Transcript health
Health Governance through Europe Brussels April 16th 2012 Investing in Progressive and Affordable Health Systems Barrie Dowdeswell Director of Research ECHAA Agenda • Setting the context: • The Cohesion Fund policy for healthcare • The changing ‘Health’ circumstances – embedded pressures • The dominance of the economic agenda – superimposed pressures • How the EU is responding • Hungarian Presidency • EU Council • High Level Reflection Process • Reconciling Cohesion Policy and Europe 2020 with SF planning • Lessons from Euregio III • Conclusions and questions Health, a defining EU societal value Unprecedented pressures Population health status The macro view Personal care The citizen • Citizens rights and MS responsibility: • Safe, accessible, reliable, affordable and progressive healthcare • EU Policy aims • Social cohesion through principles of equity and inclusiveness • Contribution to economic growth • Twin challenges • Embedded health pressures: ageing, chronic illness, technology • Superimposed pressures: the economic crisis Health equity – slow improvement and some regression Total Male Female EU 15 78.7 76.9 82.7 Bulgaria 72.6 70.0 76.2 Czech Republic 76.1 72.9 79.3 Estonia 72.8 67.3 78.2 Hungary 73.0 68.7 77.2 Latvia 70.9 65.4 76.4 Lithuania 71.1 66.3 77.1 Malta 79.4 77.2 81.4 Poland 75.3 70.8 79.7 Romania 72.6 69.2 76.2 Slovakia 74.3 70.3 78.2 Slovenia 77.5 74.5 82.0 Comparative health outcomes will become an important measure of health equity • As judged by reductions in mortality rates UK health had improved on average over the past 50 years, but in recent decades inequalities in health had either remained static or widened. "Independent inquiry into inequalities in health 2004" • National reports highlighting how inequality and disadvantage damages health have been published by other Member States including Sweden, Holland, Norway and Spain. • INSERM (Institut national de la santé et de la recherche médicale) says that mortality in France among blue-collar workers aged 4559 years is 71% higher than among their white-collar peers. • To reduce the unnecessary ill-health and shortened life span of disadvantaged people in Europe, key policy areas must be addressed. Working alone, the health sector can do little to reduce inequalities in illness, injury and life expectancy. "Independent inquiry into inequalities in health" Will ‘health’ receive a reasonable share of the next SF cycle - 2014/20 - and how ? • Health received specific earmarked HEALTH allocations in 2000/6 & 2007/13 (Euro 15 bn) – so far there is no earmarking for 2014/20 • Cohesion Policy guidelines - HEALTH is not a thematic priority but is featured in specific contributing terms • Europe 2020 - HEALTH is not a thematic or flagship target but is also featured in a number of ways The challenge • Overcome the widely held view that health is a cost to the economy • Understand how to translate guidelines and policy to reinforce health as: • • • • • Delivering measurable benefit to the economy Delivering measurable improvement in health equity Delivering measurable improvement in quality Addressing other key strategic issues e.g. cross border care, workforce. Implementing reform Cohesion Policy guidelines – there are important references - (Attachment 5, COM(2011) 615 final, 6/10/2011) Promoting social inclusion, (Annex IV, §10.2, p149), discussion of the health sector becomes much more explicit. • "The existence of a national or regional strategy for health ensuring access to quality health services and economic sustainability: • contains coordinated measures to improve access to quality health services; • contains measures to stimulate efficiency in the health sector, including deployment of effective innovative: technologies, service delivery models and infrastructure; • contains a monitoring and review system.” There is more • “A Member State or region has adopted a framework outlining available budgetary resources for health care“ • Annex IV notes under Enhancing access to ICT that there should be measurable targets for outcome of intervention in eHealth • Under Promoting employment, active and healthy ageing is mentioned as a priority - as contributing to sustaining and improving the scale and scope of the employment pool We might reasonably conclude that health has sufficient reference points to ensure access to SF. But health will be in direct and vigorous competition from more obvious economy related priorities which may be flagship initiatives “Europe 2020” Shaping future EU (SF) policy • SMART, SUSTAINABLE AND INCLUSIVE GROWTH Where do we want Europe to be in 2020? • “Three priorities should be the heart of Europe 2020: • Smart growth – developing an economy based on knowledge and innovation. • Sustainable growth – promoting a more resource efficient, greener and more competitive economy. • Inclusive growth – fostering a high-employment economy delivering economic, social and territorial cohesion.” Europe 2020 7 Flagship initiatives • Innovation Union • Youth on the move • A digital agenda for Europe • Resource efficient Europe • An industrial policy for the globalisation era • An agenda for new skills and jobs • European platform against poverty Health features as contributing to achievement of flagship targets Europe 2020 Health does have several explicit references. • Smart Growth • the Innovation Union - the need to focus on challenges including healthy ageing. • Digital agenda for Europe - promoting online health. • Inclusive Growth • the European platform against poverty - commits "To undertake an assessment of the adequacy and sustainability of social protection and pension systems, and identify ways to ensure better access to health care systems" with parallel MS action. • Sustainable growth • "Fiscal consolidation and long-term financial sustainability will need to go hand in hand with important structural reforms, in particular of pension, health care, social protection and education systems” • Resource Efficient Europe - the carbon agenda dimensions of capital and service strategy The basis of a strategic framework for Health SF • Understanding the context • The economic crisis – impact on growth and employment – achieving economic sustainability • Needs assessment and concept development • identify ways to ensure better access to health care systems • Strategic priorities - and policies • Social - Equality of Access and Quality • Economic - long-term financial sustainability will need to go hand in hand with important structural reforms • Tactical measures • Enhancing access to ICT - promoting online health • Healthy ageing programmes • Stimulating efficiency – effective innovation, technologies, service delivery models, infrastructure • Evaluation and accountability - an effective monitoring and review system The past two programmes – how has SF been applied ? • The structure of the SF process has predisposed projects towards single focus spending: • Separate ERDF and ESF funding streams • Complexity of developing cross-sectional integrated projects • Projects tend to be focused on specific ‘headlined’ elements of policy guidelines to ‘guarantee’ success e.g. • eHealth – on-line health projects • Infrastructure – facility modernisation • Time constraints (and continuity) for large scale reform • The programme projects have in the main delivered specific (but usually narrow focus) benefit • Projects rarely, if ever, achieve whole systems integrated strategic value Evidence demonstrates problems (SG2) • The level and limitations of strategic thinking • strategy is loosely coupled with the problem and mainly focuses on the elaboration of attractive project ideas without an evidence base • lack of strategic integrative coordination e.g. • Imbalance between the magnitude of infrastructure investments and the development of related human resources • The problem of dual power or division of power / accountability • (e.g. between the Ministry of Health as the professional arm of policy making and the Managing Authority) • Structural Fund bureaucracy • Limited expert capacities • Time issues (long project preparations, postponing announcement of projects, delays in payments etc.) and cost of preparation of projects • Political instability What has changed Looking ahead to 2014 /20 The economic crisis will dominate future health policy Consensus between almost all authoritative reviews • “The current economic crisis will bring about a period of budgetary constraints associated with the need to reduce large government deficits and put public finances back on the right track” • “Depending on its severity, we will see public authorities contracting their spending on health services as a reaction to the observed economic crisis” EPC-Commission Report on Health Systems GDP and health spending Healthcare costs are rising faster than levels of funding available through taxation and insurance • Ageing populations and the related rise in chronic disease • Costly technological advances • Patient demand driven by better information and by less healthy lifestyles • Legacy priorities and financing structures that are not suited to today’s needs Accumulated debt Spending Available resources Europe has been (and is still) repeating patterns of investment in healthcare from the 80’s and 90’s The hospital-centric model has often been stimulated and sustained through high levels of debt made possible by high levels of GDP growth Increasing Government debt PPP – long-term commitments e.g. UK NHS private finance initiative - £90 billion over 25 years Hospital Deficits starting to spiral out of control There is an overwhelming consensus that this model is unsustainable and knowledge, capability and capacity has moved on We are paying a high price for a hospital-centred model often without good evidence that it offers best value 95% 5% Total patient care numbers 50% / 70% Share of total health spending In an average district hospital: • 70% of patients are over 65 • 40% to 50% of patients could be better cared for outside hospital • May have contributed up to 50% of improvement in amenable mortality •Within the average population chronic disease costs are 5 times ‘other’ hospital primary care WHO view of changing focus in healthcare * * * * * * * typical SF projects – but not integrated and insufficient critical mass for reform Influencing change in EU and SF policy • The Hungarian Presidency Programme Jan / June 2011 • The Informal meeting of Health Ministers, Godollo, April 2011 • EU Council Conclusions, June 2011 • The EU Council High Level Reflection Process • The work of Sub-group 2 on SF • Exemplar SF ‘good practice’ projects Hungarian Presidency “Investing in Health Systems of the future” “Patient and Professional Pathways” Themes • An EU wide ‘common reflection’ process on health systems, structures and priorities • Monitoring and measuring the effectiveness of EU Structural Funds – and working together to introduce more innovative application • Shift healthcare from the dominance of cost containment to contribution to and investment in economic growth • Coping better with healthcare manpower mobility and volatility Pathways for change – (Godollo 2011) Changing focus What works and what Doesn’t in the ‘new’ healthcare landscape ? Whole systems disease management • Coherence • Population sensitivity • The patient as co-producer • More effective commissioning • Resource reallocation • Workforce realignment Institutional / sector delivery Care pathways Societal and economic benefit EU Council Conclusions • The Health Sector should play a role in implementation of Europe 2020 Strategy – investments in health should be seen as a contributor to economic growth • In order to create modern, responsive, efficient, effective and financially sustainable health systems SF resources can be used in complementing the financing of health sector development, in particular: • Achieving social cohesion • Developing new generation approaches to healthcare will require appropriate funding to foster transformation and rebalance investment towards new models and facilities • Sharing and analysing experiences, best practices to build up success factors for more effective use of SF • Decision to undertake a High Level Reflection Process The High Level Reflection Process of the EU Council – 4 sub-groups 1.“Enhancing the adequate representation of health in the framework of the Europe 2020 Strategy and in the process of the European Semester” – led by DG Sanco 2.“Defining success factors for the effective use of Structural Funds for health investments” - led by Hungary 3.“Finding adequate responses to society's growing and changing health needs particularly due to ageing population, and designing effective and efficient investments in the health sector” – led by Poland 4.“Measuring and monitoring the effectiveness of health investments” – led by Sweden Deliverables identified by the Working Party on Public Health at Senior Level (10th October 2011) “Very early progress should be made on key deliverables” • “common sense “success factors”, which should be present in advance as to ensure effective investments from the Structural Funds in the health sector • a tool box for the use of Member States on the effective use of Structural Funds for direct health investments • Sharing and analysing experiences and best practices • Discuss opportunities to implement PPPs or other financial engineering instruments in the health sector Sub-group 2 SF Examples of Euregio case studies that will be referenced as guides to good practice and shaping process and policy: • • • • Sicily Brandenburg, Germany Kymenlaakso, Finland Norbotten, Sweden Sicily Strategic focus: Improving accessibility and quality 1. Needs assessment 2. Technology benchmarking 3. Technology investment Brandenburg, Germany Improving accessibility to healthcare support for CVD •Understanding the problem – and need •eHealth technology as a facilitating process •The patient as co-producer of care - empowerment •Investing in healthy and active ageing •Using social networking principles to disseminate healthy living messages •Creating the basis for healthcare reform – reducing the reliance on a hospital-centred system Brandenburg - Chronic illness (cardiovascular disease) Changing the location and focus of investment – patient-centred care Patient centred interventional support Poverty Diet Transformational investment Housing Smoking Cardiovascular disease Treatment Current bias towards curative investment Death Kymenlaakso, Finland •Affordable and sustainable structural reform of the health system •Improving accessibility through integration of services •Healthy and active ageing principles •eHealth as a facilitating technology Demography as a basis for economic risk assessment The importance of healthy ageing in deciding strategic priorities in health Almost universal changes in EU retirement ages reinforces this priority Epidemiological trend analysis Risk assessment – future cost profiling Developing a sustainable reform model The key to unlocking the problem • A community focused and innovative elderly care, chronic illness strategy • Innovative hospital reorganisation Reform – service integration Moving on from the hospital culture, from illness to wellness Reforming hospital organisations Kyemnlaakso Karolinska Institute A shift away from demarcated / territorial systems and structures to multi-disciplinary ‘pole-based’ models - Inflamation /Regenerative - Cancer - Neuro / Cardio-vascular - Children Changing cultures and strategies for the elderly Innovative application of SF Getting the reform planning right • Total sum spent was 2.24 M€. • Kymenlaakso Hospital District 700 000 € for new hospital and local health plan plan • Kouvola City 350 000 € for re-planning and modernisation of local health service • Järvenpää City 200 000 € for conceptual planning of new Health Center • Espoo City for improving home care by increased teleservice • Helsinki University of Technology, (now Aalto University) 800 000 € for management and related research A whole systems integrated eHealth model as a transforming service for healthcare delivery Conclusions – the application of SF • Health investments should make a measurable contribution to: • Social inclusion and equity – accessibility and quality • Economic growth • The economic crisis has reinforced the critical need for affordable and sustainable health reform • This will require a new (integrated) strategic approach to planning and investment • The ‘common sense’ success factors will be designed to reinforce and drive these strategic objectives • SF may be one of the few facilitating funds available for many MS, access will be dependent on demonstrating how success factors will be achieved – in measurable terms • There will be a new focus on accountability Thank you for your attention [email protected]