Working Party on Public Health at Senior Level Brussels, 17 February 2015
EU Council Working Party on Public Health at Senior
Level Brussels, 17 February 2015
Hans Kluge, Sarah Thomson Division of Health Systems and Public
Health
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Economic crisis, health systems, and health in Europe
What did we expect?
What did we find?
What lessons for policy?
Joint WHO-Observatory study on the crisis
High-level meetings held in Oslo in
2009 and 2013
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Evidence from earlier economic shocks
• They affect health but don’t affect everyone equally: health worsens in people who lose jobs
• Negative effects can be mitigated
• Countercyclical public social spending is critical: greater need for services, greater reliance on publicly financed services
• Protecting access to health care is critical, especially for those at risk of job loss, poverty
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Decline in public spending on health: often small, sometimes sustained
Year
s
0
1
2
3
4
Aus
tria
Bel
gium
Finl
and
Fran
ceG
erm
any
Net
herla
nds
Pol
and
Slo
vaki
aS
wed
enU
nite
d Ki
ngdo
mB
ulga
riaC
zech
Rep
ublic
Den
mar
kM
alta
Cyp
rus
Est
onia
Hun
gary
Italy
Latv
iaLi
thua
nia
Luxe
mbo
urg
Por
tuga
lS
love
nia
Spa
inC
roat
iaG
reec
eR
oman
iaIre
land
Source: Thomson et al 2014 using datafrom the WHO Global Health Expenditure Database
Years of decline in public spending on health per person, 2007-2012: EU28
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Per
cent
age
poin
ts
Source: Thomson et al 2014 using data from the WHO Global Health Expenditure Database
Annual change in public spending on health per person, 2007-2012: countries in which 2012 < 2007
Decline in public spending on health: often small, sometimes severe
-20%
-15%
-10%
-5%
0%
5%
10%
15%
20%
Ireland Greece Latvia Croatia Portugal
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Evidence of pro-cyclical public spending on health
-30
-20
-10
0
10
20
30
40
50
Arm
enia
Latv
iaIre
land
Aze
rbai
jan
Mon
tene
gro
Kyr
gyzs
tan
Turk
men
ista
nLu
xem
bour
gIc
elan
dC
roat
iaP
ortu
gal
Gre
ece
Ukr
aine
Slo
veni
aS
pain
fYR
Mac
edon
iaD
enm
ark
Slo
vaki
aN
orw
ayLi
thua
nia
Finl
and
Mal
taR
ussi
an F
eder
atio
nFr
ance
San
Mar
ino
And
orra
Rom
ania
Hun
gary
Ser
bia
Net
herla
nds
Uni
ted
Kin
gdom Ita
lyB
elgi
umG
erm
any
Isra
elP
olan
dTu
rkey
Aus
tria
Sw
eden
Est
onia
Cze
ch R
epub
licC
ypru
sA
lban
iaB
ulga
riaS
witz
erla
ndR
epub
lic o
f Mol
dova
Uzb
ekis
tan
Bos
nia
Her
zego
vina
Mon
aco
Geo
rgia
Kaz
akhs
tan
Bel
arus
Tajik
ista
n
Source: Thomson et al 2014 using data from the WHO Global Health Expenditure Database
%
Pro-cyclical public spending on health (including in 13
EU countries)
Change in the health share (%) of total government spending 2007-2011
Counterycyclical public spending on health
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Annual change in public spending on different health services, 2007-2011
Source: Thomson et al 2014 using OECD-WHO-Eurostat data for EU and Iceland, Norway, Switzerland
Large cuts to prevention and public health
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Lesson 1: Policy makers have choices – even in austerity
Before cutting spending on health: • consider the trade-offs • balance short-term and long-term needs If cuts are chosen make sure they are: • selective • informed by value • don’t cost more in the long run Next time: no horizontal cuts across the board
Working Party on Public Health at Senior Level Brussels, 17 February 2015
02468
101214161820
Expandedpopulationentitlement
Added newbenefits
Reduceduser
charges (orstronger
protection)
HTA-basedreduction in
benefits
Restrictedpopulationentitlement
Ad hocreduction in
benefits
Increaseduser
charges
Direct response Partial response
Lesson 2: Secure financial protection and access to health care as a priority
Sou
rce:
Tho
mso
n et
al 2
014;
resu
lts a
cros
s 47
cou
ntrie
s in
Eur
ope
Num
ber o
f cou
ntrie
s
Protective responses
Non-protective responses
Changes to health coverage in response to the crisis
This time: protective action was often too little, too late Next time: prioritise protective action
Working Party on Public Health at Senior Level Brussels, 17 February 2015
There is evidence of higher unmet need due to cost in many countries, especially among the poorest 40%
Source: EU-SILC from Eurostat; the figures shows changes for the poorest 40% of the population
02468
10121416182022
Den
mar
kU
KS
love
nia
Cro
atia
Aus
tria
Lith
uani
aS
wed
enG
erm
any
Est
onia
Hun
gary
Bul
garia
Rom
ania
Net
herla
nds
Nor
way
Cze
ch R
epub
licS
pain
Mal
taLu
xem
bour
gS
lova
kia
Sw
itzer
land
Irela
ndB
elgi
umP
ortu
gal
Fran
ceIc
elan
dP
olan
dC
ypru
sIta
lyG
reec
eLa
tvia
2008 2013
Unmet need fell
Unmet need rose
%
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Source: Thomson et al 2014
Lesson 3: Cuts and savings are not always the same as efficiency gains
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Focusing on efficiency is important but has its limits
• Improving efficiency should be a permanent effort
• Complex reforms need to be underpinned by capacity, investment and realistic timeframes
• Efficiency gains will not be able to bridge a large or sustained gap between revenue and expenditure
Working Party on Public Health at Senior Level Brussels, 17 February 2015
- The estimated number of people without health insurance coverage 1,4 - 2,5 Million - Until 2014 coverage for vulnerable ensured through a “safety net” approach based on vouchers and poverty booklets (only about 10% of the entitled persons benefiting)
- Strategic shift towards UHC with the approval of the new PHC Law in February 2014, guaranteeing universal access to PHC services
- Two additional Ministerial Decisions in June 2014, guaranteeing access of uninsured (similar to those
insured) to hospital care and medicines
- Remaining challenges related to the implementation of the Law and Decisions, and to poor awareness of providers and beneficiaries about new entitlements
Moving towards UHC in Greece
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Lesson 4: Health financing policy is critical to building system resilience
Many countries were creative in mobilising public revenue during the crisis The crisis has shown the serious limitations of • entitlement based on employment or income • coverage gaps, high out-of-pocket payments It has highlighted the merits of • entitlement based on residence • automatic stabilisers to smooth revenue flows and link revenue to
population health needs
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Looking ahead . . .
• Mitigating the negative effects of a crisis requires strong governance and leadership
• In spite of awareness, promoting access and financial protection was not a priority in economic adjustment programmes
• Limited evidence of negative effects: data are not produced quickly enough and available tools are not used systematically to monitor
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Monitoring progress towards universal health coverage
Lack of financial protection: a source of hardship for individuals and inefficiency for society and economy Mainly caused by out-of-pocket payments: often for prescribed drugs WHO is now working in 15-20 European countries to measure out-of-pocket health spending that: • pushes people into poverty (and further into poverty) • is catastrophic (does not leave people with enough to spend on
other essentials)
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Resilience and moving towards universal health coverage in Ireland
WHO-Observatory analysis of health system options under financial pressure
WHO international advisory role in assessing health system resilience to crisis and pathways to universal health coverage
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Looking ahead . . .
• The health system response is critical to mitigating the negative effects of shocks
• But key levers lie beyond the health system: health and fiscal people need to speak to each other
• The crisis has created a valuable opportunity for dialogue
Working Party on Public Health at Senior Level Brussels, 17 February 2015
Presentation title (change in view slide master)
Date of presentation
Joint OECD and WHO Meetings on
Financial Sustainability of Health Systems
High Level Policy Dialogues
Ministers of Health, Finance and Parliament (Malta)
Working Party on Public Health at Senior Level Brussels, 17 February 2015
WHO-Observatory joint study: survey methodology
• Two waves of a questionnaire sent to health policy experts in 53 countries in 2011 and 2013
• In 2013, 92 experts in 47 countries responded
• Summary available at: http://www.euro.who.int/__data/assets/pdf_file/0008/257579/12-Summary-Economic-crisis,-health-systems-and-health-in-Europe.pdf?ua=1
• Full study available in spring 2015