Health systems and economic crisis in Europe

Sarah ThomsonSarah ThomsonEuropean Observatory and LSE

Oslo, 17 April 2013

Outline

� About the study

� Implications for health system performance:system performance:1. Financing2. Access3. Efficiency

� What have we learnt?

Case study authors: Carlos Artundo, Patricia Barbosa, Sarah Barry, Enrique Bernal, Sara Burke, Luis Castelo Branco, Jonathan Cylus, Charalambos Economou, Tamás Evetovits, Sandra García Armesto, Triin Habicht, Cristina Hernández-Quevedo, Matthew Jowett, Gintaras Kacevičius, Daphne Kaitelidou, Marina Karanikolos, Alexander Kentikelenis, Anna Maresso, Uldis Mitenbergs, Anne Nolan, Luis A. Oteo, José Ramón Repullo, Isabel Ruiz Pérez, Anna Sagan, Constantino Sakellarides, Aris Sissouras, Maris Taube and Steve Thomas.

Chapter authors: Jonathan Cylus, Tamás Evetovits, Josep Figueras, Cristina Hernández-Quevedo, Melitta Jakab,

About the studySurvey country experts: Baktygul Akkazieva, Tit Albreht, Anders Anell, John Appleby, Carlos Artundo, Leonor Bacelar Nicolau, Patricia Barbosa, Sarah Barry, Ronald Batenburg, Enrique Bernal, Martina Bogut, Seán Boyle, Genc Burazeri, Sara Burke, Luis Castelo Branco, Tata Chanturidze, Karine Chevreul, Irina Cleemput, Elisavet Constantinou, Thomas Czypionka, Milka Dancevic Gojkovic, Antoniya Dimova, Csaba Dosza, Charalambos Economou, Shelley Farrar, Francesca Ferre, Adriana Galan, Sandra García Armesto, Aleksander Grakovich, Sigrun Gunnarsdottir, Triin Habicht, Klaus-Dirk Henke, Maria Hofmarcher, Alberto Holly, Fuad Ibrahimov, Gintaras Kacevičius, Ninel Kadyrova, Daphne Kaitelidou, Alexander Kentikelenis, Gafur Khodjamurodov,

� New survey of key informants in 47 countries: what did countries do in response to the crisis?Figueras, Cristina Hernández-Quevedo, Melitta Jakab, Matthew Jowett, Marina Karanikolos, Hans Kluge, Joe Kutzin,

Anna Maresso, Martin McKee, Philipa Mladovsky, Mark Pearson, Aaron Reeves, Erica Richardson, Anna Sagan, David Stuckler, Steve Thomas and Sarah Thomson.

Case study referees: Daiga Behmane, Beatriz González López-Valcárcel, Maris Jesse, Richard Layte, Lycurgus L. Liaropoulos, Liuba Murauskiene and Pedro Pita Barros.

Production and project support: Teresa Capel Tatjer, Juliet Chalk, Claire Coleman, Sarah Cook, Juan García Domínguez, Champa Heidbrink, Pat Hinsley, Jonathan North, Alexander Reshetov and Caroline White.

Kaitelidou, Alexander Kentikelenis, Gafur Khodjamurodov, Jan Klavus, Ratka Knezevic, Adam Kozierkiewicz, Philippe Lehmann, Valeriia Lekhan, Fredrik Lennartsson, Anne Karin Lindahl, Marcus Longley, Jon Magnussen, Pat McGregor, Uldis Mitenbergs, Salih Mollahaliloglu, Karol Morvay, Sandra Mounier-Jack, Natasha Muscat, Lyudmila Niazyan, Anne Nolan, Irina Novik, Victor Olsavszky, Ciaran O’Neill, Luis A. Oteo, Varduhi Petrosyan, Ceri Philips, Paul Poortvliet, Mina Popova, Elena Potapchik, Wilm Quentin, Vukasin Radulovic, José Ramón Repullo, Walter Ricciardi, Bruce Rosen, Enver Roshi, Tomas Roubal, Andreas Rudkjøbing, Isabel Ruiz Pérez, Constantino Sakellarides, Valeriu Sava, Amir Shmueli, Aris Sissouras, Christoph Sowada, David Steel, Jan Sturma, Tomáš Szalay, Szabolcs Szigeti, Mehtap Tatar, Maris Taube, Mariia Telishevska, Natasa Terzic, Mamas Theodorou, Steve Thomas, Fimka Tozija, Eva Turk, Carine Van de Voorde, Karsten Vrangbæk and Lauri Vuorenkoski.

response to the crisis?

� New case studies of 7 countries: why, how, with what effect?

Health system performance:

adequate, stable, fair financing – access –

efficiency

CRISIS:challenge?

opportunity?

efficiency

The crisis challenge: sustained decline in per capita public spending on health

2008 2009 2010 2011Andorra Andorra Albania AndorraFrance Bulgaria Armenia Armenia

Luxembourg Croatia Croatia Czech RepEstonia Czech Rep GermanyHungary Estonia GreeceIreland Finland IrelandLatvia Greece Netherlands

Lithuania Iceland PortugalRomania Ireland Slovakia

San Marino Latvia SpainFYRM Lithuania UK

MontenegroSlovenia

Spain

Sou

rce:

WH

O N

HA

Other constraints: uncertainty? time? info?capacity?opposition?

Health system performance:

Adequate, stable, fair financing – access –

efficiency

CRISIS:challenge?

opportunity?

efficiency

Policy responses matter!

Re-arrange the deckchairs?

How do policy makers Let the boat go

down?

How do policy makers respond?

Get people into lifeboats?

1 Adequate, stable, fair financing: opportunities

� to demonstrate the usefulness of automatic stabilisers

� to broaden the revenue base� to broaden the revenue base

� to remove tax subsidies benefiting richer people

1 Adequate, stable, fair financing: responses

Some countries acted quickly to:

� protect the health budget

� protect the labour market

� protect poorer people

1 Adequate, stable, fair financing: lessons

� means-testing adds to financial pressure

� automatic stabilisers play a role but policy responses are the critical factorresponses are the critical factor

� countries showed it is possible to protect the budget, labour, poor; broaden the revenue base; enforce collection; improve fairness…

Pro-cyclical safety net in Ireland

60%

70%

80%

90%

100%

Large increase in entitlement but no

0%

10%

20%

30%

40%

50%

60%

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Medical card GP visit card Category II

32%

43%

entitlement but no increase in budget

Source: Thomson et al 2012 and Irish case study

User charges?NO

2 Access to effective care: opportunities

Exclude rich? NO

NO

Streamline benefits package? YES

2 Access to effective care: responses

Populationentitlement

Benefitspackage

Usercharges

No change

ARM BUL CRO GER DNK EST FIN GEO

HUN ISL ISR ITA MNE NLD NOR POR ROM

SVK TUR UKR UK (22)

GER DNK FIN GEO ISR LVA NOR SVK

SWE SLO TUR UKR UK (13)

BIH GEO ISR MNE MKD MLT NOR

SRB SWI UKR (10)

AUT BIH BEL GRC ARM AUT BGR BELBetter coverage

AUT BIH BEL GRC FRA LTU MLD MKD SRB RUS SWE SWI

(12)

ARM AUT BGR BELHRVFRA ISL ITA

MLD MNE MLT SRB (12)

AUT BEL GER DNK HUN SVK (6)

Worse coverage

CYP CZE ESP IRL (4)

BIH SWI CYP CZE EST GRE ESP HUNIRL LTV NLD POR

ROM RUS (14)

ARM BGR HRV CYP CZE IRL ISL MLD ROM SWE

SVN (11)

Mixed effects

LVA SVN (2) MKD (1)

EST GRE ESP FIN FRA ITA LVA NLD POR RUS TUR UK

(12)

Unmet need is rising in the poorest quintile

20

25

30

% o

f pop

ulat

ioni

n th

e po

ores

t qui

ntile

Latvia

Romania

Italy

0

5

10

15

2007 2008 2009 2010 2011

% o

f pop

ulat

ioni

n th

e po

ores

t qui

ntile

Italy

Greece

Iceland

EU 27

Hungary

Belgium

Source: EU SILC

2 Access to effective care: lessons

� awareness of need to protect access

� safety nets not always safe

� efficiencies can improve access

� VHI does not fill gaps in coverage

� missed opportunity for value-based policy

� need for better monitoring

3 Efficiency: opportunities

� address waste

� cut wisely

� invest carefully

� structural reform

� convince purse-string holders of ability to enhance value in public spending

3 Efficiency : responses

� efficiency gains: mainly pharmaceutical policy

� cuts across the board: � cuts across the board: including public health

� very few attempts to cut wisely

3 Efficiency : lessons

� easier to increase user charges than to streamline the benefits package

� easier to cut salaries than service prices� easier to cut salaries than service prices

� pressure for short-term savings is greater than pressure for efficiency

� savings ≠ efficiency

What have we learnt?

� policy responses are critical: policy makers have choices

� countries have picked the low-hanging � countries have picked the low-hanging fruit: complex reforms are difficult at a time of crisis and uncertainty

� if you know where the waste is, go for that first

How the US health system wastes $750 billion a year

What does harm to

patients cost the NHS in England?

NHS litigation payments have

Source: Institute of Medicine 2012, Medical Journal of Australia 2012, NHSLA 2012, Department of Health 2012, 2011

payments have risen from 0.85%

to 1.3% of the NHS budget in the

last three years

What have we learnt?

� governance: analysis, priorities, targets, monitoring, transparency

� leadership: insight, clarity, courage, � leadership: insight, clarity, courage, communication

� both are critical to health system performance – at all times