Sustainable Health Systems for Inclusive Growth in Europe
Austerity cuts have put Europe’s health systems under severe pressure, increasing health inequalities and threatening sustainability in the future. Now, European governments and the European Union (EU) need to take immediate action to prevent further damage.
The inspiration for the Vilnius Declaration, agreed at the final health event of the Lithuanian Presidency of the Council of the EU 2013, is to ensure European health systems are people-centred, sustainable and inclusive – and that they deliver good health for all. To achieve this it is necessary to:
- Increase investment in health promotion and disease prevention;
- Ensure universal access to high-quality; people-centred health services;
- Ensure that health system reforms – including workforce planning – are evidence-based and focus on cost-effectiveness, sustainability and good governance.
The Vilnius Declaration is “a crowning document” of all the work done by the Lithuanian Presidency to put the focus on the issue of ensuring health systems are sustainable for the future, said Tonio Borg, EU Commissioner for Health, responding as the Declaration was released.
Commissioner Borg told delegates, “Health is a value in itself, even if it didn’t have positive economic consequences.” Are health systems sustainable? Commissioner Borg believes the answer is yes. “The Commission is committed to doing all it can to foster higher quality healthcare, available to all, on a long-term, sustainable basis,” Commissioner Borg said.
The Vilnius Declaration is the distillation from a number of events and discussions on how to make health systems resilient for the future that have taken place during the Lithuanian Presidency. The document was finalised during the conference in Vilnius, which was organized by the Lithuanian Health Forum in partnership with the Ministry of Foreign Affairs, Ministry of Health, Ministry of Education and Science, the European Public Health Alliance, the European Patients’ Forum, and the European Federation of Pharmaceutical Industries and Associations.
Crucially, health sustainability must be predicated on the principles of solidarity and universal access. This view was echoed by Algirdas Butkevičius, Prime Minister of the Republic of Lithuania, who said healthcare represents a “prudent investment” in the economy if made in the context of “a policy based on solidarity, universal access and the reduction of health disparities”.
The conference provided the opportunity to hear leading experts describe and debate the foundations and evidence on which the Vilnius Declaration was based and to outline concrete measures that are needed to make health systems sustainable. It was emphasised that change and reform has to happen on the basis of a stated commitments to reduce social inequalities in health, to improve public health and disease prevention, and by putting patients at the centre of healthcare.
Attaining sustainability also entails taking a different view of healthcare, whereby rather than it being seen as an overhead it is considered an investment in health, job creation, industrial development and economic growth.
“Health is created, maintained and supported when everyone contributes,” said Professor Vilius Grabauskas, President of the Lithuanian Health Forum. “Especially in the context of austerity, it is important countries learn from one another,” he included.
Health spending is an investment
Convincing ministers of finance that health spending is an investment, and using innovation to increase efficiency is not easy. “This is the fundamental conundrum of the conference,” said Dr Josep Figueras, Director of the European Observatory on Health Systems and Policies.
Martin Seychell, Deputy Director General of the Directorate General for Health and Consumers of the European Commission, said that while health is a national competence, it is important not to overlook the many areas where it makes sense for Member States to work together. The challenges of the ageing population, chronic disease and the pressure from innovation are the same in all Member States. “Public budgets will be constrained for years to come,” said Mr Seychell. “The key challenge is to prevent the economic crisis becoming a health crisis.”
An opportunity to strengthen health systems
Zsuzsanna Jakab, Regional Director of the World Health Organization (WHO) Regional Office for Europe, echoed this. The financial crisis has presented health systems in Europe with a challenge “you could even say a threat,” said Ms Jakab. But she added, “It is also an opportunity to strengthen health systems.”
“One impact of budget cuts has been to increase health inequalities, both between and within countries, and as the Vilnius Declaration states, action is needed to reduce the overall disease burden, address the social determinants of health and strengthen health systems to respond to this,” Ms Jakab said.
Need for evidence-based policy and improved governance
“Europe’s governments need to work with patients, payers and providers to make sure healthcare is sustainable,” said Monika Kosinska, Secretary General of the European Public Health Alliance. Critically, governments need to increase investment in health promotion and disease prevention, through measures such as taxes on sugar, reinforcing smoking bans, strengthening vaccination programmes, improving health literacy and looking to the drivers of good health that lie outside the health system.
“The time for talking is over: we know what to do,” said Ms Kosinska, summarising the main points of the Vilnius Declaration.
Education, training, science and innovation are policy areas that lie at the core of sustainability in healthcare said Professor Dainius Pavalkis, Minister of Education and Science of the Republic of Lithuania. To take one example, changing the skills mix is central to reforms to improve efficiency that involve tasks to be shifted from doctors to nurses.
The skills mix refers not only to medically-trained staff, but also to ICT and a range of other technical specialties. “On a ministerial level, it is important to measure the outcome of education and demonstrate the impact,” Professor Pavalkis said.
There has always been economic governance at an EU level, but the messages were not targeting specific member states. “It was saying, for example, strengthen healthcare to prepare for ageing”, said Rita Baeten, Senior Researcher for the European Social Observatory. “Now, there is detailed guidance for reform.”
Value added innovation
In the view of Christopher Viehbacher, President of the European Federation of Pharmaceutical Industries and Associations, CEO, Sanofi, there are three routes to making health systems sustainable – reducing the resources burden; reducing demand; and increasing economic growth. Innovation lies at the heart of each approach.
Innovation is central in underpinning a shift to community-based care, helping patients to self-manage chronic conditions, and so reduce the disease burden. Innovation also lies at the heart of reducing demand through prevention of the chronic diseases that currently take up 75 per cent of healthcare budgets. “Europe is not low-cost; we need the skills and industries that value-add,” said Mr Viehbacher.
The financial crisis may be unprecedented in our lifetime, but health systems have weathered severe disruption in the past, most notably following the fall of the Iron Curtain. This experience provides the tools for dealing with the current crisis, said Professor Helmut Brand, President of the International Forum Gastein. “We know how to increase efficiency, we know how to select the right innovation, and understand the need to combine social and technological innovation,” he said.
“Now, there is a communication task to promote public understanding that healthcare is not a cost and a need for clear leadership to highlight that health is a value,” Professor Brand said.
Social determinants of health
At the same time it is important to acknowledge that sustainable healthcare cannot be delivered solely through efficiency improvements, said Sian Jones, Policy Coordinator at the European Anti-Poverty Network. “There is a need to tackle the social determinants of health.”
The Europe 2020 policy has the stated aim of taking 20 million people out of poverty. However, the austerity-era cuts have forced 8 million people into poverty. “The result is a health loss and an increase in costs,” Ms Jones noted.
Sustainable economic growth through better health
The financial crisis and subsequent cuts to public spending have allowed the rhetoric that healthcare is an expensive strain on resources to obscure the view of healthcare as investment that delivers a double dividend, in terms of a healthy, active population, and as a source of economic growth.
Professor Klaus-Dirk Henke of the School of Economics and Management at the Technical University of Berlin, is cooperating with the Federal Statistical Office in Germany to map the economic footprint of healthcare and how spending on health promotes growth and productivity. His analyses show healthcare is more productive than Germany’s world-leading automobile sector, generating 11 per cent of gross national product, 7 per cent of exports and 15 per cent of total employment. ”The same analyses could be done for the EU as a whole,” Professor Henke said.
Why health is wealth
While the observation that health is wealth is not novel, there needs to be an empirical basis to demonstrate the precise nature of the relationship between the two, said Professor Bengt Jönsson, of Stockholm School of Economics. “It goes in both directions; health produces wealth and vice versa.”
The sustainability of health systems depends on transferring resources into outcomes that promote health, but it also requires other policies to be in line. For example, the health status of 54-74-year olds is rising, but unless the retirement age also increases, the benefits of this rise in human capital do not translate through to economic growth.
Sustaining the EU welfare model
The structures of Europe’s health and pensions systems were put in place before the destabilising influence of changing demographics came into play. Trying to make these venerable structures fit in the context of the ageing population and sustain the European welfare model is a big problem, said Professor Fabio Pammolli of the IMT Institute for Advanced Studies, in Lucca.
A debate must be opened on the imbalance between the number of young people entering the labour market and the higher number who are retiring. While current health policy is focused on dealing with financial policy, it is necessary to focus in the longer term. “We can’t approach reforms in healthcare as if they are removed from labour productivity,” Professor Pammolli said.
There is an economic dividend from healthcare expenditure and this should be factored into economic policy.
Taking stock of health and healthcare inequalities in Europe
National income is part of the reason for health disparities between countries. However, some countries have similar national incomes but different life expectancies, indicating healthcare expenditure does not provide a full explanation, said Professor Johan Mackenbach, Chair of the Department of Public Health at the University Medical Centre in Rotterdam.
Professor Mackenbach has recently completed a study of the impact of policy interventions on population health in Europe, in which he has reviewed eleven areas of health policy including tobacco and alcohol controls, child health, food and nutrition, infectious diseases control and road safety, to find out which are the most effective in protecting health, and which countries have implemented each policy most successfully.
This analysis indicated that countries across Europe could reduce years of life lost by 30–50 per cent if they adopted and implemented each of the eleven health policies to the same standard as the country with the best practice. “This would be a huge gain,” Professor Mackenbach said.
Health and healthcare inequalities within countries
While life expectancy by country is frequently discussed, there is less examination of the variation within countries by social and economic class. “Some of the best data highlighting how large these variations can be come from the UK, showing that the top two social classes in England and Wales have a higher life expectancy than in Sweden, which is the top EU country in terms of average life expectancy,” said Professor Reinhard Busse, Head of the Department of Healthcare Management at the Technical University of Berlin.
“You would hope medical care is where the needs are, not where the money is,” Professor Busse said. However, this is not the case in Germany, for example, where – despite capacity planning measures – richer areas have more general practitioners than poor ones.
When there are equal opportunities for access, for example, being invited for free cancer screening, socioeconomic deprivation is a predictor of participation, with the lowest group being two times more likely to decline. “The introduction of an effective screening programme may result in increasing inequalities in cancer outcomes,” Busse said.
Overall, income is the best proxy for inequalities in healthcare within countries. In terms of tackling inequalities this means focussing health policies on the disadvantaged.
Improving health system productivity
“It is a daunting and difficult task, but measuring the productivity of health systems is critical to dispelling perceptions that money is badly spent and to improving efficiency,” said Professor Peter C. Smith, Co-director of the Centre for Health Policy at the Institute for Global Health Innovation, Imperial College London.
Professor Smith focussed on the need for performance information to secure productivity improvements, noting that in striving to improve productivity, it is important to distinguish between efficiency and expenditure control. The prime role of performance information in increasing efficiency, is in improving accountability. The government is in the centre as the steward, but there are many other relationships, for example between clinician, patient and provider.
“Each of these relationships needs good information to function well,” Professor Smith said. Performance information enables the various actors to make better decisions.
How innovation can transform health systems
“Research can make an important contribution to improving the productivity of health systems.” said Dr Barbara Kerstiëns, Head of Sector Public Health, Directorate General for Research and Innovation of the European Commission. There is a need for a transformation that focusses on health promotion and disease prevention; cost-effective technologies and treatments; and patient-centred systems that provide safe, high-quality healthcare.
“Many of the ingredients to achieve this are in place, and there will be opportunities within the next EU R&D programme, Horizon 2020, to carry out the research needed to push through these transformations, promoting health and active ageing, improving health outcomes, reducing inequalities and supporting a competitive health sector,” Dr Kerstiëns said.
Process improvements for better capacity of health systems
Health systems currently are wasting “a huge amount of resources,” delivering at around 70 per cent of their true capacity, according to Gary Howe, a Global Head of Health at the Ernst & Young Health Care Group.
Mr Howe stressed the importance of information in identifying waste. The service level of the outpatients department of an Oslo hospital was doubled by good governance and performance reviews; in a radiology department in Canada throughput was increased at no extra cost by altering the way in which patients are processed when they arrive for an X-ray.
There is widespread potential for such process improvements that require very little investment and do not need new policies or innovation to deliver. “Organisations can do this for themselves,” Mr Howe said.
Sustainable health systems for the future
Health has been in the spotlight throughout the Lithuanian Presidency of the Council of the European Union 2013, as Vytenis Povilas Andriukaitis, Minister of Health of the Republic of Lithuania described. While there has been progress, more work is needed to promote the uptake of modern health technologies in an appropriate and cost-effective way; develop integrated healthcare models; promote patient involvement; address the issue of chronic disease and to institute health-in-all-policies at the EU level.
For Dr Hans Kluge, Director, Division of Health Systems and Public Health, WHO Regional Office for Europe, the messages from the main international health conferences of the past year are converging. The result is, “the powerful Vilnius Declaration”. The signs are that some countries are getting out of crisis mode, and it will be possible to make progress in the next five years. “It’s about making it happen: this is starting already in some countries,” Kluge said. “It is possible to run the system and simultaneously go for reforms.”
Anders Olauson, President of the European Patients’ Forum, said he would leave Vilnius with a sense that, “everything is in place, including willingness. We are ready to support as patients’ groups. The Declaration is a strong document,” he said.