These ‘voices’ the universal access health systems as a But ultimately, plagiarising John F. Kennedy’s words, we must cornerstone of the European social model and a unique strength ask ourselves not what the EU can do for us but what we can of the EU; a view which is echoed by many of the contributors do for the EU to support its health agenda. In that regard, in this issue. Both the papers by Furtado et al (European Czabanowska calls for a new model of public health leadership Commission Directorate-General for Health and Consumers) focused on interdisciplinary collaboration to enable the and Emiroglu and Kasapi (WHO Regional Office for Europe) implementation of WHO’s Health 2020 and of a strong EU public emphasise its importance in shaping the global health agenda health agenda. However, we also agree with her in questioning and in particular the post 2015 development agenda. Indeed, how far public health leaders will be willing and able to go in the WHO-led global universal health coverage movement adopting these new roles and tackling pervasive and enduring joined by many countries, not least the US, underlines the health inequalities. While the (lack of) reaction of large parts of important leadership of Europe in this field. If anything, Europe the public health community to the financial crisis debate has is called to play a greater and more assertive role in global not been terribly encouraging, both Ekman et al and Struckmann health governance, and as Furtado and colleagues argue, et al emphasise the importance of the expert community the close collaboration, involvement and support of the EU to playing an active role in providing evidence-based research the WHO global health agenda will be central in doing so. to allow for proactive and person-centred policy making.
Perhaps not surprisingly, most contributors to this issue seem Finally, the most difficult question posed by the EHFG is tackled to sing to the same tune of increasing the EU’s role in health. head-on by Wismar and colleagues in the article ‘What is the Yet, we cannot criticise them for lack of pragmatism nor for EU’s contribution to health system performance?’ or, in other ‘preaching to the converted’ – a frequent disease amongst words, ‘What can the EU add that the Member States have the public health community. For instance, while Rose argues difficulties in achieving by themselves?’ which constitutes the that the EU can, and should, be an agent of change for health, ultimate stress test for the EU on health. Their article makes a she also highlights that it can only do so if ‘it means business.’ strong case for the EU’s positive impact, with many illustrative Referring to the unprecedented opportunity posed by the new examples such as the ‘country-specific recommendations’ (CRC) EU economic governance framework, the article emphasises to reform health systems or the range of legislation on health the need to raise the profile of the health commissioner in the determinants; cross border collaboration, health professional new Juncker college. The commissioner needs to become a key mobility and European reference networks. But they also point player in the formulation of country-specific recommendations led to the challenges posed by the fragmented nature of the EU’s by the Directorate-General for Economic and Financial Affairs. action on health, making it difficult for health stakeholders to be part of shaping EU health policy, particularly when so much The articles in this issue provide a particularly rich set of concrete decision-making takes place in forums which are not primarily examples of the kinds of strategies, instruments and initiatives focused on health. We underscore their recommendation to that the EU has at its disposal to fulfil a stronger health role. have an informed debate and explicit decision-making by EU Perhaps, only the most ardent euro-sceptic would disagree leaders on the role of the EU in health and health systems – that with the EU putting in place pro-competition regulation or should serve as a further spur for discussions at the Forum. promoting innovation in areas such as eHealth or personalised medicine – both acknowledged as key for the EU’s economic In sum, the articles in this issue provide us with a solid growth. The articles by Leyers et al on ‘Europe’s commitment introduction to the evidence and the issues for those fortunate to personalised medicine’ and by Peetso on ‘Telemedicine: the enough to have the opportunity to attend the Forum in the time to hesitate is over’ are both excellent illustrations of this. idyllic Gastein valley, but also plenty of food for thought for the Similarly, Furtado and colleagues, in their article on ‘Building EU general readership of this journal to move one step forward health policy for the future’ demonstrate the benefits of EU-led in deciding what is ‘the Europe we really want’ for health. health partnerships with the private sector and civil society. In the same way, Czypionka, when asking whether and how to Josep Figueras Dorli Kahr-Gottlieb reduce the freedom of choice in the new primary health care reform in Austria, draws on the wealth of evidence in many other Director, Secretary General, EU countries that faced a similar conundrum, thus illustrating European Observatory European Health Forum the benefits of collecting and exchanging rigorous evidence on on Health Systems Gastein best practice across EU countries. Blümel et al provide another and Policies example of the shared challenge of assuring high quality care while containing costs by illustrating Germany’s latest legislative Cite this as: Eurohealth 2014; 20(3). steps towards not only a more transparent system for patients but also the introduction of quality-related hospital payment. For the 12 former Soviet Union States, on the other hand, there are still many hurdles to take on their rocky road towards improving the quality of care and population health, which according to Rechel et al will necessitate prioritising health on government agendas and spurring on health care reforms.
Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 Eurohealth OBSERVER 5
HEALTH AND EUROPEAN INTEGRATION: PART OF THE PROBLEM OR PART OF THE SOLUTION?
By: Helmut Brand and Willy Palm
Abstract: The 2014 European Health Forum Gastein will discuss the future of the European Union’s health policy after the recent European elections and the appointment of a new Commission. Where do we stand and what are the real issues at stake? Since the Gastein Forum is traditionally based on the idea of bringing together the various stakeholders in health, including policy-makers, professionals, civil society, industry and academics, we also include initial comments and reflections coming from a panel of key stakeholders in European health policy on the four questions that will be at the core of discussion in Gastein this year.
Keywords: European Union, Health Mandate, EU integration, European Social Model, European Health Forum Gastein
Post-electoral stress disorder? part of the European population. As also shown in a recent Eurobarometer At the end of May 2014, citizens survey, trust in European institutions is from the 28 European Union (EU) historically low with an average score Member States elected a new European of 32% (ranging from 18% in Greece up Parliament. Despite the attempts to to 58% in Romania). 1 However, this is not increase its political importance and very different from national politics and in strengthen democratic legitimacy of some cases even much better. As Timothy EU institutions by linking this election Garton-Ash argued, there are 28 different with the appointment of the European “shades” of unhappiness – many of Commission’s President through the them not even EU-related; however, the so-called ‘Spitzenkandidaten’, the Helmut Brand is President of May 2014 elections are a wake-up call turnout has remained disappointingly the International Forum Gastein from which Europe may fail to wake up. 2 and Jean Monnet Professor low (only 43.09% of eligible voters). in European Public Health, On top of that, 25% of the seats went to Maastricht University. Willy Palm Clearly, an important factor of candidates from euro-sceptic parties. is Dissemination Development discontentment has been the financial Officer, European Observatory crisis and the way “Europe” has dealt on Health Systems and Policies, All of this seems to indicate a disinterest with it. The European election campaign Brussels, Belgium. in – if not a mistrust against – the Email: [email protected] was dominated by the question of how the European integration project amongst
Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 6 Eurohealth OBSERVER
ongoing economic downturn, as well as Figure 1: The Trinity of Health: the EU’s approaches to health (systems) as part of the alarming level of youth unemployment Europe 2020 in certain Member States can be countered and how to stabilise the Euro. The political debate covered more fundamental issues Wealth such as the limits of interstate solidarity, a more focused mandate for the EU to tackle Europe 2020 the big problems and a more transparent EU serving the needs of its citizens.
Traditionally, the European project has stood for peace, prosperity and social Health progress. Now that these noble goals are perceived to have reached their limits – or these achievements are taken for granted – Europe’s cultural, social and political leaders are looking for a “new narrative Economy Budget for Europe”. 3
The EU’s health mandate Source: Authors At first sight, health is not a topic in argue that the legal mandate has been too are motivated by the principles of free all these discussions. However, in all weak, the initiatives too diverse and the movement and based on internal market measurements of happiness or quality impact too illusive. 6 Due to the “invisible provisions. The second dimension is of of life, health systematically ranks high hand” of subsidiarity, imposed by Member a budgetary nature. Health expenses and it is considered a prime concern for States, EU policy in health could only largely also weigh on the Member States’ many citizens across the EU. 1 Various develop in a gradual and fragmented public budgets and are therefore critical studies have demonstrated the devastating way, often in response to “health crises”, in the context of the EU’s economic effect of the current economic crisis on using a diverse array of – often “soft governance that aims to guarantee the life quality, also through the deterioration law” – policy instruments. Even though Union’s economic and monetary stability. of health, and the growing inequalities in this process EU health policy matured Through the European semester we and occurring problems of accessibility to a consistent whole, thanks also to the have increasingly seen country-specific to health care, especially among more guiding framework of the 2008 health recommendations being issued and vulnerable population groups such as older strategy, Together for Health, it remains a endorsed by the EU institutions to push people in Central and Eastern Europe and rather small issue on the EU agenda. After individual Member States to reform their the lowest income classes. 4 all, health-related funding through the health systems and make them more various programmes (research, structural financially sustainable. At the same time, Health protection is also considered funds and the health programme) health is also considered as an important to be intrinsically part of the so-called represented only 0.08% of the EU’s budget factor for economic growth and social European social model. 5 It is striking that under the previous multi-annual financial cohesion. This is why the Commission when people are asked what values best framework (2007 – 2013). actively promotes the idea of investing represent the EU, solidarity and support in sustainable health systems, in people’s for others pop up as defining concepts health and in reducing health inequalities, for the European project. 1 So health The Trinity of Health with support from EU funds and as part could indeed play an important role in Still, this is only one part of the picture. of its social investment package. 8 reconnecting Europe with its citizens. In reality, EU health policy is much For this we need some kind of “Roaming broader than the health mandate based Even though these approaches – forming for Health” project. Just like the EU on the Treaty’s public health article. 7 the three dimensions of the Trinity of effectively addressed excessive roaming Fundamentally, the EU’s approach towards Health – may sometimes be perceived charges, it could also help to unlock health and health systems is threefold as contradictory, they all form an resources, knowledge and experience (see Figure 1). In the first place, health integral part of the EU’s encompassing in health to the benefit of citizens and is considered an important economic growth strategy Europe 2020, which patients across the EU. This is essentially sector, representing, on average, 10% of aims for economic growth that is smart, what the European Commission has GDP and 8% of employment and as such sustainable and inclusive. Still, apart from been pushing for within the EU’s health is a full part of the internal market. In the European innovation partnership mandate since the Maastricht Treaty fact, many of the legislative initiatives on active and healthy ageing, positive in 1992. However, despite the fact that EU that are of direct relevance to the health references to health are hard to find in the actions added positively to various aspects sector, such as the directives on cross- strategy’s priorities, objectives, indicators of human health protection, some would border care or professional qualifications, or initiatives. The image persists of an
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imbalance in the various approaches. used to inform the country-specific could pave the way towards a real layer of Ironically, where Member States often recommendations that are issued in the European health care and even – why not? continue to claim subsidiarity to deny a field of health system reform? The recent – European solidarity. more direct and positive action for health, Communication on effective, accessible this does not stop EU economic rules and and resilient health systems is showing References processes from indirectly impacting on the way by compiling all the elements health and health systems. available to build a consistent EU agenda. 10 1 European Commission. Special Eurobarometer 415. Europeans in 2014, March 2014. At: http:// ec.europa.eu/public_opinion/archives/ebs/ Linked to this, the question that keeps Good intentions for a new term ebs_415_data_en.pdf cropping up is whether we need a stronger 2 So what to do under the new term? What health mandate and how this can be Timothy Garton Ash. Europe: the continent for every type of unhappy. The Guardian, 26 May 2014. are the priorities that the new European achieved. Some are suggesting a review Commission and Parliament should of the EU’s health strategy. Whereas the 3 European Commission. A new narrative focus on? Commission argues that the strategy for Europe. At: http://ec.europa.eu/ debate-future-europe/new-narrative/pdf/ is still valid since the public health declaration_en.pdf Clearly, as the economic crisis seems to challenges it identified back in 2008 have 4 turn from an acute into a more chronic not really changed, it could also be said Eurofound. Third European Quality of Life Survey – Quality of life in Europe: Impacts of the crisis. condition – or as the Greek health minister that it is a compilation of issues to be Luxembourg: Publications Office of the European put it at the EHFG 2013: This is not a addressed by the EU rather than a policy Union, 2012. crisis, this is the new reality – the social document setting priorities, assigning 5 Mossialos E, Permanand G, Baeten R, Hervey T. dimension of the EU is to become ever responsibilities and outlining ways of Health systems governance in Europe: the role of more a critical and essential element of implementation and assessment. Others European Union law and policy. In: Mossialos E, European integration. The challenge that are calling for another revision of the Permanand G, Baeten R, Hervey T (eds.) Health Europe is facing today is nothing less than Treaty to establish a more solid legal systems governance in Europe: the role of European the resilience of its social model. German base for health action at EU level. 11 As Union law and policy. Cambridge: Cambridge University Press, 2010. p. 1 – 83. Chancellor, Angela Merkel, recently appealing as it may seem to push the reset reminded us that in the EU, with 7% of button and design a completely new legal 6 Rosenkötter N, Clemens T, Sørensen K, Brand H. the world’s population, we generate 25% base for public health in the EU, we should Twentieth anniversary of the European Union health mandate: taking stock of perceived achievements, of the world’s economy but also spend be aware of the serious risks connected failures and missed opportunities–a qualitative nearly 50% of all social benefits in the to that option, especially in a climate in study. BMC Public Health 2013;13:1074. doi: world. To keep this will require a great which the delegation of power back to 10.1186/1471 - 2458 - 13 - 1074. deal of creativity and innovation, she the national level is openly debated to 7 Greer SL et al. Everything you always wanted to 9 concluded. This is exactly what has compensate for loss of competencies in know about European Union Health Policies but were dominated discussions at the European other areas. Hence, any new public health afraid to ask. Copenhagen: European Observatory on Health Forum over the last few years. article might end up being less powerful Health Systems and Policies, 2014 (forthcoming). Where in 2012 the main question was the than what we have now. 8 Testori-Coggi P, Hackbart B. Investing in effects of the crisis for health, in 2013 the Health. A Commission’s perspective. Eurohealth focus turned to how health systems can Perhaps a more promising strategy would 2013;19(3):26 – 8. be made resilient and innovative. be to push for “Health in all EU policies” 9 Angela Merkel. Hat die Welt noch einen Platz in order to make sure that health impact für Europa?, Speech made at the Deutscher Next to steadfastness in sticking to the is duly considered when developing Katholikentag Regensburg, 20 May 2014. values underpinning our health systems, policy in other areas. In fact, the opening 10 European Commission. Communication on we may also need to explore new forms of of Article 168 provides a clear and solid effective, accessible and resilient health systems, health governance that also better facilitate basis for this: A high level of human COM (2014) 215 final, 4 April 2014. the integration of technological and social health protection shall be ensured in 11 Brand H. A new agenda for health in Europe. innovations. Today, no policy level can the definition and implementation of European Journal of Public Health 2013;23(6):904 – 5. claim any longer full exclusivity over all Union policies and activities. With doi: 10.1093/eurpub/ckt162. health. National, regional and international health impact assessment (HIA) we policy-makers will need to work together already have an effective tool and a sound more closely and coordinate their actions methodology. It’s just a matter of putting to achieve better outcomes. This applies this into practice. Moreover, positive in the same way to fragmentation and health impacts should be better marketed duplication within the same policy level. by the EU: the smaller but important In addition, at EU level there is scope for advances realised through initiatives, such better linkages between initiatives that are as the joint purchasing of vaccines or the undertaken. For instance, to what extent European reference networks established is the valuable work of the Reflection under the cross-border care directive, process on modern, responsive and sustainable health systems, set up in 2011,
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VOICES FROM In the light of the recent European election outcomes, how do you envisage the further development of the European social model and its core values? EUROPE EU Health Commissioner Tonio Borg does not see in the election result a rejection of the European project. Despite the crisis, there is still support for a European Union that remains united and open whilst seeking to be stronger to defend our values and interests. However, the results also call Alois Stöger: Federal Minister of Health, for addressing the concerns of those who voted in protest, or Austria who did not vote. To Professor Martin McKee this popular
discontent is due to the failure of the European institutions to
respond appropriately to the economic crisis. Especially in those
countries that have been worst affected by austerity, Europe is perceived to have prioritised the interests of the banks and other financial institutions over those of the people. According Tonio Borg: EU Commissioner for Health and to EPF’s Executive Director Nicola Bedlington the rise in Consumer Policy euro-scepticism indicates that the EU must redirect its efforts
towards concerns that are closer to EU citizens, like health,
to add value to people’s lives and renew faith in the European
process. European values of universality, access to good quality care, equity and solidarity, safety and patient involvement are unfortunately still not a reality for all patients. Disparities Zsuzsanna Jakab: Regional Director of the have been exacerbated by austerity measures. WHO Regional WHO Regional Office for Europe Director Zsuzsanna Jakab also hopes that the outcome of the
European elections may contribute to further promote these
values. As modern European communities are becoming more
globally interactive and the health and wellbeing of its citizens is becoming dramatically linked to seemingly disparate factors, a framework for health to uphold these core values and to ensure Martin McKee: Professor of European Public the right to health for everyone is really needed. Austrian Health at the London School of Hygiene and Health Minister Alois Stöger reminds us that the Union’s aim, Tropical Medicine as laid down in Article 3 of the Treaty, is to promote peace, its
values and the wellbeing of its peoples. I am deeply convinced
that economic and social progress are inseparable. Tackling the emerging social challenges in a context of financial constraints and demographic pressures requires more than ever a strong Nicola Bedlington: Executive Director of the European social model based on the values of social protection European Patients Forum (EPF) for all and solidarity.
EFPIA Director-General Richard Bergström is inherently
optimistic. With a new generation of politicians in Brussels, we have an opportunity to reaffirm what Europe stands for. Europe’s social model, for me, has to be at the heart of Richard Bergström: Director General of the defining what the EU is about. It would be deeply ironic if our European Federation of Pharmaceutical own commitment to the social model would weaken at a time Industries and Associations (EFPIA) when much of the world is trying to copy the degree of social protection – especially in health care – that we have pioneered. Also Commissioner Borg thinks it would be hazardous to speculate about the effect of this particular election on the development of the European social model. I believe that the values that underpin our health systems and our action at European level are widely shared and stable. Health systems form a cornerstone of the European social model and are a key component of our efforts to fight the challenges brought upon us by the economic crisis and can help addressing people’s current concerns. Yet, Professor McKee points to some inconsistencies. Take the secretive nature of discussions on the Transatlantic Trade and Investment Partnership. Its provision for investor-
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state dispute mechanisms is widely viewed as a means for countermeasures which I have signed with Member States in powerful corporate interests to undermine the European social June. Also The Cross-border Health Care Directive that entered model. There is a real danger that the wrong message is taken. into force last year is considered a major milestone. Nicola What is being called for is a Europe that places the interests Bedlington says: These kinds of measures can have significant of its citizens first, with the major corporations–whether in the scope to empower patients and, if implemented properly, they financial sector or elsewhere–at their service and not the other can have a transformative effect on health care that is wider way round. than the scope of the legislation itself. Minister Stöger warns however: We have to proceed step-by-step. The patient rights After the first 20 years of an EU health mandate, what directive was indeed a big step forward for the provision of do you consider as its main achievements and what cross-border health services, but now further adjustments of vision do you have for the EU’s role in health and the existing processes are needed as well as a re-thinking of all health systems in the next 20 years? involved partners. All interlocutors agree that great progress has been made in the Finally, Zsuzsanna Jakab also points to the role of the EU in area of health at EU level over the last 20 years, even if only global health. The EU tobacco regulations provide tremendous slowly. Minister Stöger: If you only look at all these measures support to the Framework Convention on Tobacco Control to secure the quality of food products, to protect consumers and (FCTC). The EU Decision on serious cross-border threats to secure a healthy environment, we see that important areas to health put the EU at the forefront in addressing global have been harmonised. Commissioner Borg continues: The EU health emergencies and implementing International Health has established a legislative environment benefiting patients Regulations. The EU’s work on environment and health is a and economic operators. With the whole body of legislation source of inspiration for other parts of the world. At the same on Organs, Blood, Tissues and Cells, the recent revision of the time, experiences such as the passage of the Tobacco Products Tobacco Products Directive and of the regulatory framework Directive provide us with valuable lessons about the activities on clinical trials and on pharmaceuticals we have further of lobbyists representing powerful corporate interests that seek consolidated European health law. to undermine health, says Professor McKee. More detailed research will call for much stronger action on transparency. Promoting cooperation between the Member States on health policy and on health systems is seen as another important aspect In preparation for the next legislative period and of the health mandate. Commissioner Borg: Guided by the implementing its Europe 2020 growth strategy, how will EU Health Strategy and supported by the successive Health the current policy frameworks and instruments have to Programmes, the Commission supported health systems' efforts be used or reviewed in order for the EU to fulfil its role to address ever growing challenges by fostering cooperation in promoting, protecting and restoring the health of and exchanging good practice across Europe on a wide range its citizens? of shared concerns, ranging from addressing lifestyle factors over and tackling chronic diseases to capacity building in areas For Minister Stöger the top priority of the next legislative period such as health technology assessment and health workforce. will be the recovery of the economy and the radical reduction of Nicola Bedlington also sees an increasing recognition by unemployment. Measures have to be taken to reduce undesirable Member States that EU collaboration is in their interest. This developments in the financial markets, which endanger the EU has been particularly apparent in the area of patient safety and as a whole, but especially social security including national quality of care. Regrettably, we also see signs of disinvestment health systems. Martin McKee adds: As a modern public in patient safety in some countries due to financial constraints. health physician I must also look upstream and call for reform This is particularly worrying as cutting health care budgets is of the flaws in Europe’s financial system that created the counter-productive and will not contribute to the sustainability current problems, coupled with action to redress the otherwise of health systems in the long run. Richard Bergström agrees: inexorable trend in inequality that has recently been explained The well-documented health consequences of the Austerity elegantly by Thomas Piketty. Nicola Bedlington confirms: The programmes – where too many blunt instruments were used EU should break down health inequalities, striving to make at the expense of genuine efficiency–could have perhaps been treatments available to everyone and encompassing the whole mitigated had health had a stronger voice in economic policy care continuum. We need more commitment to Health-in-All decisions. Martin McKee notes that despite of the EU’s limited policies, particular attention to the needs of vulnerable groups competence in the field of health, the Commission does have a and investment in key change agents. Also, Richard Bergström powerful weapon at its disposal. So far, DG SANCO has made believes it is possible to not only maintain what Europe has only limited use of its power to assess the health impact of all EU now, but to also address some of the glaring inequalities that policies, including the impact of austerity. persist. But we may have to start doing things differently, forge new partnerships and challenge old silos. In a majority Commissioner Borg recognises that there is still a long way to of EU countries my industry has entered formal agreements go to establish a European Union for Health but is convinced we with governments to provide stability and predictability of should use all means at our disposal to achieve this goal. Take for instance the new Joint Procurement agreement on medical
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the medicines bill, while seeking to improve access to new between Member States and will continue to do so. Best practice medicines. Such an approach to partnership could be extended models are for sure helpful, but a one-size-fits-all approach to other areas. would not work. There is still much to do and tuning is needed but the development goes in the right direction. Also EFPIA Commissioner Borg replies: The Commission has fulfilled Director Bergström sees a lot of good progress. In general, its role, in full respect of the Treaty and of the subsidiarity the trend towards investing in the sort of infrastructure that principle. The Europe 2020 process is currently under review – allows the more effective collection, transmission and analysis in wide consultation – with new Commission proposals foreseen of data should help health care systems make better ‘value- by early 2015. The Commission will need to listen carefully based decisions’ – not just in medicines, but throughout the to citizens and stakeholders’ views on whether or not health system. Getting this right in Europe will attract research and outcomes are sufficiently taken into consideration in our current development investment as well as promote good health policy strategy and whether more attention needs to be given to the decisions. Europe now needs to think long-term and be creative link between access to good quality health care services and in seeking out solutions to what we know will be a challenging support to the EU’s poverty reduction target. In this respect, few decades. Zsuzsanna Jakab points to the importance of universal health coverage (UHC). UHC is both a means for achieving good health For Regional Director Jakab the growing burden of non- outcomes progressively (through full coverage of health services, communicable diseases (NCDs) presents an immense challenge and across all stages of life) and a desirable end in itself (through for Member States. Given its close linkage with social and the assurance of protection from financial risk). environmental health determinants, we know that resolving this issue will require a whole-of-society, whole-of-government As European citizens demand more value for money approach and a strong partnership across sectors, as set out in health care, what can the EU contribute to improving in our new Health 2020 policy framework. The EU has a major the performance and efficiency of Member States’ role to play in addressing these issues. Nicola Bedlington adds: health systems? Chronic diseases are seen as a sustainability challenge for European health systems. This is usually presented in financial Professor McKee is rather sceptical. The role of the EU is even terms but it needs to be seen from a patient’s perspective to more limited with respect to health care than it is in relation ensure care is designed and delivered around patients’ specific to health. Perhaps more importantly, there are certain things needs. Innovation in health care should focus especially on that the EU should not do. European health systems represent the way care is organised and delivered and how it can benefit remarkable value for money. Yet, paradoxically, there are patients. Patients, when involved from the onset, can help frequent calls for more markets in health care, based on determine what valuable innovation is to us. As evidence shows ideas in use in the USA, the country that spends most among patient empowerment and involvement is also cost-effective industrialised countries and has the worst health system and leads to better health outcomes and patient satisfaction. performance. Commissioner Borg argues that no health system She concludes: What is very positive is that today patients in the EU is sustainable without in-depth reforms. The EU can are recognised as a legitimate stakeholder group and our help optimise the way Member States’ health systems work in views are sought and increasingly reflected in EU legislation several areas, by pooling knowledge and resources, fostering and documents. good practice exchange, providing economies of scale in terms
of analysis and studies, and facilitating access to expert advice (*) The reflections and quotes were picked from written contributions received from the various on health systems reform. This is explained in the Commission’s panel members to the questions submitted to them. The statements received were organised recent Communication on “effective, accessible and resilient and paraphrased by the Eurohealth editors. health systems”. We have to keep fostering innovation and safety, not only to ensure high quality standards for health products and services but also to support European research excellence that benefits patients and boosts the competitiveness of industry. Ultimately, these reforms aim at ensuring that Member States are able to provide citizens with quality health care for generations to come; and as such, to preserve our European social model of health care for all.
Minister Stöger agrees that the most important goal is to provide a sustainable financial basis for health systems. It is no question that measures are needed, to organise health systems in the most efficient and effective manner. What we need are innovative approaches, including social and organisational innovation, to balance future demands against affordable resources. Following the thought of subsidiarity, measures should be set at the right level. Health systems vary significantly
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VOICES FROM PARLIAMENT
Eurohealth asked a former, returning and new Europe will need to achieve further improvements Member of the European Parliament (MEPs) for to guarantee access to affordable medicines, their reflections on the challenges and opportunities while ensuring that they are safe and effective. for health at EU level under the new term of the The important contribution of the European European Parliament. pharmaceutical sector to economic growth, sustainable employment and wellbeing must For newly not prejudice patient safety. elected, Belgian MEP Louis Ide After being an MP and health minister in the UK (European government between 1993 and 1996 John Bowis Conservatives spent a decade in the European Parliament where and Reformists among other things he devoted much attention Group) to issues around mental health and cross-border promoting better care. He believes that it is a time for hope and even quality of life optimism in health policy making in Europe, so and addressing long as policy makers give health the priority that inequalities in it deserves. Politicians in Europe must build on its
LouisIde access to health health history; understand the crucial link between Multi-resistant care and in health health and wealth; and develop new opportunities bacteria will have a huge outcomes are impact on society in Europe key. Challenges include tackling poor mental health and the world as a whole and high rates of suicide in some EU countries and investing much more in chronic disease prevention, but without doubt he argues the highest priority should be given by the international community to combating multi-resistant bacteria for European ‘‘and global society. This is a threat that Dr Ide, as a medical microbiologist & infection control specialist, has been aware of for some time. JohnBowis Austrian MEP, Karin Kadenbach (Group The new ‘semester’ of the Progressive Alliance of Socialists and system at long last recognises Democrats in the European Parliament) has sat the part good health can play in in the Parliament since 2009 and has served before on the EP’s Environment, Public Health and Food improving economic performance Safety Committee. She stresses better access to and the economic drag that health promoting comes from poor and untreated activities and the health problems dissemination of reliable to transform both. He welcomes recognition by the high quality ‘semester’‘‘ system of the importance of health and information to points to exciting prospects for new health benefits allow citizens for citizens arising from the Cross Border Health to make better Care Directive. It opens the way to safe transferable informed choices. prescriptions, to secure transfer of health records and Her vision sees to reliable use of telemedicine. As efforts continue to preventative identify cost effective solutions, gene research and the medical measures exploration and development of personalised health
KarinKadenbach further developed care and, within that, of personalised medicine, may Preventative measures and promoted by prove to be good investments. need to be further developed the international and promoted by the community. international community ‘‘ Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 12 Eurohealth OBSERVER
BUILDING EU HEALTH POLICY FOR THE FUTURE
By: Artur Furtado, Georgina Georgiou and Patricia Nelissen
Summary: This article explores policy-making at the EU level in the area of health, particularly the importance of partnership relationships and taking into account the global dimension of health. One crucial aspect is the way that scientific advice feeds into policy-making and how that science is effectively translated into policy practice. Moreover, the EU’s contribution to the development of global health is based on promoting values, norms and regulatory models at international level in its regional, bilateral and multilateral relations. A number of key questions related to these key health policy dimensions will be explored in a session hosted by the European Commission’s Directorate – General for Health and Consumers at the 2014 European Health Forum Gastein.
Keywords: EU Health Policy, EU Policy-making, Global Health, Stakeholders, Evidence-based Policy
Introduction making at EU level, including looking at some issues related to translating To be effective, modern health policy science into policy practice. Finally, we needs to involve partners across society in look at how the EU contributes to the policy development and implementation, development of global health by promoting and has to take into account the global values, norms and regulatory models at dimension of health. This is all the more ➤ #EHFG2014 Forum 2: international level in its regional, bilateral relevant at the European Union (EU) Building EU health policy and multilateral relations. for the future level. In a session hosted by the European Commission's Directorate-General (DG) for Health and Consumers at the 2014 Stakeholder involvement: Artur Furtado is Head of Service European Health Forum Gastein, a number not enough, just right or too much of Nutrition and Physical Activity, of key questions related to these key health of a good thing? Health Determinants Unit; Georgina policy dimensions are explored. Georgiou and Patricia Nelissen While there is broad agreement that are administrators, Directorate health is a matter of relevance across General for Health and Consumers, This article focuses on certain aspects European Commission. policies and that its promotion requires of policy-making at EU level in the Email: [email protected] the commitment of multiple actors, there area of health, mainly the way EU is room for discussion about the place policy on risk factors and diseases is Note: This article sets out the of public policy and the right balance in authors’ personal views and developed and implemented through the relationship between public health should not be regarded as partnerships, globally and with Member describing a formal position authorities and health stakeholders. of the European Commission. States and stakeholders. It also explores how scientific advice feeds into policy-
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Have the public bodies been played by Policies based on science Particular attention is given to industry in the recent past, as some fear? and evidence communicating the results of the work of Or, quite the opposite, is it the case that the Scientific Committees to ensure that When preparing its policy and proposals we need to develop partnerships with the their conclusions are known to both the relating to consumer safety, public health NGOs and the for-profit sector to ensure scientific community and stakeholders. and the environment, the Commission faster policy results? Or, perhaps still, In support of this aim, the entire process relies on independent Scientific is the existing cooperation striking the of the Scientific Committees’ work is Committees to provide it with sound right balance? In hindsight, cases of lack accessible on a dedicated website (see scientific advice and to draw its attention of regulation are not difficult to identify http://ec.europa.eu/health/scientific_ to new and emerging problems. The in the wake of the financial crisis. On the committees/index_en.htm). Moreover, opinions of the Scientific Committees other hand, examples of poorly devised several scientific opinions are translated are vital for policy-makers to ensure the legislation are also easy to come by. How into layman language to ensure citizens highest level of health and environmental much and what type of involvement should can grasp the core information of protection that European citizens expect stakeholders have in the development these opinions. from the EU institutions. Policy-making of public policy in the field of health? based on sound science is the main What governance structure should The need for systematic, best practice risk principle underpinning risk governance frame those contributions? How can we assessment will increase further in years and regulation in the EU. better prepare the future, in a realistic, to come. The EU will face new challenges, practical approach? in particular the risks posed by new and Since 1978, three Committees – the emerging technologies (for example, Scientific Committee on Consumer Safety, nanotechnologies), as well as from new the Scientific Committee on Health and products and services. Environmental Risks and the Scientific Committee on Emerging and Newly Identified Health Risks – have adopted Global Health – think global, act Scientific more than a thousand scientific opinions, local, but what to do at the EU level? most of which have served as a basis Global health is an attractive but complex Committees: for regulations, contributing to a more concept that, in capturing and addressing evidence-based EU policy-making. The the world’s health problems, has come excellence, Scientific Committees, whose members to mean all things to all people, with the include eminent scientists from all over the result that no single definition exists (a independence world, review and evaluate scientific data Google search for the term on 4 June 2014 in order to assess potential risks in a wide produced 383 million hits). In 2010, the and transparency range of areas. Recent work has focused European Commission stated that global on medical devices, such as the safety of Interesting examples for this debate may health is about worldwide improvement PIP silicone breast implants and metal in be drawn from the EU action on nutrition of health, reduction of disparities, ‘‘ hip replacements, and the health effects and physical activity. It is framed by and protection against global health of electromagnetic fields. the 2007 Strategy for Europe on Nutrition, threats. It went further to acknowledge Overweight and Obesity-related Health that addressing global health requires Three basic principles govern the work Issues 1 , that set up action-oriented coherence among internal and external of the Scientific Committees: excellence, partnerships involving the Member policies and actions based on agreed independence and transparency. An States (High Level Group for Nutrition principles. There is no doubt about the open way of functioning is in place to and Physical Activity 2 ) and civil society global commitment to improve global continually attract the best scientists (EU Platform for Action on Diet, Physical health, but how can we channel this into and to encourage more dialogue with Activity and Health 3 ). Within the scope effective and sustained action? We are told stakeholders, with the aim of catalysing of the Platform, stakeholders have already to think globally but act locally, but where debate and facilitating exchange of launched more than 300 voluntary and how can the EU with its policies information. At the same time, a robust commitments. Examples range from and instruments fit into this paradigm? set of internal mechanisms is applied dedicated newsletters targeting expert And from what perspective? In its 2010 to safeguard the independence of the audiences to a food and beverage industry Commission Communication on Global scientific work and to prevent the risk pledge not to advertise to children under Health 4 , the Commission considered the of influence from economic, social or the age of twelve; a variety of results, from concept through various lenses, including other non-scientific grounds. A duty of basic to excellent, have been achieved. development, trade, security, human confidentiality applies to information What is now the best way forward? rights, foreign policy, and governance. that Committee members acquire in the course of their work.
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Analysing global health with a European development. For example, the proposed be useful to review how such a strategic perspective, mindful of EU interests, UN Task Force on Non-communicable approach has been developing and values, expertise and instruments, can be Diseases has at least 18 UN agencies highlight common goals and values. approached from three different angles, participating. Within the European as recently proposed by Kickbusch and Commission, DG Health and Consumers The EU and its Member States, as regional Szabo 5 : i) global health governance, has dialogues with 26 other Commission actors, contribute to global health, not just referring mainly to those institutions Services on health matters. One policy in driving the global agenda or in setting and processes of governance which are of direct relevance in this context is global priorities, but also in delivering related to an explicit health mandate, international trade and regulatory benefits at the local level. such as the World Health Organization cooperation. Ongoing negotiations of (WHO); ii) global governance for health, international trade agreements have References referring mainly to those institutions and shown the interest of the global health policies of global governance which have community and the need to address 1 European Commission. A Strategy for Europe an impact on health such as, for example, concerns that have been raised about on Nutrition, Overweight and Obesity related health issues, COM(2007) 279. Available at: http:// international trade or development potential negative impacts on health of ec.europa.eu/health/archive/ph_determinants/ policies; and iii) governance for global standards convergence and the ability life_style/nutrition/documents/nutrition_wp_en.pdf health, referring to the governance of governments to regulate markets for 2 High Level Group on Nutrition and Physical mechanisms established to contribute the benefit of public health. Another activity web page. Available at: http://ec.europa.eu/ to global health. example is the global problem of access health/nutrition_physical_activity/high_level_group/ to medicines which is a multi-faceted index_en.htm
The EU is a committed supporter of global problem – inside and outside the EU – but 3 EU platform for action on diet, physical activity health governance and multilateralism which is addressed in a coherent way and health web page. Available at: http://ec.europa. and it looks to the WHO for global health amongst a range of Commission Services. eu/health/nutrition_physical_activity/platform/ leadership. The European Commission index_en.htm and the WHO have put processes in place 4 European Commission. The EU Role in Global to ensure good cooperation on a wide Health, COM(2010) 128. Available at: http:// range of issues at country, regional and ec.europa.eu/development/icenter/repository/ global levels. The EU, collectively with the COMM_PDF_COM_2010_0128_EN.PDF Member States, is the third largest funder EU policy areas 5 Kickbusch I, Szabo MM. A new governance space of the WHO (behind the Gates Foundation for health. Global Health Action 2014;7:23507. and the USA) and participates actively have direct and Available at: http://dx.doi.org/10.3402/gha.v7.23507 in WHO’s governing bodies which set priorities and promote the organization’s indirect effects values. In its bilateral relations, the EU promotes international health laws, such as on health the International Health Regulations and the Framework Convention on Tobacco A third angle focuses on governance Control and the WHO International for global health, by looking at the Code of Conduct on the Recruitment mechanisms and policies designed by of Health Personnel. health authorities,‘‘ both at EU and Member States’ levels, to achieve coherence But what else can be done? The EU, between internal and external policies as the world’s first and only regional through global health strategies. The 2010 regulator and the world’s largest provider Commission Communication on Global of development aid, is a key player in Health looked at four strands of action: addressing major global health scourges, to establish a more democratic and including communicable health threats, coordinated global governance; to push non-communicable diseases and for a collective effort to promote universal humanitarian crises. In this context, it coverage and access to health services for works with and at the WHO on global all; to ensure better coherence between health issues. EU policies relating to health; and to improve coordination of EU research Looking at the EU’s role in global on global health and boost access in governance for health leads to the question developing countries to new knowledge of the policy coherence of EU positions and treatments. In recent years, several and an examination of how other EU EU Member States have developed policy areas have direct and indirect national global health strategies. It would effects on health, e.g. trade, research,
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TELEMEDICINE: THE TIME TO HESITATE IS OVER!
By: Terje Peetso
Summary: Considering demographic changes in Europe and higher demand for more expensive services, telemedicine would be helpful not only because of its effectiveness for prevention, diagnosis, treatment and rehabilitation but also because of its cost-effectiveness. Telemedicine would be even more effective if interoperability is in place as this would allow effective data sharing and analysis which would further contribute to better health outcomes. Concerns regarding the effectiveness of telemedicine, as well as collection and use of health data, have to be addressed in order to make telemedicine part of mainstream healthcare.
Keywords: Telemedicine, Interoperability, Data Management, European Union
Introduction of telemedicine has been highlighted in many documents and initiatives – Telemedicine is defined as “the provision the eHealth Action Plan 2012–2020 of health care services, through the use (published together with the Staff of Information and Communication Working Document on the applicability Technology (ICT), in situations where the of the existing EU legal framework to health professional and the patient (or two telemedicine services), 2 the European health professionals) are not in the same Innovation Partnership on Active and location. It involves secure transmission Healthy Ageing 3 and in the research and of medical data and information, through innovation programme Horizon 2020 text, sound, images or other forms needed Societal challenge 1 “Health, demographic for the prevention, diagnosis, treatment of ➤ #EHFG2014 Forum 5: 4 1 change and wellbeing”. Deploying eHealth. The time a disease and follow-up of patients”. to hesitate is over! Today, with the prevalence of chronic In 2008, the European Commission’s diseases increasing, services becoming Communication stated that: “Despite the continuously more expensive, demand Terje Peetso is a policy officer potential of telemedicine, its benefits and for health and social services increasing, at Directorate-General for the technical maturity of the applications, Communications Networks, Content and available resources to meet demand the use of telemedicine services is still & Technology (DG CONNECT), and expectations shrinking, telemedicine European Commission, Brussels, limited, and the market remains highly would be helpful not only because of its Belgium. Email: Terje.Peetso@ fragmented. Although Member States ec.europa.eu effectiveness for prevention, diagnosis, have expressed their commitment to treatment and rehabilitation but also wider deployment of telemedicine, most Disclaimer: The views expressed in because of its cost-effectiveness. Studies telemedicine initiatives are no more the article are the sole responsibility show predominantly positive results, with of the author and in no way than one-off, small-scale projects that a clear trend towards better results for represent the view of the European are not integrated into health care Commission and its services. “behavioural” endpoints, (e.g. adherence systems”. 1 Since then the importance
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to medication or diet and self-efficacy) to do certain things in health care systems to be thoroughly explained to patients compared to results for medical outcomes differently; for example, giving more and their carers. In particular, it allows (e.g. blood pressure, or mortality), responsibility to patients to self-manage the permanent monitoring of patients’ quality of life, and economic outcomes their diseases. Putting patients in the conditions, which in turn can improve (e.g. costs or hospitalisation). 5 It is also driving seat is also a motto of the eHealth treatment outcomes, prevent unnecessary an opportunity to develop innovative Action Plan 2012–2020. hospitalisation and consequently models and products that will not only improves quality of life. Turning to data provide savings and better access to care Effectively sharing information about management, patients have to be provided but also opportunities for a new growth the benefits of telemedicine with a thorough explanation on how sector for European health and wellbeing their health data is collected, stored and entrepreneurs. The Commission has funded many analysed through the implementation of projects in the area of ICT for health and relevant legislation on data protection. wellbeing and continues to do so through 7 Horizon 2020. This includes specific Telemedicine requires projects on telemedicine such as Renewing interoperability Health (http://www.renewinghealth.eu/), Concerns United4Health (http://www.united4health. Interoperability is required for the eu/) and MasterMind (http://mastermind- efficient collection and analysis of data regarding use of project.eu/). United4Health involves from different technological sources. approximately 12,000 patients and utilises This would improve the efficiency of health data have results and good practice from previous telemedicine not only within one region projects and trials, including the Renewing or in an entire Member State but also to be taken Health project. The services being across borders. Lack of national and deployed and studied target diabetes, internationally adopted standards is one of seriously chronic obstructive pulmonary disease the obstacles preventing the achievement (COPD) and cardiovascular disease. of successful applications of telemedicine. However, at the same time, the The MasterMind project looks at how Ideally, good practice would include most frequently ‘‘cited barrier to the telemedicine can treat depression. It the collection of data from different implementation of telemedicine solutions is worth underlining that the above sources, facilitating use, for example, globally is the perception that the cost mentioned projects pay particular attention through patient electronic health records. of telemedicine is too high. Almost 70% to cost-effectiveness and as such meet This obstacle was also mentioned by of countries that responded to the World the needs of many countries that have many countries participating in the 2010 Health Organization (WHO) second global mentioned a lack of this data as an obstacle WHO survey. survey on eHealth 6 indicated the need for to implementing telemedicine. First results more information on the cost and cost- from the Renewing Health project are In the eHealth Action Plan 2012–2020 effectiveness of telemedicine solutions, expected to be published in Autumn 2014. the Commission recognises the and over 50% wanted more information on All of these projects pay a lot of attention importance of working towards achieving the infrastructure necessary to implement to the dissemination and exploitation of interoperability within its four levels: telemedicine solutions. Wanting additional results among policy makers, health care legal, organisational, semantic and information on the clinical uses of managers, patients/citizens, insurers and technical. The main strategic and telemedicine was cited by almost 60% health care professionals. governance body at EU level for this of countries; it was one of the three most purpose is the eHealth Network set up requested areas of information. European Although, the lack of demand from by Directive 0211/24/EU. 8 Union (EU) Member States mentioned patients has not been highlighted as an a need for information on clinical obstacle to implementing telemedicine, Better access, better health care possibilities, although a lack of knowledge there is no doubt that it would certainly of telemedicine applications was not help its large-scale deployment. Patients' Although there have been worries that the considered to be a barrier. concerns regarding the effectiveness of use of information and communication such services, as well as collection and technologies in health care will increase There are two other barriers that the use of their health data, have to be taken health inequalities, in fact there is a trend EU Member States have highlighted: seriously and addressed carefully. towards more positive views on the role i) organisational culture that is not of these technologies in improving access supportive and ii) a lack of demand by First of all, it is important to stress that to health care services. For example, tele- health care professionals. These can be telemedicine is not meant to replace consultation may help in contacting an linked to the issues raised in the survey, traditional medicine and face-to-face expert in another hospital, town, region in particular the need for information on contact between patients/citizens and or Member State for better diagnosis cost-effectiveness, but it also stresses the health care professionals. Key information and treatment. It may also help people need for organisational change – the need and benefits about telemedicine need with chronic health problems who live
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in remote areas to be well monitored procedure for many highly qualified 3 European Commission. European Innovation without the need for long-distance travel. doctors. Modern technologies offer many Partnership on Active and Healthy Ageing. Available At the same time, immediate changes good solutions, the implementation of at: http://ec.europa.eu/research/innovation-union/ index_en.cfm?section=active-healthy-ageing in treatment plans may be introduced as which may sometimes need more of a result of real-time data received from a change in mind-set than more data 4 European Commission. Horizon 2020. daily monitoring systems. This can help to demonstrating the effectiveness of Available at: http://ec.europa.eu/programmes/ horizon2020/en/h2020-section/ avoid a serious deterioration in a patient’s the application. health-demographic-change-and-wellbeing condition and the need for hospitalisation. 5 According to the Mastermind project, the Indeed, certain issues, such as van den Berg N, Schumann M, Kraft K, Hoffmann W. Telemedicine and telecare for older use of telemedicine to treat depression interoperability and data management, patients – A systematic review. Maturitas 2012, 73;2, has demonstrated a number of advantages need to be fully addressed in order to October:94 – 114. which include low threshold access achieve the best results for telemedicine. 6 WHO. Telemedicine. Opportunities and to proven treatments, both brief and However, it is already time to start using developments in Member States. Available more extensive, which, in addition, available telemedicine solutions. The time at: http://www.who.int/goe/publications/ are less expensive. to hesitate is over! goe_telemedicine_2010.pdf
7 European Commission. Digital agenda for Europe: Conclusions References telemedicine. Available at: https://ec.europa.eu/ digital-agenda/en/telemedicine 1 European Commission. Communication on Introducing new approaches in any 8 European Parliament and the Council of the telemedicine for the benefit of patients, healthcare health care system is not an easy task, European Union. Directive 2011/24 of 9 March 2011 systems and society, COM(2008)689. Available at: on the application of patients’ rights in cross-border mainly because this affects the most http://eur-lex.europa.eu/LexUriServ/LexUriServ. healthcare. Available at: http://eur-lex.europa.eu/ precious thing that we have–our health. do?uri=COM:2008:0689:FIN:EN:PDF However, modern technologies have been LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045 2 European Commission. eHealth Action Plan :0065:EN:PDF successfully implemented in many areas 2012–2020 and Staff Working Document on the outside health care, as well as within it. applicability of the existing EU legal framework to For example, tele-radiology is already telemedicine services. Available at: https://ec.europa. part of mainstream health care and eu/digital-agenda/en/news/ehealth-action-plan- tele-consultation has become a standard 2012-2020-innovative-healthcare-21st-century
Paying for performance in Each case study analyses the design and implementation of decisions, including the role of stakeholders; critically assesses health care. Implications for objectives versus results; and health system performance examines the “net” impacts, including positive spillover effects and unintended and accountability Paying
for Performance consequences. for Paying
in Performance in Healthcare Edited by: C Cashin, Y-L Chi, P Smith, M Borowitz and Healthcare With experiences from both S Thomson Implications for health system performance and accountability high and middle-income
Cashin,Chi, Smith, Open University Press: Observatory Studies Series, 2014 Borowitzand Thomson countries, in primary and acute care settings, and Number of pages: 312; ISBN: 978 033526438 4 Edited by both national and pilot Cheryl Cashin Available to purchase at: http://www.mheducation.co.uk/ Y-Ling Chi programmes, these studies Peter Smith html/0335264387.html Michael Borowitz provide health finance and Sarah Thomson policy-makers in diverse Health spending continues to outstrip the economic growth settings with a nuanced of most member countries of the OECD. Pay for performance assessment of P4P (P4P) has been identified as an innovative tool to improve the programmes and their efficiency of health systems but evidence that it increases potential impact on the performance of health systems. value for money, boosts quality or improves health outcomes is limited. Contents: i) An overview of health provider P4P in OECD countries – Health provider P4P and strategic Using a set of case studies from 12 OECD countries (including health purchasing; P4P programme design; Strengthening Estonia, France, Germany, Turkey and the UK), this book health system governance through P4P implementation; explores whether the potential power of P4P has been over- Evaluating P4P programmes; Lessons from the case study sold, or whether the disappointing results to date are more P4P programmes; ii) Case studies of P4P programmes likely to be rooted in problems of design and implementation in OECD countries. or inadequate monitoring and evaluation.
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IN HEALTH, EUROPE MUST BE IN THE BUSINESS OF CHANGE AND MEAN BUSINESS
By: Tamsin Rose
Summary: The big challenges for health are clear: the need for a major paradigm shift by transforming health care institutions from sickness treating systems to promoters of wellbeing. We need to get better health outcomes for less resource. Health needs to be a central part of all policy-making and an explicit outcome of government action. Consumption patterns and behaviour need to change radically to reduce the burden of chronic disease. Brussels-based think tank, Friends of Europe, sees the new European Commission mandate (2014 – 2020) as an opportunity and convened health stakeholders to develop recommendations for a new, improved EU approach to health.
Keywords: Strategy, Health Policy, Change, Leadership
Introduction how they could support positive change for health in Europe. The Group met four During the summer of 2014, there was times throughout 2013 and 2014 under the intense political horse-trading behind Chatham House rules which ensured a closed doors between the new European frank exchange of views and allowed some Commission President and national out-of-the-box thinking. The consistent capitals on the allocation of portfolios. theme that emerged was that the EU could Tamsin Rose is an independent Before the new Commission College takes be the catalyst for some of the major health advocate and adviser to office, now is a good moment to reflect Friends of Europe, Brussels, transformation that is needed for public on what a strongly committed European Belgium. Email: tamsin.rose@ health and health care but change needs to gmail.com Union (EU) Health Commissioner could be an explicit EU goal for health. Another achieve for health in Europe. Friends of Europe – Les amis de red thread through the discussions was l’Europe – is a leading think-tank the need to focus on prevention both in Friends of Europe, a Brussels based that aims to stimulate thinking on terms of serious political commitment and think tank, convened a Health Working key global and European political financial resources. challenges. It promotes the Group and brought together a diverse confrontation of ideas that is vital to group of stakeholders from across Europe policymaking and encourage wider involvement in Europe’s future. representing policy-makers at EU and Strengths and weakness of health national level, international organisations, in Europe www.friendsofeurope.org academia, health-related industries and Health is a significant asset for Europe. non-governmental organisations. The The universal access health care systems Working Group sought to define coherent that exist in all EU countries are a unique messages from the health community to feature of the region. Life expectancy the new Parliament and Commission on
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has steadily risen as living and working communicable or chronic diseases. It has significant health inequalities in Europe conditions have improved and most the highest smoking rates in the world which reflect broader inequities in society citizens can expect to enjoy long periods for both men (38%) and women (19%). but are exacerbated by prejudiced attitudes of good health, accessing care when Europeans drink more alcohol (12.5 litres and poor quality care within health care they need it. 1 Europe hosts a thriving of pure alcohol per year) than in any services. The 2013 European Commission life sciences industry with world leading other part of the world – almost double report on Corruption in Healthcare companies that are producing new drugs, the global average. Only North America identified problems in some EU countries medical devices and diagnostic tools. has a higher proportion of obese citizens with fraud and informal payments, etc. There is a well-educated workforce readily (26%) than the European region (22%) all of which undermine the efficiency of available and funding for health research where more than 50% of men and women the health care system and make it hard has been ring-fenced, contributing to the are overweight. In terms of physical to reform. 5 growing body of scientific knowledge. activity, 35% of the people in Europe are The diversity of health care systems across insufficiently physically active. So Europe The economic crisis has heightened Europe presents opportunities for shared scores highly on all the key risk factors the sense of urgency and sharpened learning and exchanges of experiences. EU for chronic diseases. Unsurprisingly the the focus on reform of health systems. level data collection gives insight into the resulting non-communicable disease The dramatic drops in Gross Domestic operational efficiency of different health burden consumes up to 80% of all health Product (GDP) experienced by many systems and allows benchmarking and care costs in Europe. 1 countries post 2008 has led to deep cuts realistic target setting. The EU could and in public spending, including health and should capitalise more on its health assets social services. 6 The new economic 2 3 Can the EU be an agent of change to achieve better health outcomes. for health? governance framework gives the EU, and particularly the Directorate-General Change is not easy to achieve and there for Economic and Financial Affairs are formidable barriers: the complexity (DG ECFIN), an unprecedented right to non- of health and care systems, strong critique national investment and spending vested interests and power imbalances plans. 7 In the past, Member States have communicable in the system, information asymmetries fiercely defended their exclusive right to between users and providers of care, silo manage health care systems and therefore disease burden thinking within health care, short term have been reluctant to actively engage crisis management rather than long term at EU level on broader health issues. consumes up to strategic planning and legacy health This, in turn, led to health being a low care institutions that are out of date and profile portfolio within the European 80% of all health unsuitable for modern care models. The Commission, and the Directorate-General health care sector has also been slow to for Health and Consumers (DG SANCO) care costs adopt new technology and therefore has faces many obstacles to being seen as a not achieved the efficiency gains and major player in policy discussions. With all good news, there tends to be bad productivity increases that other sectors news. The‘‘ societal challenges ahead are have benefitted from. Change takes a Raising the profile of the EU Health well understood – demographic change has long time in health care; new approaches Commissioner profound implications for health and social often take ten to fifteen years to become care costs, chronic diseases consume enshrined in clinical guidelines and For health to get a seat at the European most health care resources but are largely ineffective treatment is hard to amend or Commission tables where the big picture preventable. Health care systems are still eradicate. Entrenched attitudes by health of public financing and health care heavily invested in expensive hospital- care professionals protecting their own spending is being discussed, it needs based curative services which deliver interests often block attempts to open up to have a strong figurehead within acute care, but are not adapted to provide areas of care for other types of skills and the European Commission. The ideal patient-centric care in community settings. qualifications. The policy environment candidate would be someone who has The poaching of health care staff from one can also be slow to respond when the credibility, having served as a Minister health system to another contributes to evidence for change is strong – it took of Health, and with experience of brain drain and both shortages of skilled three decades for politicians to act on negotiating with Finance Ministries and health care workers and skills mismatches the link between smoking and cancer. other departments. If they have seniority across Europe. Chronic diseases are Despite the terrible toll that alcohol takes within the Commission, for example interrelated, are largely preventable and on society and the WHO guidance that a Vice President post, they would be have common risk factors – tobacco raising the minimum price is an effective in a good position to convene groups use, poor nutrition, physical inactivity, way of reducing consumption, 4 only of Commissioners where health is the alcohol consumption, and environmental Scotland has attempted to regulate this linking theme; for example, consumption/ factors. Among the six World Health and has faced strong opposition from production patterns, consumer behaviours Organization (WHO) regions in the drinks companies and other governments and climate change. To really deliver world, Europe is the most affected by non under EU internal market rules. There are on the disease prevention agenda, the
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European Commissioner for Health needs policy priority at EU and global level 3 Friends of Europe. Why health is crucial to to take on some big battles. There are and health should be a central part of the European recovery? Report of European Policy powerful industries that have shaped the debate on how to address it. Summit. Brussels: Friends of Europe, 2012. Available at: http://www.friendsofeurope. environment for consumers, influencing org/Portals/13/Documents/Reports/2012/ behavioural decisions on smoking, Stakeholders’ recommendations FoE_Report_Health_2012.pdf drinking alcohol or soft drinks and eating for EU action on health 4 Increasing excise duty and value added tax on patterns. They have an economic interest alcohol. Copenhagen: World Health Organization in maintaining the status quo and their Reflecting on these challenges and Regional Office for Europe, 2012. Available at: business models would be threatened by opportunities, a new report from the http://tinyurl.com/kzatetz
significant shifts in these consumption ‘Friends of Europe’ think tank (due to be 5 European Commission – Directorate General patterns that are essential to boost disease published shortly) distils the thinking of Home Affairs. Study on corruption in the healthcare prevention. Other parts of the Commission their Health Working Group’s into a list sector. Luxembourg: Publications Office of the responsible for trade, the internal market, of 23 recommendations on what the EU European Union, 2013. Available at: http://tinyurl. industry policy, etc. act as champions should ‘Start’, ‘Stop’ or ‘Do Differently’ com/ll6wgbv for these interests and have in the past during the next mandate. This approach 6 Karanikolos M, Mladovsky P, Cylus J, et al. undermined efforts to regulate on the was designed to make sure that the report Health in Europe: financial crisis, austerity and health. basis of public health. The Commissioner did not create an unfeasible list of new The Lancet 2013; 381:1323 – 1329. for Health would need to get fellow tasks for the over-stretched European 7 Council of the European Union. Council Commissioners to buy into the vision of Commission staff to take on. The ‘Start’ conclusions on the economic crisis and healthcare. health as the key outcome of EU actions, recommendations set out some positive Luxembourg: Council of the European Union, June 2014. Available at: http://www.consilium. bringing them alongside when the external steps that the EU could take to reinforce europa.eu/uedocs/cms_data/docs/pressdata/en/ lobby pressures to block change start efforts to effect positive change for lsa/143283.pdf to mount. health. The recommendations on what the EU should ‘Stop doing’ reflects a There are some useful policy certain frustration with the prior lack developments that would assist the Health of coordination and inconsistent follow Commissioner in making the case for up of initiatives. The ‘Do Differently’ change. The utility of GDP as a measure of recommendations outline how the EU societal progress is being questioned. The could use greater focus and simplification Organisation for Economic Cooperation with more joined up thinking across policy and Development (OECD) is developing areas to end silo working. the Better Life Index, which is a more nuanced basket of eleven criteria to The Working Group was undaunted by measure performance – ranging from the size of the challenges facing health in income and housing to health and work- Europe and felt that the timing is right for life balance. 1 The incoming Commission a more proactive Commissioner for Health President has promised to invest more who would find allies in the Parliament in social Europe, marking a shift from and among Health Ministers that want the economic growth driven austerity Europe to be a friend to health systems. measures. Given the close linkages If stakeholders get a clear message at the between poverty, social exclusion, beginning of the mandate that Europe is unemployment and health, this is an in the business of change for health – and important development. Poor health it means business – they will find ways to and chronic illness can be both a driver align their strategies and activities to this of unemployment and a result of being agenda. This might be the trigger that is out of the labour market. Health should needed for the paradigm shift for health. rightfully claim a central space in future social Europe initiatives. Health is also References increasingly acknowledged as being at the nexus of climate change, as a contributor 1 OECD. Health at a glance, OECD indicators. to the problem (the sector uses resources Paris: OECD, 2014. Available at: http://www.oecd. org/health/health-systems/health-at-a-glance.htm intensively and produces high levels of waste) and a consequence of global 2 Mackenbach J, Karaikolos M, McKee M. Health warming as extreme weather events affect policy in Europe: factors critical for success, BMJ 2013;346:f533. health and shifting climate patterns bring new disease patterns to Europe. Climate change will continue to be a headline
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WHAT IS THE EU’S CONTRIBUTION TO HEALTH SYSTEM PERFORMANCE?
By: Matthias Wismar, Scott L Greer and Nick Fahy
Summary: Countries throughout Europe are striving to improve the performance of their health systems, and their impact on public finances is increasingly important. The European Union is playing a stronger role than hitherto in this area, with specific recommendations to countries on reforming health systems, and investment into health systems available from European funds, alongside its broadly positive but fragmented impact on health as a whole. As Europe emerges from the financial crisis and the strategic agenda of the Juncker Commission is developed, understanding the potential impact and contribution of Europe to health is more important than ever.
Keywords: Health Policy, Public Finances, Financial Crisis, European Union
The policy context that can serve as goals for performance. The Council emphasised the “overarching All countries in Europe are striving to values of universality, access to good improve the performance of their health quality care, equity, and solidarity” and systems. Policy-makers are aiming at “operating principles” of quality, safety, better returns from time, effort and monies evidence and ethics, patient involvement, invested in health systems. They are also ➤ #EHFG2014 Forum 6: redress, and privacy and confidentiality. seeking to eliminate or reduce the waste Health System Performance In other words, health system performance in health systems caused, for example, would be assessed against the ability to by over- and mal-treatment or the use of serve the whole population, to extend life Matthias Wismar is Senior ineffective or overly expensive procedures expectancy and improve health-related Health Policy Analyst, European and products. Needless to say, that in Observatory on Health Systems quality of life, to do so regardless of times of austerity many countries are and Policies, Brussels, Belgium. social status and to distribute the burden Scott L. Greer is Associate confronted with growing health demands of health care funding in a fair manner. Professor, Department of Health and dwindling public budgets, putting Management and Policy, University These Council conclusions have no extra pressures on them to get more value of Michigan School of Public Health, binding character. They were developed Ann Arbor, Michigan, USA and for money. Research Associate at the European in the context of a wider debate on cross- border patient mobility in which Ministers Observatory on Health Systems It is easy to postulate the quest for and Policies, Brussels, Belgium. of Health were eager to clarify that health efficiency, but it is harder to define and Nick Fahy is an independent systems objectives are separate from other consultant and PhD student at agree on desired outcomes vis-à-vis the sectors’ policies and objectives. 1 Queen Mary University of London, investment. The Council of Ministers has United Kingdom. Email: [email protected] provided some orientation as it established specific health systems values in 2006
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Efficiency and health system performance What is the European Union’s This includes a plethora of specific increasingly play an important role for contribution to health systems issues like procurement, competition law, the European Commission. In 2010 performance? cross-border collaboration, European the EU started to send Member States reference networks, e-health, European The EU is not just making country-specific recommendations (CSR). prescription, just to name a few, which recommendations on how to improve These CSRs are part of the European have, undoubtedly, an impact on health health system performance. The EU has Semester, a form of fiscal governance, system performance. in some policy areas exclusive or shared designed to contribute to fiscal discipline competencies allowing for legislating and economic recovery in a crisis- The EU has various instruments to and adopting legally binding acts. It is ridden Europe. The recommendations implement these policies, programmes therefore shaping–or helping to shape– made on health systems focus largely and actions. policies that impact on health and health on financial sustainability and are systems and their performance. And this pushing for structural reforms to improve Directives: The Directives on the impact is bigger than one may think. efficiency. Within the Commission, the recognition of professional qualifications There are several health-related articles in Directorate-General for Economic and (health professional mobility), the the Treaty on the Functioning of the EU Financial Affairs (ECFIN) is leading Directive on patient rights in cross-border (art. 168 public health, art. 169 consumer the development of the CSRs, but the health care and the tobacco products protection, art. 191 environment, art. 153 conceptual basis of the assessment is not Directive are examples of key legislation working environment). These articles entirely clear. Recently, as mandated by with major impact on health and provides the legal mandate for Community the Social Protection Committee, the health systems. action on tobacco, alcohol, environmental Directorate-General for Employment, determinants, climate changes, diet, Social Affairs and Inclusion (EMPL) has Agencies: There are plenty of agencies nutrition and physical activity, health started developing a Joint Assessment working in health-related fields: the and safety in the workplace, consumer Framework for health systems in the European Centre for Disease Prevention protection and communicable diseases. It context of the Open Method of Co- and Control (ECDC), the European Food also includes information, comparison and ordination (OMC) but also with relevance Safety Authority (EFSA), the European benchmarking and actions on substances to the CSR. This framework focuses on Medicines Agency (EMA), the European of human origin. The intensity and access, quality, efficiency and contextual Monitoring Centre for Drugs and Drug instruments chosen to tackle these areas factors, including equity-related factors, 2 Addiction (EMCDDA), the European vary greatly, but the actions are very and is therefore not so dissimilar from the Environment Agency (EEA) and the relevant with regards to unburdening values and principles suggested by the European Agency for Safety and Health health systems from diseases amenable Council of Ministers. at Work. (With a slightly different legal to prevention and health promotion – status, there is also the Consumers, Health one way to strengthen health system In the context of the social investment and Food Executive Agency (CHAFEA). performance. 4 package designed to contribute to economic recovery in Europe, the Joint action (JA): JAs are a way of Commission is also aiming to address collaboration between Member States, the needs of health systems. It is making their competent authorities and the the case for investment in health and The EU Commission. Examples under the pointing at various areas where Member health programme are the JA on Health States can improve the efficiency of health is helping to Inequalities, 5 JA on Health Workforce systems. Among the suggestions are Planning and Forecasting 6 and the JA on many examples for raising health systems shape policies Comprehensive Cancer Control. 7 performance: “using financial incentives to encourage patients to register with a that impact Budgets: There is the health programme general practitioner (GP) or family doctor, budget, although this is rather seed […] introducing activity- and/or quality- on health money in comparison with the more based payment for diagnosis-related substantial budgets of the Cohesion policy. A more indirect but often more groups, […] ensuring a more balanced mix In addition, the health-related funds of substantial impact on health system of staff skills, […] reducing unnecessary the Horizon 2020 research programme performance is caused by the internal use of specialists and hospital care, […] contribute to health. market, the coordination of social better health promotion and disease ‘‘ security systems, and fiscal governance. prevention in and outside the health sector, Fiscal governance: The European The so-called four freedoms – the free […] improving data collection, [… ] Semester, an annual review cycle, holds movement of goods, services, people using health technology assessment more together a host of surveillance, assessment, and capital within the EU’s internal systematically, [… and] the use of less benchmarking and recommendation market – is also the free movement expensive equivalent (generic) drugs”. 3 of pharmaceuticals, medical devices, diagnosis and therapy and patients.
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mechanisms based in a consciously the Treaty are wide-ranging), but rather on changing health policies or stabilising expanding base on economic policies a clear preference by national governments economies for growth, but it is worth aimed at controlling public budgets. to address social issues domestically, following. rather than at European level, and Clearly, the EU has the mandate and likewise to keep the overwhelming It is therefore overdue to have an informed instruments to impact on health and health weight of financial tools under national debate on the achievements and prospects system performance. But is there really control. The EU has also made some of the EU in health and health systems sufficient policy consistency and is it progress in addressing the behavioural and on the appropriate areas of, and focusing on the key issues? determinants of health, but most strongly instruments for, action. Only if we are for smoking. For diet and exercise or the prepared to asked these questions on the particularly European issue of alcohol, linkages between EU and health can we European action has been broadly limited make informed decisions on electing to providing information and leaving health and improving health system choices to individuals. performance at European and Member The fragmented State level. This broadly positive impact is not widely nature of EU understood, though. The fragmented References nature of the EU’s action on health – being action on health taken across a wide range of legal bases, 1 European Council. Council Conclusions on many of which do not have health as Common values and principles in European Union Health Systems (2006/C 146/01), 22 June 2006. makes it difficult an objective – makes it difficult to gain an overall picture. This consequently 2 Social Protection Committee. Developing an to gain an makes it difficult for health stakeholders assessment framework in the area of health based on the Joint Assessment Framework methodology: final to be part of shaping the EU’s health- report to the SPC on the first stage of implementation, overall picture related discussions, when so much of the 19 November 2013. Available at: file:///H:/JAF%20 ‘‘ discussion and decision-making takes health%20document.pdf place in forums which are not primarily 3 Electing health – electing European Commission. Social Investment performance? focused on health. The qualitative nature Package. Investing in Health Commission Staff of much European health cooperation – Working Document SWD (2013) 43 final. With the recent European Parliament building networks, providing comparable Available at: http://ec.europa.eu/health/strategy/ elections, fundamental discussions on the data for benchmarking, sharing good docs/swd_investing_in_health.pdf future direction of European Integration practice – has done a great deal to improve 4 Greer SL et al. Everything you always wanted to entered the political centre stage health, too, but works in ways that are know about European Union Health Policies but were sometimes resulting in strictly opposing hard to quantify and demonstrate. Often, afraid to ask. Copenhagen: European Observatory on Health Systems and Policies, 2014 (forthcoming). positions. Big themes like peace, economic EU activity based on internal market, growth, sovereignty and democracy were competition, or trade law has received the 5 Equity Action was the EU-funded Joint Action on brought forward in the debate. These attention – justly, as in the cases of EU Health Inequalities (February 2011– February 2014). Available at: http://www.health-inequalities.eu/ are certainly key themes; however, if we action on trade in essential medicines or HEALTHEQUITY/EN/projects/equity_action/ want to do justice to health systems and cross-border patient mobility. 6 their specific goals, if we are to ask what Joint action on health workforce planning and forecasting web site. Available at: http://www. benefits health systems performance, we Meanwhile, the development of EU fiscal euhwforce.eu/ would look at the EU and health from a governance is potentially important but 7 more functional, if not technocratic angle: it is difficult to say how much, or what, it European Commission. Kick-off meeting of the Comprehensive Cancer Control Joint Action what can the EU add that Member States will mean for health services. In response (CANCON), Luxembourg, 11 – 13 March 2014. have difficulties to achieve by themselves? to the fiscal crises of various EU Member Available at: http://ec.europa.eu/dgs/health_ States after 2008, the EU strengthened consumer/dyna/enews/enews.cfm?al_id=1461 Reviewing past contributions, the EU its existing fiscal governance regime in has clearly helped to improve health by order to more effectively monitor Member addressing environmental determinants; States’ fiscal policies, economic situation, European citizens are amongst the best and policies that might in the future lead to protected in the world in terms of exposure imbalances. Given the public expenditure to chemicals or pollution, for example. of health systems, it is no surprise that The EU has made progress in addressing fiscal governance mechanisms start to key social determinants, such as health make recommendations about health and safety at work, but the impact of wider system reform. It remains to be seen how social inequalities on health remains. This effective the fiscal governance system, cannot be blamed on a lack of legal powers notably the European Semester, is at to act (unlike health, the social powers in
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FROM MILLENNIUM DEVELOPMENT GOALS TO THE POST 2015 DEVELOPMENT AGENDA
By: Nedret Emiroglu and Evis Kasapi
Summary: It is crucial to accelerate efforts along the last mile of the race to meet the Millennium Development Goals (MDGs) in order to achieve the goals in the areas where progress is lagging behind. The unfinished agenda of the MDGs, noncommunicable diseases, sexual and reproductive health and rights and Universal Health Coverage, should be addressed in the post-2015 development agenda, through a holistic and inclusive approach, based on the concept of well-being and not merely the absence of death and disease. Health 2020: the European policy for health and well-being will set the ground for implementing this new vision in the region.
Keywords: Millennium Development Goals, World Health Organization, UN, Post 2015 Development Agenda, Health 2020, Health Inequalities
Introduction and there are marked gender differences. Ethnic minorities, some migrant “Better health for Europe” across communities and groups of travellers, the 53 countries in the World Health such as the Roma, continue to suffer Organization’s (WHO) European Region disproportionately from preventable and is the common priority for WHO and its treatable diseases. Member States, and collective efforts are needed in order to sustain the health The “unfinished business” of the MDGs, gains that have been made so far, and to the rapid growth of non-communicable ensure the highest attainable standard of ➤ #EHFG2014 Forum 7: diseases (NCDs), disabilities and mental health, as one of the fundamental rights From MDGs to the post – health disorders, environmental health of every human being across countries 2015 agenda risks, and the need to improve public and populations. health capacities and strengthen health systems under financial constraint, all call Nedret Emiroglu is Deputy Director, Across Europe and Central Asia, health for a new approach to health in the 21st Division of Communicable Diseases, has greatly improved in recent decades and Health Security and Environment century. Many of the initiatives designed countries have made significant advances and Special Representative of the to propel the post-2015 development Regional Director on MDGs and towards the Millennium Development agenda focus on these challenges. The Governance, WHO European Region. Goals (MDGs). 1 However, areas remain Evis Kasapi is Technical Officer, Global Thematic Consultation on Health, 2 in which action has stagnated and health Division of Communicable Diseases, one of a series of consultations convened inequities persist between and within Health Security and Environment by the United Nations to inform the new WHO European Region. countries in the region. For example, there development agenda, called for new Email: [email protected] is a sixteen year gap between the lowest goals, which, building on the existing and highest life expectancy rates at birth
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health-related MDGs, set more ambitious NCDs prevention of sexual transmission in targets and focus on sustainable health national AIDS plans remains a challenge and well-being for all. The Regional account for the for many. Consultation, Inclusive and Sustainable Development: Perspectives from Europe largest Tuberculosis and Central Asia on the Post-2015 TB is still a major public health problem Development Agenda, 3 that took place in proportion of in the WHO European Region with an Istanbul, Turkey, on 7 – 8 November 2013, estimated 350,000 new cases and more highlighted that: “Any goal on health mortality than 35,000 deaths occurring every should advocate for a whole-of- year, 10 of which more than 80% are in government, whole-of-society and a life- The European regional average maternal Eastern Europe. The major burden in the course approach, crucial for addressing mortality decreased from 44 per 100,000 region is constituted by eighteen high- the social, economic and environmental live births in 1990 to 20 in 2010. 9 Despite priority countries with 85% of TB cases determinants of health and for the the progress,‘‘ the European regional and more than 99% of all multi-drug well-being of societies at large”. The average mortality decline of 3.8% is short resistant (MDR)-TB cases. The burden unfinished agenda of the MDGs, universal of the 5.5% needed to reach the MDG varies between and within the countries, health coverage, NCDs and sexual and target 5A. In Central Asia and Caucasus from a range of less than one TB case reproductive health and rights should the annual decline is even less (2.1%). per 100,000 population to about 160 be addressed in the future development In addition, there are big discrepancies TB cases per 100,000. There are also framework. Finally, Health 2020: the between and within countries, with rates large differences in TB rates within the European policy for health and well- ranging from more than 75% above to countries, including in Western Europe, being, 4 endorsed by the WHO Regional more than 60% below the regional average. where TB rates can vary up to several Committee for Europe in 2012, provides a times higher in some districts of capital framework for action across government HIV/AIDS cities compared to other districts. and society and will set the ground for HIV remains a serious public health implementing this new vision. challenge in the region. Newly reported In the last decade, TB incidence has cases of HIV continue to increase in been falling at an average rate of 5% per Uneven progress in achieving the region, while globally, the number year, which is the fastest decline among health-related MDGs of people newly infected with HIV WHO regions. In 2012, the estimated is decreasing. The total cumulative TB prevalence was 56.4 per 100,000 Substantial progress has been made in number of people (ever) diagnosed and population, with an average decline reducing child and maternal mortality, reported in Europe is over 1.5 million, rate of 7.7% during the last decade. If and morbidity and mortality due to HIV including 131,000 new HIV cases in 2012. 7 the downward trends continue, it seems infection, tuberculosis (TB) and malaria. The gains in HIV treatment are unevenly feasible that the MDG 6 target of a 50% Progress in many countries with the distributed. In the east, antiretroviral reduction in incidence and prevalence highest rates of mortality has accelerated therapy (ART) coverage remains low, by 2015, against the baseline of 1990, in recent years; nevertheless, large gaps with relatively few people who are eligible will be reached. However, with regard to persist among and within countries. 5 actually starting ART (35%) and achieving mortality, the current modest decline – an The current trends form a good basis for viral suppression. As a result, the number estimated 36,000 deaths due to TB, equal intensified collective action and expansion of AIDS cases and deaths due to AIDS to 3.9 deaths per 100,000 population of successful approaches to overcome are increasing. In the west, where ART reported in 2012 – suggests that the target the challenges posed, and to achieve coverage is high, the numbers of cases for halving mortality will not be achieved the MDGs. and deaths are decreasing. in the region
Child and maternal health The HIV epidemic in the WHO The WHO European Region has the There has been a steady decline in both European Region is concentrated in highest MDR-TB rate in the world, with under-five and infant mortality rates socially marginalised populations: fifteen European Member States in the top across the Region – however, with stark people who inject drugs and their list of 27 high MDR-TB burden countries inequities between countries and within sexual partners, men who have sex globally. The prevalence of MDR-TB countries. The regional average of the with men, sex workers, prisoners and among new and previously-treated cases under-five mortality rate decreased migrants. Strategic information about amounted to 16% and 45% respectively. from 34 per 1,000 live births in 1990 to 14 the epidemic has become increasingly Treatment coverage for MDR-TB patients in 2010. This corresponds to a reduction available and of higher quality. However, has increased from 63% in 2011 to 96% of almost two-thirds, and is very close to even though an increasing number of in 2013; however, the treatment success the 2015 target of 11 deaths per 1,000 live countries are adopting evidence-informed rate for MDR-TB patients is 48.5%, far births. Regional average infant mortality policies for preventing HIV among key below the target of 75%. rates also have declined, from 28 per 1,000 populations, implementing harm reduction live births in 1990 to 12 in 2009. 6 7 8 interventions and programmes targeting
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Growing burden of NCDs and Universal Health Coverage (UHC) and National and subnational health policies, mental health access, suggested as the key contribution strategies and plans are vital to ensure a by the health sector to achieving health comprehensive and structured approach Today, NCDs account for the largest goals and targets and to improving to long-term planning and priority setting. proportion of mortality in the WHO population health more broadly, combines Health policies must become more European Region, accounting for access to health services (promotion, evidence informed, intersectoral and about 80% of deaths in 2008. Three main prevention, treatment and rehabilitation), participatory, and leadership transformed disease groups (cardiovascular diseases, the living conditions needed to achieve accordingly. cancer and mental health disorders) cause good health and financial protection to more than half the burden of disease prevent ill health from leading to poverty. (measured using disability-adjusted life- A development agenda focused on Few countries reach the ideal, but all – rich years – DALYs). health and well-being, and equity and poor – can make progress. The MDG agenda is an unfinished The determinants of these conditions business in the region. It is crucial to are complex and involve both individual accelerate efforts along the last mile of the and societal factors. Individual variation race in order to achieve the MDGs in the in susceptibility and resilience is in part areas where progress is lagging behind, genetically determined, while the social and which remain critically important determinants – the circumstances in which Strengthening today. The unfinished agenda of the people are born, grow, live, work and age – MDGs, universal health coverage, NCDs are largely influenced by inequities in the health systems and sexual and reproductive health and distribution of power, money and other rights should be addressed in the future resources. In particular, socioeconomic is key development framework. status in early life greatly influences later Across the region skills and infrastructure susceptibility and experience of disease. are patchy. Coordination between public The Global Thematic Consultation on health and health and social care services Health concluded that an overarching The economic impact of these conditions is often poor and financial policies goal for the wider post-2015 agenda threatens to overwhelm health systems in and incentives are not conducive to should recognise health as a critical many countries in the region. For example, effective coordination of care. There is contributor to, and outcome of, sustainable cardiovascular diseases cost the European ‘‘ variation in clinical practice and a lack development. It should call for a holistic Union (EU) economies an estimated of evidence-informed pathways for the and inclusive approach, based on the €192 billion per year. 11 There are growing whole continuum of care. Priority and concept of well-being and not merely costs to the health care system, but also expenditure continue to favour acute the absence of death and disease. The broader effects: absenteeism at work, curative services and high-technology Consultation aimed at maximising decreased productivity and increased diagnostics. healthy life expectancy, with the UHC employee turnover. Individuals and being a key instrument in this respect. their families face reduced income, Furthermore, many people experience The Regional Consultation Inclusive and early retirement, increased reliance on out-of-pocket health expenditure that Sustainable Development: Perspectives welfare support and a burden of direct and places a catastrophic burden on their from Europe and Central Asia on the indirect health care costs, while the state household budgets, raising severe barriers Post-2015 Development Agenda, echoed faces huge losses in taxes from both lack to accessing care. This situation has the necessity of taking a holistic approach of employment and reduced consumer worsened during the economic downturn. and tackling the social, economic and spending. There is now good evidence that long-term environmental determinants of health. unemployment is associated with higher Public health capacities and health levels of disease, especially mental health Moving towards UHC requires strong systems under financial constraint problems, and increased mortality from efficient health systems that can respond suicide, especially among the poor and to the full range of health determinants Strengthening health systems is key vulnerable. 5 and deliver quality services on a broad to improving population health – it is range of country health priorities. Health an investment in a healthy workforce, Faced with these challenges, across the financing systems are required that can economic growth and human and WHO European Region, much remains to raise sufficient funds for health, and also social development. The requirement, be done. There are powerful arguments provide access to essential medicines particularly at times of economic for “going upstream” to address the root and other supplies and equipment, good downturn, is for a needs-driven health causes of ill health, yet investment in governance and health information, and system that improves health outcomes, and health promotion and disease prevention a well-trained and motivated workforce. the protection of access and services for remains weak. Establishing coherent low-income and other vulnerable people. interdisciplinary health care teams with Universal access provides a benchmark effective management is a priority. for this.
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Setting the ground for the new and society and calls for a combination development agenda, Health 2020, through of governance approaches that promote its strategic objectives aims to: health, equity and well-being. • improve health for all and reduce health inequalities; and References • improve leadership and participatory 1 Building more inclusive, sustainable and governance for health. prosperous societies in Europe and Central Asia, A common United Nations vision for the post-2015 development agenda. Geneva: United Nations Combating health inequalities and Economic Commission for Europe. Available at: achieving the best possible health and http://www.unece.org/fileadmin/DAM/publications/ well-being for all requires a range of oes/images/Building_more_inclusive_sustainable_ policy and governance interventions, societies-English.pdf mainly in the following areas: 2 Global Consultation on Health. Available at: http://www.worldwewant2015.org/health • Addressing the social, economic and 3 environmental determinants of health Report of the Regional Consultation. Available at: www.worldwewant2015.org/ through intersectoral action and EuropeCentralAsia integrated policy measures; 4 WHO, Regional Office for Europe. Health 2020: • Tackling environmental threats to A European policy framework supporting action across human health, including those related government and society for health and well-being. to air quality, climate change, transport Copenhagen: WHO, 2012. Available at: http://www. euro.who.int/en/health-topics/health-policy/health- and water and sanitation. In this regard, 2020-the-european-policy-for-health-and-well-being/ the European Environment and Health about-health-2020 Process is critical to shaping appropriate 5 Review of social determinants and the health policies and actions in the region; divide in the WHO European Region. Available • Taking a life-course approach to at: http://www.euro.who.int/en/health-topics/ health-policy/health-2020-the-european-policy- increased equity in health, beginning for-health-and-well-being/publications/2013/ early in life (with pregnancy and review-of-social-determinants-and-the-health-divide- early childhood development) and in-the-who-european-region.-final-report
continuing with school, the transition 6 Child Mortality Report 2013 Estimates Developed to reproductive age, working life, by the UN Inter-agency Group for Child Mortality employment and working conditions, Estimation. Available at: http://www.childinfo.org/ and circumstances affecting older files/Child_Mortality_Report_2013.pdf people; 7 World Health Statistics 2014. Available at: http://www.who.int/gho/publications/ • Intervening to prevent the transmission world_health_statistics/2014/en/ of disadvantage and health inequity 8 across generations; Child mortality and causes of death. Available at: http://www.who.int/gho/child_health/mortality/en/
• Putting in place policies that remove 9 Trends in Maternal Mortality: 1990 to 2013. gender differences in health and social Estimates by WHO, UNICEF, UNFPA, The World and economic opportunities; Bank and the United Nations Population Division. Available at: http://www.who.int/reproductivehealth/ • Strengthening national health publications/monitoring/maternal-mortality-2013/ information systems, civil registration en/
and vital statistics, down to the district 10 European Centre for Disease Prevention level and below, as prerequisite for and Control/WHO Regional Office for Europe. measuring and improving equity. Tuberculosis surveillance and monitoring in Europe 2014. Available at: http://www.euro.who.int/__data/ Building the governance required to assets/pdf_file/0004/245326/Tuberculosis- surveillance-and-monitoring-in-Europe-2014. orchestrate a coherent response across pdf?ua=1 government and society which results in 11 better health outcomes remains one of European Cardiovascular Disease Statistics 2008. Available at: http://www.ehnheart.org/component/ the greatest challenges in global health. downloads/downloads/683.html Addressing the priorities put forward by Health 2020: the European policy for health and well-being provides a framework for action across government
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LEADERSHIP IN PUBLIC HEALTH: REDUCING INEQUALITIES AND IMPROVING HEALTH
By: Katarzyna Czabanowska
Summary: There is a developing consensus that public health organisations should engage in building leadership capacity. To develop effective public health leadership therefore requires these organisations to actively engage in developing more leaders at every level. This article aims to stimulate debate on the kind of public health leadership needed today to reduce inequalities and improve health and well-being. Definitions and a new model of public health leadership are discussed, and its meaning is further explored via the results of interviews with European public health leaders. Some new developments in transformational public health leadership training and capacity building initiatives are highlighted.
Keywords: Public Health Leadership, Continuous Professional Development, Public Health Capacity, Europe
Introduction consumerism and individualism all have an effect on health and health-related Although leadership is a well-known issues leading to increasing health concept within organisational science, inequalities. In addition, modern global public health leadership has still not developments include: over consumption, been well-defined. There is a developing increasing social inequalities and rising consensus that public health organisations rates of mental distress and disorder. In should engage in building leadership Europe, these challenges are currently capacity. To develop effective public exacerbated by the impact of global health leadership therefore requires ➤ #EHFG2014 Forum 1: recession and austerity measures that these organisations to actively engage in Public health leadership have been introduced in many European developing more leaders at every level. countries, which are putting health systems under significant financial Katarzyna Czabanowska A key driver in improving leadership pressures and forcing them to deliver is Associate Professor at the within public health is that the nature of Department of International Health, more with diminishing resources. the challenges faced by such professionals CAPHRI, Faculty of Health, Medicine Therefore, developing effective leadership and Life Sciences, Maastricht is evolving. The combination of a range of is essential. University, the Netherlands. socioeconomic drivers, including ageing Email: kasia.czabanowska@ maastrichtuniversity.nl populations and workforces, globalisation,
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What is public health leadership? Public health leadership competency common for leadership development to framework be included in European public health Definitions of public health leadership training programmes. 9 At the same vary from the idea that it includes Whilst considerable work has been time, The Lancet Commission raised commitment to the community and the done in the development of leadership the question of how higher education values it stands 1 for to the argument that competencies in the field of health institutions delivering public health public health leaders differ from leaders worldwide, these frameworks seem very education can provide the content and in other sectors as they are required to generic and none have been specifically context to initiate a major reconsideration balance corporate legitimacy, whilst developed to support the educational of working and learning patterns also existing outside the corporate curriculum for public health professionals. which incorporate novel forms, based environment. 2 A more collaborative A new model has been developed on the principles of inter-professional world will require a new generation of within the framework of the Leaders collaboration. 10 In response to this need, leaders in public health with new mind- for European Public Health Erasmus a model representing the meaning of sets, an appetite for innovation and Multilateral Curriculum Development contemporary public health leadership in interdisciplinary collaboration and a Project (LEPHIE), supported by the EU a European context was developed based strong dose of political savvy. 3 A public Lifelong Learning Programme. Based on in-depth interviews with prominent health leader “must be the transcendent, on a review of public health and public European public health leaders 11 within collaborative ‘servant leader’ who knits health leadership competency frameworks, the LEPHIE Project. and aligns disparate voices together behind leadership literature and expert review a common mission.” 4 panels, the framework was developed to support the continuing professional development (CPD) curriculum and Box 1: Six themes shaping public facilitate self-assessment of public health health leadership make leadership competencies. • European public health context decisions in an Competencies are composites of individual • Inner path of leadership attributes (i.e. knowledge, skills, and increasingly attitudinal or personal aspects) that • Essence of leadership represent context-bound productivity. 8 • Emerging styles of leadership complex Fifty-two competencies are distributed • Future leader’s imperatives around nine domain areas, including: • Benefiting society and improving environment Systems Thinking, Political Leadership, wellbeing Building & Leading Interdisciplinary
Public health leaders need to be Teams, Leadership and Communication, Source: Reference 11 exceptional networker-connectors, Leading Change, Emotional Intelligence & capable of putting the pieces of the Leadership in Team-based Organisations, puzzle together; they must combine Leadership Organisational Learning & ‘‘ 7 administrative excellence with a strong Development, Ethics and Professionalism. The interviews were conducted to develop sense of professional welfare and actively The Public Health Leadership Competency an understanding of the nature of public develop the profession, articulate its shared Framework can serve as a useful tool health and identify skills needed by values, and build for the future. 5 Today, in identifying gaps in knowledge and public health leaders to successfully meet the particular type of leadership required skills and shaping adequate competency- present and future patient and population is not of a traditional command and based CPD curricula for public health health requirements as well as help tackle control variety but rather akin to what has professionals. It is also an attempt to health inequalities. The model consists of been termed adaptive leadership: leading define, profile and position public health six themes identified from the interview in contexts where there is considerable leadership through a systematically data (see Box 1). This model does not uncertainty and ambiguity, and where developed, comprehensive and reflect a particular leadership theory there is often imperfect evidence and multidisciplinary competency framework or orientation but presents a picture of an absence of agreement about both the which can be used by public health current public health leadership based on precise nature of the problem and the professionals as a tool for self-assessment the real life experiences of public health solutions to it. 6 Professional development and personal development planning. 8 leaders. However, elements of it resonate of public health leaders requires with aspects of generic theories such as competency-based instruction to help Leadership in the contemporary transformational leadership, situational them develop the abilities to address the public health context leadership, and servant leadership. 11 complex and evolving demands of health care systems. The results of a recent survey carried The content of the interviews showed that out by the Association of Schools of public health leaders, confronted with Public Health in the European Region major shifts in the nature of ill health (ASPHER) reveal that it is still not
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and growing diversity within health CPD options may be optimised if they are to face, print and information technology – professions, have to make decisions in an collaborative, interdisciplinary, inter- is encouraged as it supports busy increasingly complex environment. To add professional as well as global and digital. professionals interested in developing their a further layer of challenge, globalisation The CPD course LEPHIE delivered by expertise through CPD 11 and facilitates and the economic crisis significantly Maastricht University* and developed transformational learning for health equity. impact on public health functions and in collaboration with ASPHER, can how to operationally deal with existing serve as an example of such a training However, the question remains: who and emerging health problems. These course targeted at busy public health should take responsibility for the problems establish a strong mandate for professionals. Bearing in mind that the development of public health leadership public health leaders to develop more key to differentiating leadership in public that is fit for purpose, accessible and proactive health service models. Public health from other areas is the context, this supports the career development path health leaders need horizontal, alliance- course includes current meaningful public of public health leaders? based leadership, allowing them to work health problems and challenges which closely with stakeholders at all levels of participants try to solve by using problem- Developing public health leadership society to effectively meet the challenges based learning methods. Participants capacities of population health and well-being. take responsibility for and plan their own They should be driven by values of social learning as they construct or reconstruct It seems that there is a strong awareness justice, equity, honesty and responsibility, their knowledge. Learning becomes among the public health professional coupled with expertise, ability to discern a collaborative process by sharing a community – supported by targeted trends in the midst of complexity and common goal, responsibilities, and policies such as the Health 2020 and the to capitalise on those trends by creating learning needs through open interaction. WHO European Action Plan about the smart, adaptive strategies in an evolving The content of the course is based on the importance of developing public health environment. Public Health Leadership Competency leadership to tackle health inequities and Framework, which also serves as a self- inequalities. Moreover, WHO Essential Public health leaders demand leadership assessment tool in executive coaching Public Health Operations (EPHOs) form skills and behaviours that value decision- which supports individual leader a framework for the entire public health making by inclusion, collaboration and the development and is an indispensable part system. In particular, EPHO No. 7 on broader participation of interdisciplinary of training to produce effective public Assuring a sufficient and competent public health care teams engaging all members in health leaders. health workforce is a key operation for shared leadership roles and collaborating WHO to promote strategies supporting the with publicly-led health and equity related development of a public health workforce. campaigns. Today’s leaders need to be At the same time, it provides a mandate enablers and facilitators who support active for developing the adequate and modern groups in creating and achieving shared training in which public health leadership goals. This principle of leadership is and inquiry- can play a prominent role. reflected in the notion of empowerment that is central to health promotion: based learning In 2013, the WHO Regional Office enabling people to improve their health for Europe delegated responsibility to and address its determinants. Such In developing the content of other new ASPHER to lead its working group on an approach reflects transformational public health leadership courses, a starting EPHO No. 7. The development of a public leadership, in which power for change is point may be to identify the competency health workforce and shaping the public based on goals that serve a higher purpose, capacities of future leaders in relation health profession is a key action area in this case better health and wellbeing to population health and well-being focusing on preparing the public health as a societal goal. This is the essence of and apply the results of the interviews disciplinary cluster to face and respond the new framework for European public with public health leaders to inform to the health and health care challenges health leadership. education,‘‘ training and culture change of the 21st Century. 12 In this area, WHO throughout public health workforce. and ASPHER concentrate on collaboration Public health leadership training: Topical cases, active and inquiry-based to develop comprehensive educational a vision for the future learning processes should be at the heart strategies for public health based on the of the learning experience. Participants systematic mapping of member states’ Since leadership, in general, is still not should be encouraged to engage directly workforce capacities. With direct access common at undergraduate, postgraduate with community organisations and draw to public health schools and departments, and CPD level of public health education, on the knowledge sources that inform the development and adaptation of public there is a need for providers of public public health theory, policy and practice. health leadership programmes as well as health training to practically develop more Blended learning – a combination of face leadership competencies have significant progressive curricula which incorporate potential for success.
leadership. * http://www.maastrichtuniversity.nl/web/Main/Sitewide/ Agenda1/LeadershipCourseForPublicHealthInEuropeLEPHIE1. htm
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Conclusion 2 Grainger G, Griffiths R. For debate: public health 9 Bjegovic-Mikanovic V, Vukovic D, Otok R, leadership – do we have it? Do we need it? Journal of Czabanowska K, Laaser U. Education and training of The development of strong and effective Public Health Medicine 1998;29: 375 – 6. public health professionals in the European Region: public health leadership is essential at variation and convergence. International Journal of 3 Kimberly JR. Preparing leaders in public health Public Health 2012; DOI: 10.1007/s00038 - 012 - 0425. all levels. There are examples of public for success in a flatter, more distributed and health leadership training approaches collaborative world. Public Health Reviews 2011; 10 Frenk J, Chen L, Bhutta ZA, Cohen J, et al. supported by innovative IT and leadership 33: 289 – 99. Health professionals for a new century: transforming education to strengthen health systems in an competency models which can be adjusted 4 Koh H. Leadership in public health. Journal of interdependent world. The Lancet 2010; 375 (9721): to specific contexts and illustrated by Cancer Education 2009; 24: S11 – 8. 1137 – 8. real-life problems reflecting the struggles 5 Day M, Shickle D, Smith K, Zakariasen K, et al. 11 Czabanowska K, Rethmeier RA, Lueddeke G, of public health communities. The Time for heroes: public health leadership in the Smith T et al. Public Health in the 21st Century: commitment of key stakeholders in the 21st Century. The Lancet 2012 Oct; 380 (9849): “Working Differently Means Leading and Learning 1205 – 6. area of policy, education and practice Differently” (A qualitative study based on interviews to support public health capacities is in 6 WHO Regional Office for Europe. Strengthening with European public health leaders). European place. Therefore, the question remains on Public Health Capacities and Services in Journal of Public Health 2014; doi: 10.1093/eurpub/ how far new public health leaders will be Europe: A Framework for Action. Interim Draft, cku043. 2011. Available at: http://www.euro.who.int/ willing and able to go in order to tackle 12 Foldspang A, Otok R, Czabanowska K, Bjegovic- data/assets/pdf_file/0011/134300/09E_ pervasive and enduring health inequalities, Mikanovic V. Developing the public health workforce StrengtheningPublicHealthFramework_110452_eng. in Europe. The European Public Health Reference particularly in view of the new post- pdf election political landscape which may Framework (EPHRF): Its council and online repository. 7 Concepts and policy brief. Brussels: ASPHER, 2014. see an increasingly conservative and Loo JV, Semeijn J. Defining and measuring competences: An application to graduate surveys. Euro-sceptical shift. Quality & Quantity 2004; 38, 331 – 49.
8 Czabanowska K, Smith T, Könings KD, Sumskas L, References et al. In search of a public health leadership competency framework to support leadership 1 Rowitz L. Public health leadership: putting curriculum – a consensus study. European Journal principles into practice. Sudbury: Jones and Bartlett of Public Health 2013. doi: 10.1093/eurpub/ckt158. Publishers, 2003.
Facets of public health in Europe In addition, the authors consider the existing public health structures, capacities and services in a range of European countries, identifying what needs to be done to strengthen Edited by: B Rechel and M McKee action and improve outcomes for public health. Open University Press: Observatory Studies Series, 2014 Reflecting the broad geographical scope of the entire WHO Number of pages: 400; ISBN: 978 033526420 9 European Region, this book uses examples from a diverse range of countries to illustrate different approaches to public Available to purchase at: http://www.mheducation.co.uk/ health. It is essential reading for anyone studying or working html/0335264204.html in the field of public health, especially those with an interest In the last two centuries, public health has reduced the impact in European practice. and prevalence of infectious diseases, but much remains to be Contents: Introduction; The changing context of public health done to reduce in Europe; Monitoring the health of the population; The health noncommunicable diseases, security framework in Europe; Occupational health and safety; such as heart disease and Environmental health; Food security and healthier food choices;
in Europe Facets cancer, which comprise the Facets of public health Health care public health; Screening; Health promotion; the last two centuries nd prevalence of Public health has had positive results in bulk of the disease burden when it comes to reducing the impact a of infectious disease. duce non-communicable publichealth Tackling the social determinants of health; Intersectoral r, which make up the However, much remains to be done to re an Region. diseases such as heart disease and cance on the WHO European major disease burden of the WHO Europe in of public health approach to public health Facets Europe working and health in all policies; Health impact assessment; This book takes a broad but detailed ehensive analysis of this in Europe and offers the most compr rs a huge range of key in Europe apters on the following Region. This book takes region currently available. It conside topics in public health and includes ch topics: Organization and financing of public health; Developing the Screening • Health Promotion lth a broad but detailed • Recheland McKee • Tackling social determinants of hea Health Impact Assessment public health workforce; Developing public health leadership; • The Public Health Workforce • Public Health Research • the authors consider the approach to public health ties and services across In addition to these topics and themes ing what needs to be Public health research; Knowledge brokering in public health; existing public health structures, capaci and improve public a range of European countries; identify done to strengthen public health action in Europe and offers the health outcomes. of the entire WHO Drawing the lessons. Reflecting the broad geographical scopeples from a diverse range Edited by aches to public health. European region this book uses exam most comprehensive of countries to illustrate different appro studying or working in e with an interest in Bernd Rechel and This book is essential reading for anyone the field of public health, especially thos Martin McKee European practice. Department analysis of the Region is an Honorary Senior Lecturerat the in London the School of Bernd Rechel archer at the European of Health Services Research and Policy ies. Hygiene and Tropical Medicine and Rese the Observatory on Health Systems and Polic available. It considers a is Professor of European Public Health at Martin McKee al Medicine and Research London School of Hygiene and Tropic on Health Systems and Director at the European Observatory Policies. huge range of key topics in public health.
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WE CARE: COORDINATING THE DEVELOPMENT OF AN R&D ROADMAP
By: Inger Ekman, Karl Swedberg, Reinhard Busse and Ewout van Ginneken on behalf of the WE CARE partners
Summary: How will a European high quality health care system – that can be afforded by society and still capture the inevitable societal, medical and technical progress – look like in twenty years? The WE CARE project coordinates the development of a new roadmap for Research and Development (R&D) towards 2035 to achieve a breakthrough in increasing health care costs while maintaining quality of care. The project challenges the European scientific community, policy makers and other key players within and outside the health care field to get involved and looks into current R&D, recently implemented cost containment strategies, and barriers to implementation.
Keywords: R&D, Cost Containment, Quality of Care, Implementation
Inger Ekman is Professor and Director of the Centre for Person- Centred Care (GPCC), University of Introduction often under the labels of “increasing Gothenburg, Sweden. Karl Swedberg efficiency” (such as changing payment is a Senior Professor of Medicine at Across the European Union (EU), there systems towards capitation or diagnosis- the University of Gothenburg and is a clear and urgent need to curb health Professor of Cardiology, Imperial related groups) or “value-for-money” (such care costs. Health care spending in the five College, London, United Kingdom as health technology assessment – HTA), largest economies of the EU has grown and Scientific Advisor at GPCC. but not overall cost containment. Reinhard Busse is Professor and by 27% from 2005 to 2010. 1 The situation Head of Department and Ewout is equally alarming in other EU Member van Ginneken is Senior Researcher in the Department of Health Care States. The societal and economic impact The scientific problem Management at Berlin University of this trend is enormous, jeopardising Containing costs and improving of Technology, Germany. the affordability and accessibility of Email: [email protected] health care quality are often viewed as health care to all EU-citizens. The biggest conflicting aims. R&D and innovation challenge is to capture the constant Note: WE CARE is a two-year funded within the health area over the past twenty project by the European Union within development of health care, to improve years has led to significant improvements the 7th Framework Programme. quality, and at the same time to contain More information on the project and in health care but generally have not increasing costs. This should ensure the partners can be found at: contributed to curbing costs or keeping http://www.we-do-care.eu/ that all EU citizens have equal access to health care sustainable and affordable. future health care, not only those who can Moreover, in current research funding, afford private solutions. This is simply not much attention is given to cost a democratic issue. However, where the containment at the macro level. current European research and policy agenda addresses this issue, it is most
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Figure 1: The multi-disciplinary competences of the WE CARE partners – The financial mechanisms for reimbursement, institutional settings, the culture within the sector, and the Person- lack of a shared responsibility amongst centred participants may cause deficits in the care national health care budgets across Culture, System of the EU. institutional & systems’ organisational approach context Is there potential for cost savings? Sustainable & affordable IBM published the results of a survey healthcare of 518 economists 3 and concluded that the health sector (with an estimated system Health Technology value of $4.27 trillion (€3.2 trillion) has policies development the highest percentage of inefficiency – estimated to be above 40%. This is in Economic line with the estimate by Berwick and paradigms Hackbarth 4 for the United States of around one third. Of this inefficiency, the surveyed economists estimated that
Source: Authors nearly 35% (or c. 15% of total expenditure) could be avoided, leading to savings or providing room for improvement – Technological, pharmaceutical and Due to the complexity of the health while the analysis of the American service-line innovations potentially result care sector, fundamental knowledge scenario suggested that the reduction of in better health outcomes and possibly of institutional mechanisms, systems, inefficiencies could be used to keep health more ‘value for money’. Unfortunately, methods and paradigms for change are expenditure at 17.5% of Gross Domestic reality often shows that instead of more needed. The challenge is enhanced by the Product (GDP) stable for the next decade ‘value for money’, the aggregate costs of fact that a multi-disciplinary approach is (instead of growing to more than 20% health care provision to European citizens a pre-condition to change. The different by 2020). Examples of challenges in future increase. 2 This increase is primarily scientific fields are too intertwined to health care are multi-fold. caused by the reactive mechanisms allow for a mono-disciplinary approach. in the entire health care system and Cross-sectoral collaboration is therefore its environment: 1) HTA looks at the crucial in opening and supporting the cost-effectiveness of innovations, but innovative potential of non-health care multi- is limited to available evidence which disciplines to the benefit of the health often concentrates on patients with high care sector. disciplinary ability to benefit; 2) after the innovation is included in the public benefit baskets, it is The mechanisms behind the increase in approach is also “inappropriately” applied to patients cost are complex and not well understood. in which it may not be cost-effective; For instance: pre-condition 3) this increase in the number of patients is – Demographic change and increases fuelled by higher efficiencies of providers, in chronic diseases play a role, but are to change made possible by other reforms such as not dominant. new forms of payment; and 4) savings Often discussed is the person-centred are thus not translated into macro level – The health sector is highly fragmented approach where care is tailored together savings (i.e. lower total expenditure on and organised along different sectors, with each patient – in contrast to a health care) but end up as extra revenue disciplines and (with regard to R&D) personalised‘‘ medicine approach where in the hands of the providers. diseases. Even though individual every patient’s unique features are participants within the sector measured down to proteins and genes. Therefore, the challenge for WE CARE is might take limitation of costs into As both options are in progress, there to define a new strategic plan and R&D consideration, many aspects hinder is a need to define the values of these roadmap that embeds clear and viable change and prohibit a breakthrough approaches and to find out how they can plans on how science/R&D can facilitate in containing costs. be combined and optimised. Although a breakthrough in cost containment while, there is substantial evidence on the direct – Technological innovations play at the same time, improving the quality of effects of policy efforts towards cost an important role and can lead to care (which not only considers efficacy in containment in health systems, it tends substantial cost reduction but can clinical studies but also actual provision, to be focused on single policies, often also lead to increased expenditure including the appropriateness of services). (see above).
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in specific settings and whether macro systems. Workshops will be held References
level cost containment is achieved often during 2014 with the goal to define a 1 OECD. OECD Health Statistics 2014. Available at: remains unclear. number of R&D gaps that can be included http://www.oecd.org/els/health-systems/health- in the roadmap. In the meantime, the data.htm
consortium welcomes posts and comments 2 The WE CARE project WE CARE. Green Paper WE CARE Workshops. on the online Forum. On 14 – 15 April 2015, Available at: http://www.we-do-care.eu/wp-content/ The WE CARE project is a two- a congress will be held in Gothenburg uploads/2014/07/WECARE_green-paper.pdf
year project funded by the European to discuss and synthesise the results of 3 IBM Institute for Business Value. The world’s Commission’s framework programme the WE CARE project and to finalise the 4 trillion dollar challenge, Using a system-of-systems FP7. The WE CARE Consortium Strategy Plan and R&D Road Map for the approach to build a smarter planet. Somers, NY: IBM is set up in a very diversified and future EU HEALTH R&D programme. corporation, 2010. Available at: http://www-935.ibm. multifunctional fashion with seven com/services/us/gbs/bus/html/ibv-smarter-planet- system-of-systems.html partners. The mission of WE CARE Conclusion 4 is to coordinate the development of a Berwick DM, Hackbarth AD. Eliminating waste new Strategic plan and R&D roadmap The economic and societal relevance of in US health care. JAMA 2012;307(14):1513 – 6. on cost containment of health care with this action is enormous due to the high maintained or even improved quality, by impact of health care costs on national stepping-up coordination between EU governmental budgets. If no breakthrough key players (see Figure 1). This will be in cost containment will be realised in accomplished by inviting EU key players due course, health care could become from politics, industry and academia to unaffordable for many citizens within participate in the project and to contribute EU Member States. Therefore, health care to the development of the strategy plan systems in Europe need to be realigned and a R&D roadmap for 2035, which and innovations to control costs need to should become part of the EU’s future be developed while maintaining, or even health research. improving, quality of care. The question is not whether this needs to happen, but In a multidisciplinary environment, how it should be achieved. WE CARE different options to improve health care hopes to provide a forum for all involved quality and at the same time contain cost stakeholders and make some important will be explored. This will cover diverse first steps in drafting a European R&D areas of the health care system, like roadmap for 2035. organisation of health care on a micro level, the use of technology, efficient policy-making and optimal reimbursement
New HiT on Croatia However, continued reform effort are necessary, especially as the EU, alarmed by the recent deterioration of Croatia's economy, has put it under increased budgetary scrutiny. By: A Džakula, A Sagan, N Pavić, K Lončarek and Recently, the European Commission urged Croatia to K Sekelj-Kauzlarić strengthen its cost-effectiveness, especially in the hospital Copenhagen: World Health Organization 2014 (acting as the sector, which still is fraught with inefficiencies and remains a host organization for, and secretariat of, the European key source of debt in the system. Observatory on Health Systems and Policies) This mounting pressure may Health Systems in Transition Number of pages: 162, ISSN: 1817-6127, Vol. 16, No. 3, 2014 Vol. 16 No. 3 2014 further spur the implementation of the Government's 2012-2020 On 1 July 2013 Croatia became the 28th Member State of Croatia National Health Care Strategy, the European Union, after over three decades of political Health system review which sets out reform priorities and economic transformation. In the years before accession, for the health care sector, such Croatia implemented a number of important reforms in the as coordination between various health sector, including changes in payment mechanisms,
• Anna Sagan levels of care as well as improving Aleksandar Džakula Karmen Loncˇarek pharmaceutical pricing and reimbursement as well as health Nika Pavic´ • Katarina Sekelj-Kauzlaric´ quality and accessibility of care care provision (emergency care reform). The most important across regions. one was the 2008 financial reform to address long-standing problems of hospital deficits.
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CARING FOR PEOPLE WITH MULTIPLE CHRONIC CONDITIONS IN EUROPE
By: Verena Struckmann, Sanne Snoeijs, Maria Gabriella Melchiorre, Anneli Hujala, Mieke Rijken, Wilm Quentin and Ewout van Ginneken
Summary: Until recently, multimorbidity has not received much attention from European policy-makers. This is changing now that it has become clear that the number of people with multimorbidity is rapidly increasing. The ICARE4EU project will help to improve, analyse and disseminate innovative patient-centred multidisciplinary care programmes or practices for people with multiple chronic conditions in Europe. Early project results show that although policy-makers Verena Struckmann is a Researcher, Wilm Quentin is Senior Researcher are increasingly aware of the challenge of multimorbidity, national and Ewout van Ginneken is Senior Researcher, Department of Health policies and strategies focusing on these patients have not yet been Care Management at the Berlin University of Technology, Germany. developed. Nevertheless, various types of multimorbidity programmes Sanne Snoeijs is a Researcher and Mieke Rijken is Programme or practices have been implemented in all four countries under study. Coordinator, Care Demand for the Chronically Ill and Disabled at The Netherlands Institute for Keywords: Multiple Chronic Conditions, Multimorbidity, Integrated Care Practices, Health Services Research (NIVEL), The Netherlands. Maria Gabriella Finland, Germany, Italy, The Netherlands, ICARE4EU Melchiorre is a Senior Researcher, the Centre of Socio-Economic Research on Ageing, at the Italian National Institute of Health and Multimorbidity – the challenge for are explicitly addressed, while the World Science on Aging (INRCA), Italy. Anneli Hujala is a Senior Researcher, care delivery in Europe Health Organization recently launched Faculty of Social Sciences and a roadmap on a framework for action Currently, an estimated 50 million Business Studies at the University towards coordinated/integrated health of Eastern Finland. (mostly older) people in the European services delivery. Email: [email protected] Union (EU) live with multiple chronic diseases. 1 This deeply impacts on their The ICARE4EU (Innovating care The ICARE4EU project (2013 – 2016) quality of life, not only physically, but aims to support the European for people with multiple chronic also mentally and socially. Until recently, Innovation Partnership on Active and conditions in Europe) project 2 is an Healthy Ageing and is co-funded by multimorbidity – the occurrence of initiative co-funded by the EU’s Health the Health Programme 2008 – 2013 more than one chronic disease within of the European Union. More Programme 2008 – 2013, which will an individual – has not received much information on the project and its help improve, analyse and disseminate partners can be found at: attention from European policy-makers. innovative patient-centred multi http://www.icare4eu.org This is changing, now that it has become disciplinary care programmes for people clear that the number of people with with multiple chronic conditions. In a multimorbidity is rapidly increasing. previous article published in the 2013 Indeed, the European Commission started Eurohealth Gastein edition, 1 we discussed a European Innovation Partnership on the multifactorial challenges that chronic Active and Healthy Ageing in 2012, in illness care places on European health which care integration and multimorbidity
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systems. The key question is how to Care practices addressing already been evaluated. For instance, respond to this increasing demand for multimorbidity in Germany the programme Gesundes comprehensive multimorbidity care. Kinzigtal had been evaluated on its Despite the lack of national policies Integrated care models have been seen processes, outcomes, long-term effects and specifically addressing multimorbidity, by many as a solution to overcome this cost-effectiveness. For the programmes care practices focusing on multimorbidity question by taking a holistic approach that have not been evaluated thus far, care or management have been developed while making efficient use of resources. evaluations are planned. For this purpose and implemented within the four countries. data on several indicators are collected Overall 25 care practices or programmes* This article describes some early results regularly within the programmes have been identified in the study so far. from our project. 3 4 5 6 We first describe (monitoring), so that quality information In Box 1 we provide two examples from whether national policies exist for chronic will become available for evaluation each country in the study so far. Most illness care, and more specifically purposes. are limited to the local or regional level, multimorbidity care, and/or integrated focusing on daily patient care. Regarding care in four countries: Finland, Germany, the multimorbidity orientation, several Italy and the Netherlands. Furthermore, we programmes in Finland, Germany and introduce some first results of our survey the Netherlands focus on multimorbidity among country experts by providing some in general. Other programmes are aimed examples of innovative integrated care at a specific diagnosis with a variety of programme programmes for patients with multiple possible co-morbidities or at a combination chronic conditions in these four countries. of specific chronic diseases. outcomes are
The programmes display similarities generally positive with regard to process and quality lack of related objectives, such as improved care Conclusion coordination, increasing multidisciplinary While policy-makers across Finland, national policies collaboration and the promotion of Germany, Italy and the Netherlands are evidence-based practice. In Germany, Italy aware of the challenge of multimorbidity, The policy response to and the Netherlands programme objectives national policies specifically focusing on multimorbidity were similar and focused on utilisation and ‘‘ multimorbidity care or management have costs, prevention/reduction of over-use of While policy-makers across Finland, not been developed as yet. Nevertheless, services and reduction of acute care visits. Germany, Italy and the Netherlands the implementation of multimorbidity care Most programmes address patients and/ are aware of the challenge of chronic practices is increasingly considered to be or medical care providers as target groups. diseases and multimorbidity, national an important issue in these four countries. The main care providers involved in the policies specifically focusing on patients The current care practices or programmes programmes across all four countries with multimorbidity have not yet been addressing multimorbidity that we are general practitioners (GPs) and developed. Italy is the only country, described in this article vary with regard ‘‘ medical specialists. Overall, the number where regional policies on multimorbidity to their target groups, care providers and disciplines of medical specialists management have been formulated (e.g. involved and especially their level of participating in the programmes vary by the Chronic Related Group, and by collaboration and integration. There is greatly. In Finland, multi-professional the Expanded Chronic Care Model). 7 8 9 great value in making an inventory of such development groups have been established In Germany, Italy and the Netherlands integrated care programmes addressing to enhance integration and collaboration disease specific policies focusing multimorbidity for all European countries at a practical level. Most programmes on chronic diseases exist; however, and by doing so providing a rich dataset involve hospitals and primary care these may not meet the special needs to better study their features, factors practices. Overall, the programmes vary of multimorbidity patients. All four and conditions for successful outcomes according to the level of integration of countries have developed policies aiming and implementation, as well as their care, especially with respect to the number at better integration of care. While these transferability to other European regions of medical specialists and health care do not explicitly target patients with or contexts (e.g. patient groups, health care professionals involved. multimorbidity, they often contribute to systems). The next step in the ICARE4EU improved care for these patients as well. project aims to do so by identifying So far, the impressions of country experts good practices, based on survey data and programme managers regarding from 31 European countries and related programme outcomes are generally to four main perspectives, namely their positive and some programmes have patient centredness, the use of e-health technology, their ways of financing
* We do not assume that all available (eligible) care practices and management and professional or programmes in Finland, Italy, Germany and the Netherlands integration issues. were identified.
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Box 1: Characteristics of programmes addressing multimorbidity in four countries
Care providers / Programme Main objectives Target group organisations Results Finland Process Patients with Health centres, patient Evaluated internally; PIRKKA-POTKU incl. e.g. Improving care coordination, improving multimorbidity or organisations, GPs, objectives mainly care pathway for integration of different organisations, increasing patients who use a lot informal carers, reached. patients with multi-disciplinary collaboration of services from many district/community The programme has organisations or nurses, multimorbidity, Patient outcomes supported integration clinics. physiotherapists/ A regional sub- of care services, Improving functional status exercise therapists. programme of POTKU In particular patients collaboration between Utilisation and cost (see above) in whose needs are not care providers, Pirkanmaa area. e.g. Preventing or reducing over-use of services, met by the services, competencies of care reducing emergency/acute care visits, reducing who need proactive providers, patient (public) costs care planning or who centredness, patient Access need long-term care. involvement, involvement of informal Reducing inequalities in access to care and carers, use of e-health support services tools and cost- Patient centredness effectiveness. e.g. Identification of target group patients, Closer collaboration improving patient involvement between public health care and patient associations and patients are now included in the development of care. Finland Process Patients with multiple Primary care practices, Evaluated internally; chronic diseases and health centres, patient objectives mainly Chronic Care Model for e.g. Improving professional knowledge on patients with organisations. reached. Patients with Multiple multimorbidity, improving care coordination, cardiovascular Diseases in Primary increasing multi-disciplinary collaboration GPs, many medical The programme has diseases dementia, Care. Patient outcomes specialists, district/ promoted integration asthma/COPD, community nurses, of care services, e.g. Improving early detection of additional/ rheumatoid arthritis, physiotherapists/ collaboration between comorbid diseases, decreasing/delaying depression, atrial exercise therapists, care providers, complications, decreasing mortality fibrillation, dieticians, competencies of care Utilisation and cost osteoarthritis, etc. psychologists/ providers, patient- e.g. Preventing or reducing misuse of services, psychotherapists. centredness and reducing hospital admissions, reducing (public) patient involvement. costs The care model is a Access useful tool for staff. Reducing inequalities in access to care and From one portal the support services, improving accessibility of professionals can find services everything they need to follow up with a patient Patient centredness with chronic diseases. Identification of target group patients, improving The model is patient involvement multidisciplinary and provides patient empowerment.
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Box 1: Characteristics of programmes addressing multimorbidity in four countries (continued)
Care providers / Programme Main objectives Target group organisations Results Germany Quality of care Patients with General hospitals, The programme multi-morbidity in primary care practices, suggests improved Gesundheitsnetz Improving integration of different organisations, general, medical care nursing homes, coordination of care, Qualität und Effizienz increasing multi-disciplinary collaboration providers, non-medical policlinics, patient improved cooperation eG Nürnberg Patient outcomes care providers and organisations, social between medical and Health network quality Improving early detection of additional/ management. care organisations, non-medical care, and efficiency eG in co-morbid diseases physiotherapy, staff and patient Nürnberg, the federal Utilisation and cost self-help and GPs and satisfaction, better state of Bavaria Preventing or reducing over-use of services several medical patient involvement, specialists, namely: changes in utilisation Improving patient centredness cardiologists, of resources, cost e.g. patient involvement surgeons, internists, savings and it is E.N.T. specialist, transferable. pulmonologist, etc. The objectives set in the programme were said to be completely reached. Germany Quality of care The programme refers General hospitals, The programme to patients with primary care practices, improved integration Gesundes Kinzigtal in e.g. Promoting evidence-based medicine, multi-morbidity in nursing homes, of services, the Haslach in the federal improving professional knowledge on multi- general, medical care policlinics, patient collaboration of care state of Baden morbidity, increasing multi-disciplinary providers, non-medical organisations, social providers and cost Württemberg collaboration care providers and the care organisations, effectiveness. Patient outcomes population. pharmacy, insurer and The objectives of the Improving early detection of additional/ management company. programme were said co-morbid diseases, decreasing complications, The programme to be almost morbidity, mortality involves several care completely reached. Utilisation and cost providers such as GPs, Reducing hospital admissions, (public) costs cardiologists, internists, Improving patient centredness neurologists, etc., e.g. patient involvement. social workers, physiotherapists, dieticians and psychologists. Italy Quality of care Patients, informal University and general Results seem to ARIA Project Improving care coordination/integration carers and medical hospitals, patient suggest mainly care providers. The organisations. Care improved integration/ Patient outcomes programme specifically providers involved in collaboration of care Decreasing complications/morbidity/mortality addresses people with the programme are services/providers, Utilisation and cost physical disabilities medical specialists coordination of care, Preventing misuse of services (e.g. neuromuscular (pulmonologists) and involvement/ diseases, and chronic physiotherapists/ satisfaction of Improving patient centredness respiratory failure exercise therapists. patients/informal Improving patient/informal carers involvement as comorbidity. carers, etc. The programme seems also to be transferable. The results also suggest that the remote monitoring of fragile outpatients brings out physiological tranquility for patients and their caregivers.
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Box 1: Characteristics of programmes addressing multimorbidity in four countries (continued)
Care providers / Programme Main objectives Target group organisations Results Italy Quality of care Patients, informal University and general Results show mainly carers and medical hospitals, primary care integration/ Renewing Health Improving care coordination/integration care providers. The practices, nursing collaboration of care REgioNs of Europe Patient outcomes programme generally home, policlinic/ services/providers, WorkINgtoGether for addresses people with outpatient/ambulatory patient/informal carers’ Decreasing complications/mortality HEALTH * chronic diseases care, patient involvement, staff/ Utilisation and cost (e.g. heart failure, organisations, patients/informal * Multicentre Project COPD, diabetes) aged community/home care carers’ satisfaction, involving the following Preventing over-use/misuse of services 18+ years, and more organisations, ICT changes in utilisation European countries: Improving access specifically frail elderly departments, research of resources Italy, Denmark (Lead people aged 65+. institutes, regions and (e.g. reduced partner),Norway Reducing inequalities and Improving accessibility external providers. hospitalisations), use Finland, Sweden Spain, in/to care and support services of e-health tools and Greece, Austria and Care providers involved Improving patient centredness cost savings/ Germany in the programme are effectiveness. Improving patient/ informal carers involvement GPs, medical specialists The programme is also (cardiologist, transferable. pulmonologist, geriatrician and diabetologist)and different health professionals. The Netherlands Process Patients aged 65 or Involvement of primary The Guided Care Model older suffering from care practices, health is an appropriate Guided Care Model – e.g. Improving professional knowledge, more than one disease centres and centres of method for general A disease seldom improving care coordination, increasing or problem (physical, expertise in long-term practices. It enables stands alone. multi-disciplinary collaboration social, psychological, care. care providers to Patient outcomes functional). manage the care for multimorbidity patients Early detection of comorbidities, improving Within this target in a different way. functional status, decreasing complications group the following Patients are positive subgroups are Utilisation and cost about the increase in specifically addressed: attention towards their Reducing hospital admissions, reducing frail elderly, low health personal health goals emergency care visits literacy, low income and the active support groups and people Access they feel they are from deprived areas. receiving in reaching Improving accessibility these goals. Patient centredness Identification of target group, improving patient involvement, involvement of informal carers. The Netherlands Process Patients suffering from Involves primary care The evaluation showed diabetes, COPD and/or practices (general that the INCA approach INCA – the Integrated e.g. Improving integration of different units, vascular risk practice). helps to realise the Care programme increasing multi-disciplinary collaboration management. shift from disease Additional (medical/ Patient outcomes orientation to patient Within this target non-medical) care orientation. The e.g. Early detection of comorbidities, decreasing group no specific sectors are involved harmonisation across morbidity subgroups are according to patient health care standards/ specifically addressed. needs. Utilisation and cost disease management Patients aged 18 years Research institute programmes (DMPs) Preventing over- and misuse of services, or older. provides a base for a reducing hospital admissions, reducing (public) more individualised costs (tailored) approach. Access The modular approach is key for further Reducing inequalities in access to care and elaboration and support services application. Patient centredness Identification of target group, improving patient involvement
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References 8 Ministry of Health. Criteria for clinical, technological and structural appropriateness in 1 Rijken M, Struckmann V, Dyakova M, caring for complex patient. Papers of the Ministry of Melchiorre MG, Rissanen S, van Ginneken E, on Health 2013; 23: XVIII-XXII [Criteri di appropriatezza behalf of the ICARE4EU partners. ICARE4EU: clinica, tecnologica e strutturale nell’assistenza del Improving care for people with multiple chronic paziente complesso. Quaderni del Ministero della conditions in Europe. Eurohealth 2013; 19(3):29 – 31. Salute, 2013; 23: XVIII-XXII]. Available at: http:// 2 Innovating care for people with multiple chronic www.quadernidellasalute.it/download/download/23- conditions in Europe web site. Available at: settembre-ottobre-2013-quaderno.pdf www.icare4eu.org 9 Chronic diseases in Tuscany Region, 2013 3 Caring for people with multiple chronic conditions [Le malattie croniche in Toscana, 2013]. Available at: in Finland. Available at: http://www.icare4eu.org/pdf/ www.ars.toscana.it/it/aree-dintervento/problemi-di- Country_Factsheet_Finland_ICARE4EU.pdf salute/malattie-croniche.html
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Policy Summary on what is providers along the continuum of care. The review covers three economic outcomes: utilisation, cost-effectiveness and cost or the evidence on the economic expenditure and also looks at data on core health outcomes impacts of integrated care? such as health status, quality of life or mortality, as well as process measures.
By: Ellen Nolte and Emma Pitchforth Available evidence of integrated care programmes points to a positive impact on the quality of patient care and improved Copenhagen: World Health Organization / European health or patient satisfaction outcomes. However, uncertainty Observatory on Health Systems and Policies, 2014 remains about the relative effectiveness of different system- Number of pages: 45, ISSN: 2077-1584, Policy Summary 11 level approaches on care coordination and outcomes, with particular scarcity of robust The rising burden of chronic disease, and the number of people evidence on the economic with complex care needs in particular, require the development impacts of integrated care POLICY SUMMARY 11 of delivery systems that bring together a range of professionals approaches. In addition, it and skills from both the cure (health-care) and care (long- What is the is important to come to an evidence on the term and social-care) sectors. Failure to better integrate or economic impacts understanding as to whether coordinate services along the care continuum may result in of integrated care? integrated care should be suboptimal outcomes. Ellen Nolte, Emma Pitchforth considered an intervention or whether it should be This Policy Summary analyses published reviews on the interpreted, and evaluated, as economic impacts of integrated care approaches. Given the a complex strategy to innovate wide range of definitions and interpretations of the concept, and implement long-lasting it proposes a working definition that builds on the goal of change in the way services integrated care and which considers initiatives seeking to in the health and social-care sectors improve outcomes for those with (complex) chronic health are being delivered and that involve multiple changes at problems and needs by overcoming issues of fragmentation multiple levels. through linkage or coordination of services of different
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CSA PERMED: EUROPE’S COMMITMENT TO PERSONALISED MEDICINE
By: Lada Leyens, Erica Hackenitz, Denis Horgan, Etienne Richer, Angela Brand, Ulrike Bußhoff and Wolfgang Ballensiefen on behalf of the PerMed consortium
Summary: Personalised medicine is one of the most innovative areas in the future of health research. At present, its full potential cannot be developed due to fragmented activities, insufficient communication, and lack of generic solutions in the different areas of personalised ➤ #EHFG2014 Forum 4: medicine; moreover, implementation is a major challenge. The EU- Personalised Medicine funded Coordination & Support Action PerMed was initiated to step 2020 up coordination efforts between key European stakeholders, to
Lada Leyens is Researcher at the allow synergies and avoid duplication or competition, and to provide Institute for Public Health Genomics (IPHG), Maastricht University, The recommendations to foster the implementation of personalised Netherlands; Erica Hackenitz is Program Officer at the Netherlands medicine in transnational research and health systems. Organisation for Health Research and Development (ZonMw), The Hague, The Netherlands; Dennis Keywords: Personalised Medicine, Strategic Research and Innovation Agenda (SRIA), Horgan is the Director of the European Alliance for Personalised Europe, PerMed Medicine (EAPM), Brussels, Belgium; Etienne Richer is Assistant Director at the Canadian Personalised Medicine: present However, we are only at the beginning of Institute of Health Research (CIHR), Canada; Angela Brand is Founding and future the road and many challenges have to be Director of the Institute for Public overcome in order to benefit from PM’s Health care as we know it is radically Health Genomics (IPHG), Maastricht full potential. The era of ‘one size fits all’ University, The Netherlands; changing to give way to increasingly in medicine is slowly coming to an end. Ulrike Bußhoff and Wolfgang more personalised health interventions for Ballensiefen are senior scientific Personalised treatment options are being citizens and offering more personalised officers at the Project Management developed for an array of conditions and Agency, German Aerospace Centre therapies and treatments for patients. some have already entered the market. (PT DLR), Bonn, Germany and Essentially, Personalised Medicine (PM) is Treatments for cancer are leading the coordinate the CSA PerMed. Email: an innovative method of treating citizens [email protected] field, but they are followed closely by and patients that utilises research, data and treatments in cardiovascular, pulmonary, up-to-the-minute technology to provide Note: The CSA PerMed project infectious and psychiatric conditions, (2013 – 2015) is funded by better diagnostics and follow-up for among others. Personalised therapies the European Union within citizens than is currently the case. Among the 7th Framework (No.602139) aim to provide “the right treatment to the others, it uses genomic information to Programme. More information on right patient at the right time”, with early the project and the partners can discern whether a particular intervention diagnosis, increasing efficacy, decrease in be found at www.permed2020.eu. will work for a particular patient and adverse drug reactions, and cost-effective assists clinicians in deciding which treatments that may result in cost savings, treatment will be the most effective. It can quality of life improvement, and reduction also have a huge impact in a preventative of general morbidity in the population. sense (see Box 1).
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Figure 1: Number of publications per year on Personalised Medicine, 1971– 2014 General of DG Health and Consumers (DG SANCO), Paola Testori Coggi, puts it “it is essential for Europe to build on 1000 our strengths to develop innovations to promote growth and benefit European 819 800 784 citizens. Genomics has the potential to be a key sector contributing to this in the future … Advances in PM can bring 600 business development and economic 543 growth to Europe in addition to improved 461 441 prevention, treatment and care to 400 European citizens.” 5 These objectives 309 form the basis of CSA PerMed, otherwise
204 known as the Coordination & Support 200 143 Action (CSA) Personalised Medicine 2020 75 85 and beyond (see Box 2). 53 27 38 3 8 8 0 1 1 1971 1990 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Source: PubMed, last search on 1 June 2014 with search terms “personalized medicine”‑ or “personalised medicine” in title or abstract. still only cancer. The development of many more at the start Box 1: Definition of Personalised is underway. However, the scope and Medicine approach of PM is not limited to the The development of PM in Europe treatment of diseases only; it is much represents an important paradigm shift “Personalised medicine refers to broader and inclusive, also covering for all health care systems and poses a medical model using molecular areas such as lifestyle advice, prevention, major challenges – both for the present profiling for tailoring the right environmental interventions and even the and the future. These challenges need therapeutic strategy for the right structure and organisation of hospitals and to be overcome to meet the objectives person at the right time, and/or health systems. Furthermore, the increased of Europe 2020, the Digital Agenda, the to determine the predisposition to interest from physicians, decision Innovation Union and Horizon 2020 6 disease and/or to deliver timely and makers, regulators and the general public by bringing together: research for health, targeted prevention.” in PM has contributed to its increased innovation‘‘ for health and health equity, application. Figure 1 shows the number of and significant contributions to global Source: Ref. 1 publications on PM in the past 40 years, research and innovation systems. and their exponential rise particularly in A general change in mind-set in health the last ten years. Notwithstanding the care delivery is also needed. Despite being a concept already applied great interest, we are still only at the start. by Hippocrates more than two thousand Realising potential benefits years ago in Ancient Greece, the Although the US may have been leading advances in the so-called “omic” sciences the field in the past, Europe is showing Why should we strive towards the (genomics, transcriptomics, proteomics, a clear commitment to PM. Reports personalisation of health care and metabolomics, etc.) and in Information have been published by the European promote the four Ps in health (predictive and Communication Technologies (ICT) Commission (EC) supporting the and preventive, personalised and have led to enormous advances in the mission of personalisation of health and participatory)? field of PM in the past two decades. many politicians and decision makers Greater understanding of the molecular have expressed their support. For There are potential benefits from applying basis of disease and all the factors, such example, in the UK, 2 Germany 3 and evidence-based personalised treatments, as environmental factors influencing France, 4 the national governments have including: 7 disease onset, progression and response made a strong commitment – implicitly – improvement of informed medical to treatment, together with the staggering or explicitly – to genomic medicine and decisions fall in the costs of gene or genome the application of PM, mostly in cancer sequencing and genotyping, plus faster research and treatment. Furthermore, the – shift from reaction to disease towards results availability, have resulted in the EC’s new Horizon2020 research grants prevention and prediction of disease market entry of over twenty personalised programme – initiated in January 2014 – – targeted therapies with higher therapeutics; such as Herceptin, the first will promote research in all aspects of probability of success personalised treatment approved sixteen targeted therapies, including ICT to assist years ago for HER2+ metastatic breast decision-making in PM. As the Director
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widely discussed and described in a large to their full potential and will surely number of reports and publications (see push forward the individualisation of Box 2: The PerMed consortium next paragraph for examples). medicine in all areas (research, translation, diagnosis, treatment decision-making, CSA PerMed is a consortium – created follow-up, etc.). by decision makers in Europe, including The way forward more than ten ministries and funding PerMed has identified and evaluated the 2. Adaptive business models, bodies – which aims to prepare information already available as well as translational pathways and systematic Europe to be a global leader in the the strategy documents published by key early dialogue implementation of PM. It differs from stakeholders, including reports, guidelines The current business model for other consortia and working groups and roadmaps on PM. A gaps and needs pharmaceutical companies is no longer due to the partners involved and its analysis was performed on 18 relevant valid once we move away from the “one aim to carry out focussed discussions reports – from the EC, 1 the European size fits all” drugs. Pre-competitive on concrete research actions, rather Science Foundation (ESF), 7 the European collaboration between companies than prolonging on-going broad Alliance for Personalised Medicine (pharmaceutical companies and medical discussions and recommendations (EAPM), 8 the Public Health Genomics device manufacturers, for example), the (see www.permed2020.eu). Moreover, European Network (PHGEN), 9 the increase in public-private partnerships transparency, openness, collaboration European Medicines Agency (EMA), 10 the and a more flexible and adaptive business and the avoidance of duplication lie at iNNOVAHEALTH Conference under the model is needed for the development and the core of the CSA PerMed approach. Cyprus EU Presidency 11 and the European translation into health care of personalised The consortium’s unique features create Hospital and Healthcare Federation technologies. Furthermore, systematic the potential to develop a strategic (HOPE) 12 among others – and over 35 early dialogue with regulators and patients research and innovation agenda for interviews were carried out with relevant at an early phase of development would Europe (SRIA) and be the starting point stakeholders. lead to more efficient drug development for a European Innovation Partnership and translation processes. Clinical trial (EIP) in PM acting across the entire designs need to change: Phase III studies research and innovation chain, bringing with thousands of patients are not possible together key actors at European, change and adaptive designs with smaller numbers national and regional level. of patients are needed, like the ones in mind-set in already being conducted in cancer that permit the application of personalised – risk reduction with fewer adverse health care treatment options under one protocol. reactions to medicines New dynamic and sustainable pathways that lead to timely and effective translation – timely/early disease interventions delivery of innovative technologies into health – cost-efficient treatment solutions and Regardless of their authors, interests and policies and health care are needed, always general health care cost containment. target group, these reports and interviews ensuring high quality, safe and efficient reach similar conclusions on the aspects treatments entering the market. For health systems as a whole, potential that need to be tackled. These are: benefits include early systematic dialogue 3. Make regulation simple, coherent between the relevant key stakeholders, 1.‘‘ Targeted research in molecular and predictable citizen-centred health care systems, mechanisms and ICT In addition, the regulations that are in encouragement of patients to be more Targeted research to better understand place nowadays do not consider the active in their health management and feel the molecular mechanisms of disease specificities of personalised interventions, greater ownership in the responsibility of and all implicated factors, as well including therapeutics. Many of the their health, support quality of life, health as the identification and validation ones that affect PM are being revised, and wellness, yield a maximum return on of biomarkers, is essential for the but remain far from ideal. Especially health care investment and adjustment to development of further personalised in Europe – considering the inherited the needs of sub-sectors of the population, therapeutics. Multidisciplinary research heterogeneity of our Member States – among others. teams, joining the knowledge from a simplified, harmonised, coherent (across variety of sciences, together with cross- directives and regulations) and predictable Nevertheless, a great deal still needs to disciplinary and cross-border collaboration regulatory procedures are welcomed. be done to reach these benefits across in research and in drug development Some positive steps forward are the new the entire health care spectrum, and are essential parts of the R&D process medical devices directive regulating (for not restrict them to a limited number of of PM. Further developments in data the first time in Europe) in-vitro and conditions. The challenges have been collection, storage, management, sharing, companion diagnostics, and the proposed mining, processing and analysis are also adaptive licensing model from EMA. 10 imperative. ICTs have not been exploited In order to expand its leadership role, it is
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PerMed’s view that Europe could engage patients access to safe, highly efficient and in international efforts to harmonise targeted treatments in a timely and cost- regulatory aspects. efficient manner.
4. Driving health care systems towards References preventive care When it comes to health care systems, a 1 European Commission. Use of ‘-omics’ general change in mind-set in health care technologies in the development of personalised medicine. Brussels: European Commission, 2013. delivery and provision is needed. From a coordinated reimbursement process for 2 Technology Strategy Board. Stratified Medicines in drugs and diagnostics, new financing the UK, Vission and Roadmap. Swindon: Technology Strategy Board, October 2011. strategies, new structures and models at the provider level, updated health care 3 BMBF. Personalised Medicine – Action Plan, a professional training and a change in new approach in research and health care. Germany: Federal Ministry of Education and Research (BMBF), attitudes, a shift towards preventive care, February 2013. towards new cost assumption models, 4 changes in patient behaviour and an Claeys A, Vialatte J-S. Advances in genetics: towards a Precision Medicine? Technological, increased interest and literacy from social and ethical scientific issues of personalised citizens in general are needed. The social medicine. [Les progrès de la génétique : vers une consequences of the implementation médecine de précision ? Les enjeux scientifiques, of PM have not been fully studied, and technologiques, sociaux et éthiques de la médecine there are many ethical challenges that personnalisée], January 2014. Available at: http:// www.ladocumentationfrancaise.fr/rapports- lay ahead, which is why the principles of publics/144000117/index.shtml “Ethical, Legal and Social Implications” 5 (ELSI) are essential and need to be further Testori Coggi P. A European view on the future of personalised medicine in the EU. Eur J Public explored by research and applied by all Health 2011;21(1):6 – 7.doi: 10.1093/eurpub/ckq202 stakeholders. 6 European Commission. Europe 2020, the Digital Agenda, the Innovation Union and Horizon 2020. Conclusion Available at: http://ec.europa.eu
7 Even though PM may be one of the European Science Foundation. Forward Looks. Personalized Medicine for the European citizen. most innovative areas in the future of Towards more precise medicine for the diagnosis, health research, the full potential for treatment and prevention of disease (iPM), 2012. patients, citizens and the economy in 8 EAPM. Innovation and Patient Access to Europe currently cannot be realised due Personalized Medicine, 2013. Available at: http:// to the inherited fragmentation between euapm.eu/wp-content/uploads/2012/07/ European Member States, inadequate EAPM-REPORT-on-Innovation-and-Patient-Access- communication and lack of common to-Personalised-Medicine.pdf vision on the solutions that are needed. 9 Brand A, Lal JA. European Best Practice Appropriate governance levels are Guidelines for Quality Assurance, Provision and use required to solve these challenges. of Genome-based Information Technologies: the 2012 Decalaration of Rome. Drug Metabolism and Drug Interaction Studies 2012; 27(3):177 – 82. PerMed aims to provide concrete recommendations and to take a big step 10 European Medicines Agency. Pilot project forward towards PM for all, without on Adaptive Licensing. Available at: http://www. ema.europa.eu/docs/en_GB/document_library/ forgetting that the ultimate goal is to Other/2014/03/WC500163409.pdf bring the right health intervention to the 11 right patient at the right time, to avoid as iNNOVAHEALTH. Building on Open Innovation ecosystem in Europe for Healthcare, October 2012. many adverse reactions as possible during Available at: http://www.enterpriseisrael.org.il/ treatment, to make it affordable for health wp-content/uploads/2013/04/Innovahealth-Report. care systems and to ensure equality in pdf
access to personalised innovations. As 12 HOPE and PwC. Personalized Medicine in long as the interests of citizens drive work European Hospitals, 2011. Available at: http:// towards this common mission, Europe can www.hope.be/05eventsandpublications/ become a leader in PM, with the potential docpublications/88_personalised_medicine/88_ to also create business and economic HOPE-PWC_Publication-Personalised-Medicine_ February_2012.pdf growth and, most importantly, give
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SOLVING THE CONUNDRUM: HOW TO BALANCE CARE COORDINATION AND PATIENT CHOICE IN AUSTRIA?
By: Thomas Czypionka
Summary: Strengthening primary care is central to the ongoing health care reform in Austria, where patients can still enter the system at any point. Limiting this high degree of freedom is crucial for the reform to be effective. However, as it is much less popular to reduce choice than to extend it, the challenge health policy-makers are currently facing is considerable. Rebalancing care coordination, choice and voice in a multi-faceted approach might be a solution.
Keywords: Primary Health Care, Gatekeeping, Coordination, Patient Choice, Austria
Introduction Austria’s health care system has been criticised for its fragmented, hospital- With the rise of chronic diseases, change focused way of providing care for its towards providing evidence-based, population. The ongoing health care continuous care across sectors has become reform in Austria envisages a change a paramount goal for health care systems, towards strengthening primary health care including a strengthened primary care (PHC), an area in which the country is system to improve care coordination. traditionally weak, and a first concept was However, this goal seems somewhat approved on 30 June 2014. Thus, decision antithetic to the idea of a patient’s freedom makers find themselves in exactly the to choose any provider. Whereas in many position of promoting new ways of service countries, people are required to register delivery that have the innate feature of with a general practitioner (GP) and reducing freedom of choice. After a phase to use him or her as the primary entry of tiptoeing around the subject, they need point, patients in health care systems to get more specific on the details as like in Austria or Germany are used to the design for implementation has to be having access to nearly any provider at drawn up. any time. However, this comes at the cost of patients entering the care process The case of Austria ➤ #EHFG2014 Forum 3: at arbitrary points and impairs efforts to ensure coordination and continuity Balancing care coordination When, in 2012, policy-makers decided to of care. Reducing this freedom for the and patient choice implement a fundamental reform, they “greater good” might be met with a lot of wanted to amend some of the traditional resistance by insurees as well as provider challenges with the Austrian health care Thomas Czypionka is Head of representatives and therefore might come system. In the outpatient sector, the HealthEcon at the Institute for at a high cost for health policy-makers. Advanced Studies, Vienna, Austria. prevalent form of care delivery is the Email: [email protected]
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single practice, with the physician as the by accepting him/her as the primary the perception of choice as inequitable, only medical professional. Out-of-hours entry point to the health system they are as it favours the better educated and well care is rarely provided in the GP sector, effectively constraining their freedom. off. Then again, not giving anyone the making the hospital a convenient entry opportunity to make an informed choice point. There is no real PHC system in the is not in itself beneficial. sense outlined by Starfield et al. 1 or the European Commission’s Expert Panel on satisfied Other arguments invoked are increased Investing in Health 2 in terms of continuity transaction costs, as can be seen in the or care coordination. The patient is free to patients due to a overall higher health care spending of enter the health system at a GP, a self- most SHI countries, where the feature of employed specialist, or a hospital. If he/she menu of care provider choice is normally built-in. In never does go to the doctor, in principle no the context at hand, probably the most one cares. Due to fragmented financing of options important downside of choice is the danger acute care between social health insurance of fragmenting care. On the other hand, (SHI) and all levels of government, When it comes to Austria, these effects being able to choose a provider might also coordination of care efforts is usually poor. can be perceived with one notable improve satisfaction and provide a better The somewhat paradoxical consequences exception. Health care costs are among provider-patient fit. are i) rather satisfied patients due to a the highest in Europe, and introducing menu of care options and few restrictions; primary care in this case might actually Eventually, people just seem to “want” ii) health care expenditures among the drive‘‘ down costs in the long run due to to be able to choose. For health care top five in Europe; and iii) only average better allocative efficiency of spending, systems that offer free choice of provider, outcomes for chronic diseases. after a phase of investing in better this fact seems to be the biggest policy primary care. challenge when attempting to increase The ongoing reform emphasises the care coordination. need for more preventive care, a true The costs and benefits of provider PHC system and refocusing care and choice Challenges in Austria corresponding funds by payers sharing the responsibility and funding rather than Choice can be exerted on different levels. From discrete choice experiments (DCE) butting heads. However, there is still no The first level is choice of insurer and we know that people value choice quite clear position on how to cope with one of choice of insurance plan (with its different highly when they are used to it (see for the less popular elements of the reform, the subcategories), which is normally only example a DCE for Germany and the need to reduce freedom of choice in favour potentially possible in insurance-based Netherlands 6 ). The reality test in the form of more care coordination and continuity. countries, with the exception of moving of the Hausarztmodell in Germany or elsewhere in regionalised Beveridge HMO/telemedicine-plans in Switzerland The costs and benefits of PHC systems. The second is choice of providers show that insurance companies have to on different sub-levels, i.e. choosing a GP, compensate people for reduced choice The case for PHC has been well made in a specialist, an integrated care programme, with considerably reduced premiums and/ the literature by Starfield 1 and subsequent a treatment centre or a hospital for or user charges. In fact, when not using authors. 3 Strong PHC means a lower ambulatory or inpatient care. The third considerable financial incentives (or threshold for comprehensive care for the is choice with respect to treatment. probably even then), such initiatives are population. This results in more timely However, we will first concentrate on met with little enthusiasm. interventions, better coordination and provider choice as this is at stake when continuity of care for chronic conditions strengthening primary care. But the preference not to give up (some) and better conditions for preventive efforts. choice is only part of the story. Setting These features of PHC have numerous A lot has been written about the costs up a PHC system that lives up to the beneficial effects: hospitalisations for and benefits of provider choice in the name requires a whole lot more than just many chronic conditions can be reduced; context of health care systems that giving up the possibility of self-referral population health can be improved on consider expanding it, 4 5 but less so for to a specialist. Many failed attempts to several dimensions; while socioeconomic health care systems that probably need improve care coordination by restricting inequality is reduced. When it comes to to reduce it in favour of patient guidance provider choice seem clumsy in hindsight. the downsides of such a system, probably and how this can be achieved. While the Just by offering some monetary incentive two things are worth mentioning. freedom to choose providers is expected or introducing user charges does not make Countries with a stronger PHC system to increase their quality and efficiency people go where policy-makers want, were found to have higher health care through competition, these effects also especially if the attempts are indecisive. expenditures, albeit lower growth rates. 3 hinge on some form of overcapacity and If visiting my GP first* is so beneficial, Moreover, an innate feature of PHC is the availability of information as well as
that people stay on the list of a GP and the ability of patients to process it. The * The point here also is that just visiting a GP as a formality latter requirement has sometimes led to prior to a specialist is not what strong primary health care is about.
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then why is it voluntary and people try goal-oriented, trying to implement the Traditionally, these countries also engaged to pay me for it? Problems here seem state of the system envisaged rather than in some form of public involvement and to arise at least from three aspects: the implementing the change needed to attain strengthened patients’ rights. The Danish, prerequisites for, the process of, and the this state in the future. for example, conduct an annual patient means used in the reform. survey and feed the information back The means to introduce more care to all levels of decision making. They coordination have also been quite simple also support patients with information despite the experience that changes on health related matters and quality of what to complex systems need a bundle of providers on www.sundhed.dk as well as measures to balance out its adaptions. The through a system of patient counsellors. forms of choice answer has often been to simply introduce In England, the system’s struggle for gatekeeping, some disease management patient empowerment produced the really matter programme (DMP) and/or user charges NHS constitution. NHS Choices (online) to discourage other forms of care use. and NHS Direct (replaced by NHS 111 When it comes to prerequisites, it was In 2000, Austria introduced user charges since March 2014) provide information probably underestimated in many cases for outpatient departments in hospitals on a wide variety of topics including how demanding a PHC system is. Making (Ambulanzgebühr) as a singular measure, support to find the right provider and GPs gatekeepers does not make them which was abolished the same year. In (unusually detailed) information on better trained or allow them to acquire contrast to Austria or Germany, France quality of providers. Local Involvement knowledge instantly about procedures found itself with the comfortable solution Networks are supposed to empower the for which they have previously referred that it relies on in-cash benefits. In a public in matters of local health care, patients ‘‘to a specialist. Neither will second attempt to introduce a voluntary and the Care Quality Commission, patients believe this is so, and even less form of gatekeeping in 2004, the médecin while keeping a close eye on providers, so after having been told for decades traitant (a preferred provider system), also conducts numerous surveys that that specialists provide better care. Self- reimbursement was severely cut for are expected to improve the system. In employed specialists depend on self- directly accessing specialists along with the Netherlands, with the quite unusual referrers for income and have gotten used incentives for the common voluntary feature of gatekeeping in an insurance- to being bothered with minor problems insurance schemes not to cover this form based country, there is a strong tradition that are treated by GPs in other countries. of user charge. of public involvement and laws that In addition, outpatient departments in emphasise the right to information and hospitals have expanded their capacities A more complex matter: provider strengthen the position of patients and to receive many people who are simply choice and voice their representatives under the umbrella of unwilling to make an appointment the Netherlands Patients and Consumers outside, and while complaining about While Hirschmann 9 started to draw our Federation (NPCF), apart from choice of the encumbrance, hospital management attention to the importance of voice and insurance company. Strong patient rights remains reluctant to move services and exit as a means to improve responsiveness to information and involvement in the care funds to other providers. In other words, in more than forty years ago, the interaction process have been enacted. Kiesbeter is countries like Germany, France or Austria, of preferences in the population, different a website with similar information to its there is simply no tradition, no culture levels of choice and options to voice Danish or English counterparts. Insurers and no institution that would ready these opinions is very complex. Nevertheless, and providers are required to involve the countries for the quick introduction of the literature on the matter has begun to public in their decisions through counsels true PHC. develop a far more differentiated look at and/or surveys, and the NPCF is also what forms of choice really matter and represented on national boards. The underestimation of these institutional what numerous ways there are to make factors also seems to be an explanation for oneself heard. Naturally, not all of these activities work the fact that the process of reform in these perfectly and much can be improved. countries might not always have been up Many health care systems have tried However, these examples show how health to the challenge. When France, in 1998, to increase choice and/or voice and we systems try to handle the delicate balance shyly introduced the option for insurees to can find a wide variety of combinations between choice and voice. enrol in a gatekeeping system connected out there. 10 While maintaining the to financial incentives, uptake was very gatekeeping-function of the GP, the UK A new balance is needed poor. 7 In Germany, the Hausarztmodell gradually expanded choice of GP as well is still contested by many and far from as choice on higher levels of care, similar Whether Austria really offers that the success it was expected to be. 8 What to the Scandinavian countries. So instead much choice in the first place has to is even more striking is the timeframe of choosing between all providers, choice be scrutinised. People have no choice of these reforms. Institutional change can be exerted when entering a new level concerning their insurer, nor can they can only be achieved over extended of care. choose between different insurance plans. periods of time, but reforms often seem When it comes to choosing a provider,
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the field is wide open, but information on care reform, but efforts should also be medical issues (like patient versions of refocused. The health care system is not guidelines), services or quality of service a machine, but a complex social system. provided is widely lacking compared to Therefore, it seems to be necessary not what is offered in countries like England only to implement the beneficial changes or the Netherlands. that are on the agenda. Before these seeds can take roots, the ground itself has to be An imminent challenge for health policy more thoroughly prepared by measures in Austria is to find a new balance between that are aimed at changing institutional provider choice and the introduction of patterns. a functioning primary care system. As always in such complex matters, bundles References of measures rather than singular measures seem appropriate, and internationally we 1 Starfield B, Shi L, Macinko J. Contribution of can find a lot of role models. Primary Care to Health Systems and Health. Milbank Quarterly 2005;83(3):457 – 502.
Austria could change the “choose between 2 European Commission. Expert panel on effective all providers” maxim to a “choose ways of investing in health web site. Available at: http://ec.europa.eu/health/expert_panel/ between the right providers” maxim. index_en.htm Choice can still be exerted, but only 3 on each level of care separately, as is Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care common in other countries. In addition systems are linked to better population health to this, people should be empowered to but also to higher health spending. Health Affairs make informed choices in the first place, 2013;32(4):686 – 94.
by making available patient guidelines, 4 Appleby J, Harrison A, Devlin N. What is The Real more information on providers and a Cost of More Patient Choice? London: King’s Fund telephone service. Decision makers also 2003.
have to ensure the quality of primary care 5 Le Grand J. Choice and competition in publicly providers, so people can trust them with funded health care. Health Economics, Policy and Law their health. They also have to actively 2009;4:479 – 88.
communicate the benefits of primary 6 MacNeil VJ, Zweifel P. Preferences for health care to the population rather than leaving insurance and health status: does it matter whether the field to the preservers of the status you are Dutch or German? European Journal of Health quo. When provider choice is limited to Economics 2011;12(1):87 – 95. some degree in a new system, it is also 7 Chevreul K, Durand-Zaleski I, Bahrami S, important to make sure that patients have Hernández-Quevedo C, Mladovsky P. France: a say in their treatment. This is still far Health system review. Health Systems in Transition too uncommon in the rather paternalistic 2010;12(6):1 – 291. medical tradition. 8 Sachverständigenrat für die Begutachtung der Entwicklung im Gesundheitswesen: Wettbewerb On a more general level, there are many an der Schnittstelle zwischen ambulanter und stationärer Gesundheitsversorgung. [Competition other ways to gauge the preferences of at the interface between outpatient and inpatient people. While introducing primary care, care]. Drucksache 17/10323, Deutscher Bundestag, Austria can improve public involvement in 2012. Available at: http://dip21.bundestag.de/dip21/ the decision making process. The position btd/17/103/1710323.pdf of patient representatives and self-help 9 Hirschman AO. Exit, Voice and Loyalty: Responses groups with respect to providers can be to Decline in Firms, Organizations and States. strengthened. Furthermore, surveys can be Cambridge MA: Harvard University Press, 1970. used on a more regular basis to ensure that 10 Czypionka T, Riedel M, Röhrling G, Sigl C. information is fed back to providers and Bürgerorientierung im Gesundheitswesen. decision makers. [Public involvement in healthcare systems]. Vienna: IHS Final Report, May 2011. While we can learn a lot from other countries to rearrange the balance between choice of provider and care coordination, the political process poses an immense challenge. A lot remains to be done to ensure the success of the ongoing health
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HEALTH SYSTEM TRENDS IN THE FORMER SOVIET COUNTRIES
By: Bernd Rechel, Erica Richardson and Martin McKee
Summary: Key trends in population health, the organisation and governance of health systems, health care provision and health financing in twelve former Soviet States are presented. The health systems in the region are still doing poorly in improving population health. Many of the post-Soviet countries are restricted in their ability to provide effective, timely and responsive care to those in need of it. One of the key prerequisites for making further progress is to move health higher up the political agenda.
Keywords: Health Status, Health System Trends, Health Reforms, Former Soviet Countries
Introduction Health trends More than two decades have passed since The collapse of the Soviet Union was the break-up of the Soviet Union in 1991. followed by one of the most dramatic This momentous event changed the drops in life expectancy in peace time. political geography of Europe, with many Declines were particularly pronounced countries that were once part of the Soviet among men in the Russian Federation, bloc eventually entering the European with male life expectancy falling Union (EU) in 2004 and 2007, including by 6.2 years between 1990 and 1994, to the three Baltic states (Estonia, Latvia and just 57.6 years. Although declines were Lithuania). The situation has been different less dramatic in other countries of the for the twelve former Soviet states that region, as a rule, life expectancy dropped have remained outside the enlarged EU in the first half of the 1990s, with only (Armenia, Azerbaijan, Belarus, Georgia, a slow recovery since then. Overall, Kazakhstan, Kyrgyzstan, the Republic the gap in life expectancy with western of Moldova, the Russian Federation, Europe has increased over the past two Tajikistan, Turkmenistan, Ukraine and decades. Worryingly, people in the region Bernd Rechel is Researcher and Erica Richardson is Uzbekistan). Many of them are still can expect to die much earlier than their Research Officer at the European beset with problems resulting from an counterparts in western Europe, even Observatory on Health Systems unrealised reform agenda, as well as in those countries with economies that and Policies, London School of Hygiene & Tropical Medicine, problematic socio-economic or political are booming thanks to the extraction of United Kingdom. Martin McKee contexts. This article examines what has natural resources (Azerbaijan, Kazakhstan is Professor of European Public been happening in the health systems and the Russian Federation). Health at the London School of in these twelve former Soviet countries, Hygiene & Tropical Medicine, and Research Director at the European summarising key elements of a newly The main causes of death contributing Observatory on Health Systems published comparative analysis. 1 to this persisting gap in life expectancy and Policies, United Kingdom. are circulatory system disorders (most Email: [email protected] notably ischaemic heart disease)
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and external causes such as injuries, of informal payments, underdeveloped in almost all former Soviet countries, violence and poisoning. In 2011, directly systems to ensure patient rights, lack of often supported by international standardised all-cause mortality rates for awareness of entitlements, fragmentation agencies. 6 Most commonly, however, under 65 years old per 100,000 population across different tiers of government, the Soviet model of primary health care, in the Commonwealth of Independent insufficient regulation of the emerging delivered by doctors with only basic States (CIS) exceeded the EU average by private sector, and a limited involvement training and able to treat a limited range a factor of three for males (801 and 269 by the public and of professional of conditions, has been retained and per 100,000 respectively), while mortality associations in health policy development. primary health care based on a model rates were more than two times higher In all these respects, the post-Soviet of comprehensive family medicine for females (308 and 131 per 100,000 countries are restricted in their ability to is confined to pilot sites. Exceptions respectively). Major risk factors include provide effective, timely and responsive are Kyrgyzstan and the Republic of high alcohol consumption (in particular care to those in need of it. Moldova. In general, progress in primary hazardous drinking of spirits and surrogate health care reforms has been slow. One alcohols, i.e. substances including ethanol Health care provision challenge is that resource allocation but not meant for consumption), high still prioritises secondary and tertiary smoking prevalence, poor nutrition and Two major foci of reforms in health care care. Weak gatekeeping and referral poor access to effective health care. Other provision in the post-Soviet period were systems, poor integration of care, and pertinent health problems include high attempts to downsize hospital sectors low public confidence in primary health (although decreasing) rates of tuberculosis and, correspondingly, strengthen primary care are other problems. Primary health and, in several countries, an increasing health care. The collapse in government care facilities in rural areas also find it burden posed by HIV/AIDS. health funding in the early 1990s difficult to attract staff and to secure necessitated reductions in the oversized other resources. hospital sectors inherited from the Soviet period. However, closures were often Despite attempts to improve it, quality the gap confined to small rural facilities, while of care remains a concern at all levels few hospitals in urban areas were affected of care. The reasons for poor quality are in life expectancy and politically powerful tertiary care many but include a lack of investment facilities have remained virtually immune. in facilities and technologies (as noted with western Most countries in the region still have a above), problems with the pharmaceutical higher ratio of acute care hospital beds per supply chain, inadequate training of Europe has capita than EU member states and there health workers, underdeveloped patient is also still a much longer average length rights, absence of systems for quality increased of stay. However, the lack of investment improvement, the paucity of locally in modern technology, or if it is present, generated evidence, limited access to the Organisation and governance of using it effectively, coupled with the international literature, widespread out-of- low status of nurses and some other health pocket payments (encouraging expensive The organisation and governance of health workers, limits the scope to improve and unnecessary treatments), poor systems‘‘ in the region has also seen major productivity. integration of different levels of care, and upheavals in many countries, although the persistence of incentives to hospitalise some have been resistant to change. Far too often, patients are admitted to patients. 3 7 8 Surveys have shown Several countries have experimented with hospitals for the wrong reasons. In some that only a very small percentage (less the decentralisation of responsibilities, countries of the region, patients are up to than 10% in many post-Soviet countries) usually as a consequence of broader ten times more likely to be hospitalised of those with high blood pressure take administrative reforms. Sometimes, for hypertension than in OECD necessary medications regularly, 9 and this has exacerbated unclear divisions countries, a condition that rarely requires treatment rates for those with elevated of responsibilities, leading to weak hospitalisation in western countries. 2 levels of cholesterol are even lower. 2 coordination and major inequities among Other examples of conditions that are regions. To varying degrees, parallel commonly treated in hospitals rather than Health financing health systems from ministries or major outpatient facilities include tuberculosis, state companies inherited from the diabetes and drug addiction. 3 Reasons for Some of the most profound changes in Soviet period have persisted, resulting keeping patients in hospitals longer than the post-Soviet period have occurred in in duplication and fragmentation, necessary include weak gatekeeping in the area of health financing. Following undermining the effectiveness of the primary care, poor integration of care and the collapse of government funding for broader health system. Overall, the perverse financial incentives for over- health in the early 1990s, private out-of- effective governance of health systems hospitalisation. 4 5 pocket payments have become common, is undermined by a lack of quality data, both in the form of official co-payments lacking transparency and accountability, Strengthening primary health care was and in the form of informal, under-the- large informal sectors, the existence another key objective of health reforms counter payments. In 2012, the proportion
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of government spending in total health made, it will be essential to afford health expenditure was less than 50% in five a higher priority on government agendas (Georgia, Azerbaijan, Tajikistan, Armenia and push the reform agenda forward. and Republic of Moldova) of the twelve post-Soviet countries considered here. References This poses a serious challenge to equity, as out-of-pocket payments reduce financial 1 Rechel B, Richardson E, McKee M (eds). Trends protection, equity in finance, equity in in health systems in the former Soviet countries. Copenhagen: World Health Organization, 2014. utilisation and access to services. 10 2 Smith O, Nguyen SN. Getting Better. Improving Health System Outcomes in Europe and Central Asia. Washington, DC: The World Bank, 2013. quality 3 Rechel B, Kennedy C, McKee M, Rechel B. The Soviet legacy in diagnosis and treatment: Implications for population health. Journal of Public of care remains Health Policy 2011;32(2):293 – 304. a concern 4 Raikhel E. Post-Soviet placebos: epistemology and authority in Russian treatments for alcoholism. Culture, Medicine and Psychiatry 2010;34(1):132 – 68. Governments have responded to this new 5 reality by defining benefits packages with Marx F, Atun R, Jakubowiak W, McKee M, Coker R. Reform of tuberculosis control and DOTS limited scope and shallow coverage. Most within Russian public health systems: an ecological often, outpatient pharmaceuticals are study. European Journal of Public Health 2007; excluded and so they now form a major 17(1):98 – 103. component of private health expenditure. 6 Rechel B, McKee M. Health reform in central A secondary analysis of household surveys and eastern Europe and the former Soviet Union. in eleven‘‘ eastern and central European The Lancet 2009;374(9696):1186 – 95. countries found that expenditure on 7 Guindon G, Lavis J, Becerra-Posada F et al. drugs accounted for as much as 75% Bridging the gaps between research, policy and of household spending on health in the practice in low- and middle-income countries: a Republic of Moldova and more than 50% survey of health care providers. Canadian Medical in Kyrgyzstan, Tajikistan and Azerbaijan. 2 Association Journal 2010;182(9):E362 – 72. 8 Rechel B, Roberts B, Richardson E et al. Health Some countries (most notably Kyrgyzstan, and health systems in the countries of the former the Republic of Moldova, and the Russian Soviet Union. The Lancet 2013;381(9872):1145 – 55. Federation) have instituted mandatory 9 Roberts B, Stickley A, Balabanova D, Haerpfer C, health insurance systems. These reforms McKee M. The persistence of irregular treatment have sometimes been the driving force of hypertension in the former Soviet Union. Journal of Epidemiology and Community Health for comprehensive reforms of health 2012;66:1079 – 82. financing, designed to improve equity 10 and efficiency. 11 Many countries are also Balabanova D, Roberts B, Richardson E, Haerpfer C, McKee M. Health Care Reform in adopting payment mechanisms used in the Former Soviet Union: Beyond the Transition. western Europe, with case-based payment Health Services Research 2012;47(2):840 – 64. mechanisms for hospitals, while primary 11 Kutzin J, Jakab M, Cashin C. Lessons from health care is now predominantly financed on financing reform in central and eastern Europe and a capitation basis. the former Soviet Union. Health Economics, Policy and Law 2010;5:135 – 47. Conclusion Health systems in the former Soviet countries still have a long way to go to reach the standards found in western Europe. Most fundamentally, they perform poorly in improving population health. This applies to both non-communicable and communicable diseases, as well as curative care and inter-sectoral public health actions. For more progress to be
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ASSURING QUALITY OF INPATIENT CARE IN GERMANY: EXISTING AND NEW APPROACHES
By: Miriam Blümel, Dimitra Panteli and Ewout van Ginneken
Abstract: During the last 25 years Germany has put more emphasis on quality in the inpatient sector and has fundamentally revised the demands placed on quality assurance in hospitals. A new Act furthers quality assurance in health care by making hospital quality more transparent for patients and by establishing a new scientific institute. A potential task for the future Institute for Quality Assurance and Transparency in Health Care may be not only to develop quality measures, but also to monitor their implementation and to take action based on the results.
Keywords: Quality, Inpatient Care, Hospital Payment, Diagnosis Related Groups, Germany
Introduction the German health system’s performance only ranked 25th in the WHO Health European health care systems all face Report 2000, which initiated both the same challenge: assuring high- extensive discussions and an increased quality health care while at the same time focus on improving quality of care. containing costs. Quality of care is one Both the Statutory Health Insurance of the most frequently mentioned goals (SHI) Reform Act of 2000 and the SHI of health care systems and ranks high Modernisation Act of 2004 introduced on the European as well as on the global new requirements for internal and health policy agenda. 1 The introduction external quality control in service of measures aiming to achieve more cost provision, encompassing structural, efficiency, e.g. hospital payment through process- and outcome-related dimensions Diagnosis Related Groups (DRGs), to of performance. The 2013 coalition many, may appear diametrical to this agreement includes further proposals quality objective. Against this background, for various measures with a focus on the the development of approaches assuring promotion of quality. Some of these have quality of care is of crucial importance entered into effect with the Act to Further in Germany and may hold lessons for Develop the Financial Structures and Miriam Blümel is a Researcher, other countries looking to improve Quality in SHI, which passed parliament Dimitra Panteli is a Researcher, hospital quality. and Ewout van Ginneken is on 5 June 2014. Senior Researcher, Department of Health Care Management at Berlin Quality assurance measures have already This article aims to provide an overview University of Technology, Germany. been legally required in Germany since Email: [email protected] of quality assurance measures in place in the Health Care Reform Act of 1989. Yet,
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the German health system. To this end, we for hospitals is voluntary. Most hospitals minimum volume during the previous year first describe the regulatory environment that apply for accreditation use the has become a precondition for receiving a for quality assurance. Second, we explore Cooperation for Transparency and new contract in the next year. 4 the approaches to internal and external Quality in Health Care (Kooperation quality control in German hospitals. für Transparenz und Qualität im The introduction of DRG-based payments Third, we examine to what extent and how Gesundheitswesen – KTQ) or the proCum for the hospital sector in 2003 highlighted quality is publicly reported. Lastly, we Cert systems, which rely on an initial stage the need for better documentation and discuss what benchmarking approaches of self-assessment before evaluation by procedure coding, as well as increased are in use before finishing with new external auditors. As of June 2014, there scrutiny of resource utilisation and initiatives and conclusions. were 489 hospitals with a current valid quality of care. Hospitals are subject to KTQ qualification. Interestingly, a survey external quality control also by means of published in 2011 contests the correlation a nationwide reporting mechanism. This between hospital accreditation status and falls within the remit of the Federal Joint explicit patient satisfaction, despite the fact that Committee and has been implemented accreditation is widely used as a quality by the AQUA Institute since 2010. focus on quality endorsement and patient satisfaction is Each year, the Federal Joint Committee stressed in the criteria catalogues of both decides on the areas of care to be assurance the KTQ and the proCum Cert systems. 3 documented. Hospitals are mandated to collect information on all cases in these Regulatory environment for quality Quality elements have also been areas and send it to AQUA, as well as assurance incorporated in the contracting process to state-level quality assurance bodies. of hospitals. Sickness funds use AQUA processes and evaluates data from The Federal Joint Committee quality indicators to compare hospital all hospitals and feeds the information (Gemeinsamer Bundesausschuss) is the performance in their negotiations back to the providers, thus enabling highest decision-making body in the with providers. For this purpose, the them to assess their own performance in self-regulation and governance system in Federal Office for Quality Assurance comparison to others. However, external German‘‘ health care. Its main responsibility (Bundesgeschäftsstelle Qualität – BQS) quality control mechanisms could be is to ensure the implementation of the was established to assist the contract ineffective: a recently published study legislator’s demands in every-day practice partners in choosing and developing on the development of hospital service (§ 92, SGB V). Its directives span the areas quality indicators to be monitored as well volumes reveals that the data in hospital of ambulatory and inpatient care, dentistry as to collect, compile and analyse the performance reports often do not conform and psychotherapy, reimbursement and data, and to make the findings available to to administrative claims data. For provision of diagnostic procedures, individual hospitals in the form of reports example, in the case of hip replacement pharmaceuticals and other therapeutic and recommendations. 4 In 2009, these some hospitals reported fewer mortality procedures as well as medical devices. health care-related tasks were transferred rates than coded in the claims data. 5 They are binding once the Federal from the BQS to the AQUA Institute for Ministry of Health has approved them. Applied Quality Promotion and Research Public reporting The Federal Joint Committee has an in Health Care. Since 2005, each hospital is obliged to explicit focus on quality assurance through publish biannual performance reports its Quality Assurance Subcommittee. Its Additionally, minimum service volumes addressing patients and their relatives but focal points include mandatory measures to be provided by hospitals eligible for also with reference to practitioners and the for quality assurance at the federal level SHI funding were set for certain services general public. All hospitals contracted and the endorsement of its enhancement, by the Federal Joint Committee in 2002 within the SHI system have to make these internal and external quality control, and integrated into the contracting reports available to the sickness funds for as well as setting minimum volumes process. Contract partners, i.e. the former online publication and to their visitors in of services and postgraduate training federal associations of sickness funds, hard copies. The reports have to follow a obligations for medical specialists and the German Hospital Federation (DKG – uniform structure provided by the Federal psychotherapists. Deutsche Krankenhaus Gesellschaft) and Joint Committee and include data on the Federal Chamber of Physicians, were structure, process and outcomes of care. Internal and external quality control required by law to develop a list of elective General information on the hospital, its Quality control measures differ in services (e.g. transplantation and bypass administrative organisation and priorities content, form and enforcement. Quality surgeries, neonatal intensive care units) in need to be covered, as do department- management has been mandatory for which there is a clear positive relationship specific data on diagnoses (following hospitals since the SHI Reform Act between the volume of services provided the ICD classification) and procedures of 2000. The Federal Joint Committee and the quality of the health outcomes. (following the OPS classification). The allows hospitals to choose their quality For the services, delivery of a predefined reports also have to include information management tool freely, but stipulates on the hospital’s compliance with external the aspects to be included. 2 Accreditation control legislation and their participation
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in related activities, their achievement aimed to improve inpatient care by purpose, it will be allowed to collect and of minimal volumes and continuing means of inter-institutional comparisons analyse administrative sickness fund data education, as well as the types of tools and and learning from best practice. An and to publish advice. mechanisms they use to enhance quality evaluation of these projects showed management. However, as mentioned varying degrees of development during Although not clearly stated in the Act, earlier, the reports’ accuracy is not subject the funding period and no overall trend quality-related payment will receive higher to control mechanisms and, thus, in some regarding patient outcomes. 7 The Federal priority in hospitals. Plans foresee, for cases may publish incorrect figures. Association of German Private Hospitals example, that hospitals providing high- (Bundesverband Deutscher Privatkliniken) quality services could be excluded from launched a new program for online public the 25% payment reduction for increases reporting called Quality Hospitals (www. in revenue budgets. Conversely, below plans to qualitaetskliniken.de), which reports on average quality for individual services clinical quality (process and outcome), may, in the future, lead to larger payment strengthen patient safety and satisfaction as well as on reductions. Pay-for-performance has the satisfaction of the referring physician. not yet been formally established in the quality by law It uses administrative data, survey data German health system. However, the and information from the statutory development of comprehensive quality Public reporting on hospital performance reports of participating hospitals and thus assurance indicators stimulates outcome- is primarily based on the official biannual provides not only a useful tool for patients related financing and payment for hospital reports, which are used by several but also a comprehensive benchmarking the future. platforms. For example, the White List platform for hospitals themselves. 8 (Weisse Liste) is run by the Bertelsmann Another benchmarking approach, based Conclusions Foundation in cooperation with the on routine data collection and peer largest umbrella organisations of patient review, is followed by the Initiative on During the last 25 years Germany has and‘‘ consumer protection institutions. Its Quality Medicine, which was launched put more emphasis on quality in the search engine allows patients to search as a collaboration between a group inpatient sector. Since the Health Care for providers by diagnosis, intervention consisting of private hospitals, charities, Reform Act of 1989, quality assurance and geographic area. The indicators university departments and not-for profit measures are a legal obligation and available for each search depend on the organisations (http://www.initiative- through the SHI Reform Act of 2000 and condition and/or procedure, but structural qualitaetsmedizin.de/). A recent survey the SHI Modernisation Act of 2004, the information, the number of patients per pinpointed 53 benchmarking initiatives demands placed on quality assurance in physician and nurse and the frequency of with differing levels of adherence to the hospitals and the ambulatory sector have treatment of similar cases are always in plan-do-check-act (PDCA) cycle active in been fundamentally revised. The new place. Data on outcomes are more rare, the German health system. 9 Act to Further Develop the Financial but when available they are presented in a Structures and Quality in SHI furthers traffic-light format (green = within normal New initiatives quality assurance in health care, not only range/comparable to national average; by making the quality of hospital services red = beyond expected limits). Similar Since the elections in September 2013, more transparent for patients, but also comparison platforms are also run by Germany is governed by a grand coalition by establishing a scientific base for the the AQUA Institute and certain sickness of Christian and Social Democrats introduction of quality-related hospital funds (AOK-Gesundheitsnavigator, TK- with Hermann Gröhe being the Federal payment. It is worth noting that quality Klinikführer, Kliniklotse). The reported Minister of Health. The coalition plans to assurance mechanisms are important, data are sometimes supplemented strengthen quality by law as an additional but only as long as they are actually with the experience of the sickness criterion for decisions on hospital planning used to improve health care quality. A funds’ insured. The DKG runs the and payment. The Act to Further Develop potential task for the future Institute for German Hospital Registry (Deutsches the Financial Structures and Quality Quality Assurance and Transparency in Krankenhausverzeichnis – DKV), which in SHI commissions the Federal Joint Health Care may be not only to develop provides the option of searching according Committee to establish a new independent quality measures, but also to monitor their to quality criteria, documented in hospital scientific institute: The Institute for implementation and to take action based reports in addition to geographic and Quality Assurance and Transparency on the results. diagnostic criteria. 6 in Health Care. To this end, the Federal Joint Committee installed a private-law References foundation to become the responsible body Benchmarking 1 of the new institute and will nominate its World Health Organization. Quality of care: The Federal Ministry of Health widely director (upon approval by the Ministry of A process for making strategic choices in health systems. Geneva: WHO, 2006. supported the concept of benchmarking Health). The institute’s task is to develop in inpatient care between 2003 and 2007: indicators for quality assurance and it endorsed ten model projects that documentation of quality of care. For this
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2 Gemeinsamer Bundesausschuss. Agreement in 7 de Cruppé W, Blumenstock G, Fischer I, accordance with § 137 para 1 sentence 3 No. 1 SGB V Selbmann H-K, Geraedts M. Results of the evaluation on the fundamental requirements for internal quality by the Ministry of Health funded benchmarking management in hospitals approved pursuant to § 108 networks in Germany. [Ergebnisse der Evaluation der SGB V. [Vereinbarung gemäß § 137 Abs. 1 Satz 3 Nr. 1 vom Bundesministerium für Gesundheit geförderten SGB V über die grundsätzlichen Anforderungen an ein Benchmarking-Verbünde in Deutschland]. Zeitschrift einrichtungsinternes Qualitätsmanagement für nach für Evidenz, Fortbildung und Qualität im § 108 SGB V zugelassene Krankenhäuser]. Berlin: Gesundheitswesen. 2011;105(5):339 – 42. Gemeinsamer Bundesausschuss, 2004. Available at: 8 Haeske-Seeberg H, Piwernetz K. Benchmarking http://www.g-ba.de/downloads/62-492-14/2004-08- of clinics for the public using the example of the 17-Vereinbarung-QM.pdf 4QD-Qualitätskliniken.de. [Benchmarking von Kliniken 3 Sack C, Scherag A, Lütkes P, Günther W, für die Öffentlichkeit am Beispiel der Jöckel KH, Holtmann G. Is there an association 4QD-Qualitätskliniken.de]. Zeitschrift für Evidenz, between hospital accreditation and patient Fortbildung und Qualität im Gesundheitswesen satisfaction with hospital care? A survey of 37,000 2011;105(5):401 – 3. patients treated by 73 hospitals. International Journal 9 Blumenstock G, Fischer I, de Cruppé W, for Quality in Health Care. 2011;23(3):278 – 83. Geraedts M, Selbmann H-K. Benchmarking projects in Available at: http://intqhc.oxfordjournals.org/ patient care in Germany: methodology for analysis, content/early/2012/01/22/intqhc.mzr086.abstract results and good practice. [Benchmarking-Vorhaben 4 Busse R, Blümel M. Germany: health system in der Patientenversorgung in Deutschland: review. Health Systems in Transition 2014; Analysemethodik, Erhebungsergebnisse und gute 16(2):1 – 296. (forthcoming) Praxis]. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2011;105(5):335 – 8. 5 Schreyögg J, Bäuml M, Krämer J, Dette T, Busse R, Geissler A. Commissioned research on developments in hospital supply according to § 17b para 9 KHG. Final Report. [Forschungsauftrag zur Mengenentwicklung nach §17b Abs. 9 KHG]. Endbericht, 2014.
6 Cacace M, Ettelt S, Brereton L, Pedersen J, Nolte E. How health systems make available information on service providers: Experience in seven countries. London: RAND Europe, 2011. Available at: http://www.rand.org/pubs/technical_ reports/TR887.html
New HiT on Germany the statutory health insurance system, paying providers and assessing and reimbursing pharmaceuticals.
By: R Busse and M Blümel Today the German health care system has a generous benefit basket, one of the highest levels of capacity as well as modest Copenhagen: World Health Organization 2014 (acting as the cost-sharing. Expenditure per capita is high and access is host organization for, and secretariat of, the European good. However, the system also shows areas in need of Observatory on Health Systems and Policies) improvement when compared to other countries and has low Number of pages: 296, ISSN: 1817-6127, Vol. 16, No. 2, 2014 satisfaction figures with the health
Health Systems in Transition system in general and issues In the German health care system, decision-making powers Vol. 16 No. 2 2014 around quality of care, if the are traditionally shared between national (federal) and state outcomes of individual illnesses (Land) levels, with much power delegated to self-governing Germany Health system review are analysed. bodies. It provides universal coverage for a wide range of benefits. Since 2009, health insurance has been mandatory for This new health system review all citizens and permanent residents, through either statutory or (HiT) on Germany examines private health insurance. Characteristics of the system are free changes and reforms that have
• Miriam Blümel choice of providers and unrestricted access to all care levels. Reinhard Busse taken place and discusses A key feature of the health care delivery system in Germany challenges for the new is the clear institutional separation between public health government that came to power services, ambulatory care and hospital (inpatient) care. at the end of 2013.
Since reunification various governments have implemented a number of important reforms in the German health sector, including changes in self-governing structures, financing
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NEWS The new Strategic Framework builds on Ministry for the Environment, Nature the 2007 – 2012 EU Occupational Health Conservation, Building and Nuclear Safety and Safety (OHS) Strategy. 27 Member in Germany, made a statement stating that States now have a national OHS strategy, “climate change responses have been adapted to the national context and key rather reactive, as was seen recently in International priority areas. The new framework will be the multiple floods hitting Europe this year. reviewed in 2016 in order to take stock of Advance planning for what climate change Health and safety at work: Strategic its implementation and to take into account will likely bring is an important component Framework sets out EU objectives the results of an on-going comprehensive of the health-in-climate-change response, for 2014 – 2020 evaluation of EU occupational health and so capacities need to be evaluated and safety legislation which will be available actively developed.” The conference On June 6 the European Commission by the end of 2015. aimed to pave the way for consideration published a new Strategic Framework on of health and climate issues in the More information on the new Strategic Health and Safety at Work 2014 – 2020. UN Climate Summit, held in New York Framework at: http://eur-lex. It identifies three key challenges: on 23 September 2014. europa.eu/legal-content/EN/TXT/ 1. To improve implementation of existing PDF/?uri=CELEX:52014DC0332 More information at: http://www.who.int/ health and safety rules, in particular by globalchange/mediacentre/events/climate- enhancing the capacity of micro and health-conference/en/ small enterprises to put in place effective WHO calls for stronger action on and efficient risk prevention strategies climate-related health risks 2. To improve the prevention of work- New report: preventing suicide a global related diseases by tackling new and Measures to adapt to climate change could imperative emerging risks without neglecting save lives around the world by ensuring existing risks that communities are better prepared On 4 September WHO published 3. To take account of the ageing of to deal with the impact of heat, extreme “Preventing suicide: a global imperative”. the EU’s workforce. weather, infectious disease and food It reviews current data on suicide attempts insecurity. For example, changes in energy and mortality. The report notes that A number of different proposed and transport policies could save millions of suicide accounts for 17.6% of all deaths strategic actions are set out to meet lives annually from diseases caused by high among people aged 15 – 29 years in high- these challenges. They include further levels of air pollution. The right energy and income countries and is thus a leading consolidating national health and safety transport policies could also reduce the cause of death among people in this age strategies through, for example, policy burden of disease associated with physical group. Globally, 8.5% of deaths among coordination and mutual learning. Further, inactivity and traffic injury. These were key young adults are due to suicide. The the framework recommends simplifying messages discussed at the first-ever global WHO European Region includes 33 of existing legislation where appropriate conference on health and climate, which the 54 high-income countries identified to eliminate unnecessary administrative took place at WHO headquarters in Geneva in the report and tackling suicide is a key burdens, while preserving a high level of from 27 to 29 August. The conference element of the WHO Euro’s Mental Health protection for workers’ health and safety. brought together over 300 participants, Action Plan and the European Commission The importance of the enforcement of including government ministers, heads supported Joint Action on Mental Health health and safe workplaces is made clear, of UN agencies, urban leaders, civil and Wellbeing. with one proposed suggestion being to society and leading health, climate and The new report is available at: evaluate the performance of national labour sustainable-development experts. inspectorates. Other actions include the http://tinyurl.com/ose3ser The environment and health sectors in the provision of practical support to small The European Mental Health Action Plan is WHO European Region have a long history and micro-sized business to help them available at: http://tinyurl.com/kby82ma to better comply with health and safety of collaboration, consolidated in 2010 rules, including the use of web based through the establishment of the European The Joint Action on Mental Health and risk assessment tools. The framework is Environment and Health Ministerial Board. Wellbeing is available at: http://www. also mindful of the need to take account Participants from the WHO European mentalhealthandwellbeing.eu/ of the ageing of the European workforce Region participated in sessions on policies, and to improve the prevention of work- mechanisms and tools for building health related diseases. It also recognises the resilience to climate change, issues Additional materials supplied by: importance of developing better monitoring in urban settings and the leveraging EuroHealthNet tools and reinforcing coordination with of environment and climate finance to 6 Philippe Le Bon, Brussels. international organisations (such as the strengthen health systems. European Tel: + 32 2 235 03 20 International Labour Organisation, the Working Group on Health in Climate Fax: + 32 2 235 03 39 World Health Organization (WHO) and Change (HIC) co-chairs, Louise Newport of Email: [email protected] the Organisation for Economic Co- the Department of Health, United Kingdom, operation and Development. and Jutta Litvinovitch of the Federal
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E u ro p e a n H e a l t h F o r u m G a s t e i n