Source OECD HEALTH DATA 2010, October
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1 Financial Crisis in the EU countries Health impact Health Systems Response A framework for decision making Lisbon, 11 th January 2012 Josep Figueras
2 Total Health Expenditure % GDP ( ) 11 % GDP Austria Belgium Czech Republic Denmark Finland France Germany Greece Hungary Ireland Italy Luxembourg Netherlands Poland Portugal Slovak Republic Slovenia Spain Sweden United Kingdom Source OECD HEALTH DATA 2010, October
3 Economic recession Those of us who have looked to the self-interest of lending institutions to protect shareholder's equity -- myself especially -- are in a state of shocked disbelief Threat to health and health systems? A. Greenspan E.g. Indiscriminate cross cutting E.g. Further ration health budgets or Opportunity to reform? E.g. Demonstrate the value of health on wealth E.g. Reform health services E.g. Prioritize interventions
4 Outline Impact on Health Social protection response Health services response Protect health budget Health for economic productivity Invest on health services as economic sector Reduce (or raise) statutory resources Ration HS (coverage & private funding) Prioritise / reallocate resources Improve health systems performance Concluding remarks
5 Health impact? Falling road deaths and increasing suicide
6 Contradictory evidence Health impact? In short... Effects on alcohol, tobacco, diet? Negative health impact of recovery? Increase in psychiatric disorders and suicide Decrease in traffic accidents Strengthen Social Protection Decrease in access in some countries / services Labour protection and unemployment policies Increase Family health & housing service benefits utilisation in others Anti-poverty measures Shifting from private to public sector Foster Social Support Networks
7 Social Spending and Mortality Stuckler, Basu & McKee, BMJ 2010
8 Health System Response In short... In majority of countries many new policies introduced e.g. Czech Republic, Greece, Ireland, Portugal. In few countries few policy changes e.g. Denmark, Finland, Germany, Norway, Poland. Pre 2008 reforms (continuation, acceleration, reversal) Health budget Cuts in most e.g. Bulgaria, Czech Republic, Estonia, Ireland, Italy, Greece, Latvia, Romania, Portugal, Spain. Maintain e.g. ring fenced in the UK and Belgium Increase in France and Denmark Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
9 1. Protect the health budget Health Impact on Economic Productivity Health Systems Demonstrate performance!!! Societal Well-being Direct contribution to the economy Health Wealth Effects of ill health on economic growth Figueras J, McKee M 2011
10 1. Protect the health budget Invest on HS as component of economy Component of stimulus packages: Hospitals (France, Denmark) Health employment Retraining (Germany) But in most countries cuts in capital investment Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
11 2. Reduce (or raise) statutory resources How much to spend vs other sectors? Decrease tax base in most countries Increase tax base only Italy and Czech Republic. Increased SHI contribution rates: Bulgaria, Czech Republic, Greece, Portugal, Romania and Slovenia Increase (tax based) unemployment contributions to SHI e.g. Bulgaria, Czech Republic, Estonia, Hungary, Romania Increase sin taxes: alcohol, tobacco, fat. E.g. Bulgaria, Czech Republic, Denmark, Greece, Hungary, Israel & Estonia Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
12 3. Rationing Health Services Coverage dimensions R. Busse 12
13 3. Rationing Health Services Reduce coverage Population (breadth): no changes in most Benefit package (scope): no changes, only small in Ireland, Netherlands & Portugal Services: e.g. Waiting times in many countries Increase private funding Private voluntary health insurance Cost-sharing / out of pocket: E.g. Czech Republic, Denmark, Estonia, Finland, France, Greece, Ireland, Latvia, Netherlands, Portugal and Romania. Reduced cost-sharing: e.g. Belgium Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
14 Public-private mix in financing in the EU (Thomson, S. and E. Mossialos (2009). Private health insurance in the European Union. Percent distribution of health system funding sources, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cyprus Bulgaria Latvia Greece Poland Lithuania Portugal Slovakia Hungary Spain Romania Belgium Slovenia Finland Austria Germany Italy Malta Estonia France Ireland Netherlands Sweden Denmark United Kingdom Czech Republic Luxembourg Public VHI OOP Other
15 The well-known 20/80 distribution actually the 5/50 or 10/70 problem 100% 90% 80% 70% 60% 50% How can we predict who these 5 or 10% are? 53,2 40% 15,6 30% 20% 50 8,8 5,6 10% 0% % of population % of expenditure 6,9 4 2,5 3,4
16 Where the cost of seeking care is lower, the reduction of utilization is also lower Reductions in routine care today might lead to undetected illness tomorrow and reduced individual health and wellbeing in the more distant future. Source: Lusardi et al. The economic crisis and medical care usage Harvard Business School
17 4. Prioritise / reallocate resources Target services to vulnerable populations and with highest health need: e.g. mental health services Cost effective interventions Primary Health Care Public Health / Rebalancing prevention and cure Health in All Policies e.g Increasing long term unemployment coverage e.g. Measures to combat poverty Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
18 5. Improve performance Reforms in purchasing & payment systems Purchasing leverage Introduce case mix / payment for performance Austria, Hungary, Bulgaria, Czech Republic, England Reduce/freeze prices paid to providers, reduction of salaries of health professionals e.g. France, Greece, Spain Ireland, Lithuania, Romania, England, Portugal, Slovenia Rationalising hospital/specialist services e.g. Hospital mergers in several countries Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
19 5. Improve performance Improve pharmaceutical / technology policies Most EU27 strengthened policies to reduce the prices of medical goods or improve the rational use of drugs Austria, Belgium, Czech Republic, France, Estonia, Greece, Ireland, Hungary, Latvia, Lithuania, Malta, Poland, Portugal, Romania, Slovakia, Slovenia and Spain Wide variety of measures generic substitution Improve quality of prescribing claw-back mechanisms negotiations on prices Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
20 5. Improve performance Eliminate ineffective / inappropriate services & cut the volume of least cost-effective services Strengthened HTA but limited use in cuts European Network for HTA Improving evidence/base/medicine Enhancing integrated care Skill mix optimisation Market like mechanisms / New public management e.g Hospital Self Governance
21 In conclusion... Fiscal sustainability: constraint, not policy objective Cost containment efficiency (Extra) spending should demonstrate value Be transparent & explicit about trade offs Don t forget the other sectors (social)! Learn to communicate the case for Health & Wealth
22 In conclusion... Coverage (two dimensions) largely unaffected Benefits package and population Increase coverage targeted at low-income groups Increased user charges If substantial: likely to decrease equity and efficiency Few public health policies: missed opportunity
23 In conclusion... Increases in performance: reducing costs through efficiency Hospital reconfiguration Improved purchasing Drugs: rational use and pricing Evidence base medicine Savings may not be inmediate: hospital restructuring The short-term balancing acts are not sustainable on the long run Delaying investments and maintenance Lowering salaries carries the risk of losing qualified staff
24
Source OECD HEALTH DATA 2010, October
Impacte de la crisi econòmica sobre la salut i els Sistemes Sanitaris a Europa Terrassa, 15 th November 2011 Josep Figueras www.healthobservatory.eu Total Health Expenditure % GDP (1975-2010) 11 % GDP
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