Report of the EXPERT PANEL ON EFFECTIVE WAYS OF INVESTING IN HEALTH (EXPH) on Access to health services in the European Union Health and Food Safety EXPERT PANEL ON EFFECTIVE WAYS OF INVESTING IN HEALTH (EXPH) Access to health services in the European Union The EXPH approved this opinion at the 14th plenary meeting of 3 May 2016 after public consultation Access to health services – Final opinion About the Expert Panel on effective ways of investing in Health (EXPH) Sound and timely scientific advice is an essential requirement for the Commission to pursue modern, responsive and sustainable health systems. To this end, the Commission has set up a multidisciplinary and independent Expert Panel which provides advice on effective ways of investing in health (Commission Decision 2012/C 198/06). The core element of the Expert Panel’s mission is to provide the Commission with sound and independent advice in the form of opinions in response to questions (mandates) submitted by the Commission on matters related to health care modernisation, responsiveness, and sustainability. The advice does not bind the Commission. The areas of competence of the Expert Panel include, and are not limited to, primary care, hospital care, pharmaceuticals, research and development, prevention and promotion, links with the social protection sector, cross-border issues, system financing, information systems and patient registers, health inequalities, etc. Expert Panel members Pedro Barros, Margaret Barry, Helmut Brand, Werner Brouwer, Jan De Maeseneer (Chair), Bengt Jönsson (Vice-Chair), Fernando Lamata, Lasse Lehtonen, Dorjan Marušič, Martin McKee, Walter Ricciardi, Sarah Thomson Contact European Commission DG Health & Food Safety Directorate B: Health Systems, medical products and innovation Unit B1 – Performance of national health systems Office: B232 B-1049 Brussels [email protected] The opinions of the Expert Panel present the views of the independent scientists who are members of the Expert Panel. They do not necessarily reflect the views of the European Commission or its services. The opinions are published by the European Union in their original language only. 2 Access to health services – Final opinion ACKNOWLEDGMENTS Members of the Working Group are acknowledged for their valuable contribution to this opinion. The members of the Working Group are: Expert Panel members Professor Pedro Barros Professor Margaret Barry Professor Werner Brouwer Professor Jan De Maeseneer Chair Dr Fernando Lamata Professor Lasse Lehtonen Professor Martin McKee Dr Sarah Thomson Rapporteur External experts Dr Michele Cecchini Professor Sara Willems The declarations of the Working Group members are available at: http://ec.europa.eu/health/expert_panel/experts/working_groups/index_en.htm The Working Group would like to thank Pooja Yerramilli and Jens Detollenaere for their help in preparing some of the figures. 3 Access to health services – Final opinion ABSTRACT The 28 Member States of the European Union (EU) have a clear mandate to ensure equitable access to high-quality health services for everyone living in their countries. This does not mean making everything available to everyone at all times. Rather, it means addressing unmet need for health care1 by ensuring that the resources required to deliver relevant, appropriate and cost-effective health services are as closely matched to need as possible. Access is a multi-dimensional issue. Barriers to access can be found at the level of individuals, health service providers and the health system. Access is also affected by public policy beyond the health system – especially fiscal policy, but also social protection, education, employment, transport and regional development policy. Survey data suggest that financial barriers are the largest single driver of unmet need for health care in the European Union. Between 2005 and 2009, EU Member States made huge progress in improving access to health care. The number of people reporting unmet need for health care due to cost, travel distance or waiting time fell steadily from 24 million in 2005 to 15 million in 2009. Since 2009, however, this positive trend has been reversed – a visible sign of the damage caused by the financial and economic crisis. By 2013, the number of people reporting unmet need for health care had risen to 18 million (3.6% of the EU population). This report highlights key access problems and policy responses in EU health systems. It is structured around eight policy areas: financial resources linked to health need; services affordable for everyone; relevant, appropriate and cost- effective services; facilities within easy reach; staff with the right skills in the right place; quality medicines and medical devices available at fair prices; everyone can use services when they need them; services acceptable to everyone. The report includes a focus on three groups of people who are systematically underserved: Roma, undocumented migrants and people with mental health problems. A final section of the report discusses the roles and responsibilities of the European Union and its Member States in ensuring equitable access to health services. The report emphasises the need for a new generation of data collection for effective, accessible, resilient and accountable health systems. It calls for better monitoring to identify the magnitude of access problems in a timely manner, to measure changes over time and across groups of people and to enhance international comparability. The ability to disaggregate data at sub- national level and by sub-groups in the population is essential. The report also calls for more policy analysis to enable a deeper understanding of the causes of access problems and to identify cost-effective policy responses, underpinned by research targeting groups of people facing multiple vulnerabilities. Policy responses should reflect the multi-dimensional nature of access problems, the importance of intersectoral action and the specificities of national and regional contexts. Keywords: EXPH, Expert Panel on effective ways of investing in Health, scientific opinion, access to health services 1 In this report, the term ‘unmet need’ refers to a situation in which people are not able to obtain the health services they need – at any level of the health system – because they face barriers to access due to cost (too expensive), distance (too far to travel) or waiting time. All data on unmet need in the report come from the EU Survey on Income and Living Conditions (EU-SILC). See the report for details. 4 Access to health services – Final opinion Opinion to be cited as: Expert Panel on effective ways of investing in Health (EXPH), Report on Access to Health Services in the European Union, 3 May 2016 © European Union, 2016 ISSN 2315-1404 ISBN 978-92-79-57112-1 doi:10.2875/10002 EW-BA-16-001-EN-N http://ec.europa.eu/health/expert_panel/index_en.htm NOTE TO THE READER Each chapter in this report begins with a summary of the chapter’s main points. 5 Access to health services – Final opinion [This page intentionally left blank] 6 Access to health services – Final opinion TABLE OF CONTENTS ACKNOWLEDGMENTS ............................................................................................. 3 ABSTRACT ............................................................................................................. 4 TERMS OF REFERENCE ............................................................................................ 9 An introduction to access to health services in the European Union............................. 11 1. Financial resources are linked to health need ................................................... 29 2. Services are affordable for everyone .............................................................. 39 3. Services are relevant, appropriate and cost-effective ........................................ 53 4. Facilities are within easy reach ...................................................................... 61 5. There are enough health workers, with the right skills, in the right place ............ 67 6. Quality medicines and medical devices are available at fair prices ...................... 73 7. People can use services when they need them ................................................. 83 8. Services are acceptable to everyone ............................................................... 91 Access for Roma, undocumented migrants and people with mental ill health ................ 95 Ensuring equitable access: EU and Member State responsibilities and responses ........ 107 Annex 1 Informal care and its impact on access to health services ........................... 121 Annex 2 Trends in unmet need for health care in each EU Member State ................... 123 Annex 3 Indicators for monitoring access in Europe ................................................ 137 PUBLIC CONSULTATION ..................................................................................... 141 LIST OF ABBREVIATIONS .................................................................................... 143 REFERENCES ..................................................................................................... 145 7 Access to health services – Final opinion [This page intentionally left blank] 8 Access to health services – Final opinion TERMS OF REFERENCE The Expert Panel on Effective ways of Investing in Health (EXPH) is requested to give its views on options for action to improve equity of access to health services in the EU. In