Cover_WHO_nr41_Mise en page 1 11/06/15 12:38 Page 1 41 ECONOMIC CRISIS, HEALTH SYSTEMS AND HEALTH IN EUROPE AND HEALTH SYSTEMS HEALTH ECONOMIC CRISIS, COUNTRY EXPERIENCE COUNTRY Economic crisis, 41 The financial and economic crisis has had a visible but varied impact on many health systems in Europe, eliciting a wide range of responses from governments faced with increased financial and other pressures. This book maps health system responses by health systems country, providing a detailed analysis of policy changes in nine countries and shorter overviews of policy responses in 47 countries. It draws on a large study involving over one Observatory hundred health system experts and academic researchers across Europe. and health in Europe Studies Series Focusing on policy responses in three areas – public funding of the health system, health coverage and health service planning, purchasing and delivery – this book gives policy- Country experience makers, researchers and others valuable, systematic information about national contexts Edited by of particular interest to them, ranging from countries operating under the fiscal and structural conditions of international bailout agreements to those that, while less severely Anna Maresso affected by the crisis, still have had to operate in a climate of diminished public sector Tamás Evet Jonathan Cylus, Erica Richardson, Marina Karanikolos, Anna Sagan, Thomson, Sarah Philipa Mladovsky, Anna Maresso, by Edited Philipa Mladovsky spending since 2008. Sarah Thomson Along with a companion volume that analyses the impact of the crisis across countries, Anna Sagan this book is part of a wider initiative to monitor the effects of the crisis on health systems Marina Karanikolos and health, to identify those policies most likely to sustain the performance of health Erica Richardson systems facing fiscal pressure and to gain insight into the political economy of Jonathan Cylus implementing reforms in a crisis. Tamás Evetovits Matthew Jowett The editors Josep Figueras Hans Kluge Anna Maresso, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Hans Kluge Josep Figueras, Jowett, Matthew ovits, Sarah Thomson, WHO Regional Office for Europe Anna Sagan, European Observatory on Health Systems and Policies Marina Karanikolos, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Jonathan Cylus, European Observatory on Health Systems and Policies Tamás Evetovits, WHO Regional Office for Europe Matthew Jowett, World Health Organization Josep Figueras, European Observatory on Health Systems and Policies Hans Kluge, WHO Regional Office for Europe 9 7 Observatory Studies Series No. 41 8 ISBN 9289050340 9 2 8 9 0 5 0 3 4 0 Economic crisis, health systems and health in Europe The European Observatory on Health Systems and Policies supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in Europe. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory is a partnership hosted by the WHO Regional Office for Europe; which includes the Governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia, Sweden, the United Kingdom, and the Veneto Region of Italy; the European Commission; the World Bank; UNCAM (French National Union of Health Insurance Funds); the London School of Economics and Political Science; and the London School of Hygiene & Tropical Medicine. The Observatory has a secretariat in Brussels and it has hubs in London (at LSE and LSHTM) and at the Technical University of Berlin. This is one part of a study on the impact of the crisis on health and health systems in Europe prepared jointly by the WHO Regional Office for Europe and the European Observatory on Health Systems and Policies. It provides an overview of health system responses to the crisis by country and case studies of the impact of the crisis in selected countries. For an analysis of the impact of the crisis across countries, see: Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M and Kluge H (2014). Economic crisis, health systems and health in Europe: impact and implications for policy. Maidenhead: Open University Press. For a summary of the whole study, see: Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M and Kluge H (2014). Economic crisis, health systems and health in Europe: impact and implications for policy. Copenhagen: WHO Regional Office for Europe/European Observatory on Health Systems and Policies (Policy Summary 12). The study is part of a wider initiative to monitor the effects of the crisis on health systems and health. Those interested in ongoing analysis will find updates through the Health and Crisis Monitor of the European Observatory on Health Systems and Policies in collaboration with the Andalusian School of Public Health (www.hfcm.eu), and the website of the Division of Health Systems and Public Health at the WHO Regional Office for Europe (www.euro.who.int/en/health-topics/Health-systems). Economic crisis, health systems and health in Europe Country experience Edited by Anna Maresso, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Sarah Thomson, WHO Regional Office for Europe Anna Sagan, European Observatory on Health Systems and Policies Marina Karanikolos, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Jonathan Cylus, European Observatory on Health Systems and Policies Tamás Evetovits, WHO Regional Office for Europe Matthew Jowett, World Health Organization Josep Figueras, European Observatory on Health Systems and Policies Hans Kluge, WHO Regional Office for Europe Keywords: DELIVERY OF HEALTH CARE EUROPE HEALTH CARE SYSTEMS HEALTH FINANCING HEALTH PLANNING © World Health Organization 2015 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) Address requests about publications to: Publications, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark. Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/ pubrequest). All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the European Observatory on Health Systems and Policies to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the European Observatory on Health Systems and Policies be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the European Observatory on Health Systems and Policies or any of its partners. ISBN 9789289050340 Printed in the United Kingdom Cover design by M2M Contents List of abbreviations x List of tables and figures xii List of contributors xix Acknowledgements xxviii Preface xxx Part I 1 Chapter 1 3 The impact of the crisis on the health system and health in Belgium Irina Cleemput, Joeri Guillaume, Carine Van de Voorde and Anna Maresso Introduction 3 1. The nature and magnitude of the financial and economic crisis 4 2. Health system pressures prior to the crisis 7 3. Health system responses to the crisis 9 4. Implications for health system performance and health 24 5. Discussion 34 6. Conclusions 40 References 41 Chapter 2 47 The impact of the crisis on the health system and health in Estonia Triin Habicht and Tamás Evetovits Introduction 47 1. The nature and magnitude of the financial and economic crisis 47 2. Health system pressures prior to the crisis 50 3. Health system responses to the crisis 50 4. Implications for health system performance and health 63 5. Discussion 68 6. Conclusions 70 Appendix 2.1 71 Acknowledgements 72 References 72 Chapter 3 75 The impact of the crisis on the health system and health in France Matthias Brunn, Karen Berg Brigham, Karine Chevreul and Cristina Hernández-Quevedo Introduction 75 1. The nature and magnitude of the financial and economic crisis 75 2. Health system pressures prior to the crisis 78 3. Health system responses to the crisis 81 4. Implications for health system performance and health 87 5. Discussion 92 vi Economic crisis, health systems and health in Europe: country experience 6. Conclusions 97 References 97 Chapter 4 103 The impact of the crisis on the health system and health in Greece Charalampos Economou, Daphne Kaitelidou, Alexander Kentikelenis, Anna Maresso and Aris Sissouras Introduction 103 1. The nature and magnitude of the financial and economic crisis 104 2. Health system pressures prior to the crisis 106 3. Health system responses to the crisis 110 4.