Financial Crisis in the EU countries Health impact Health ... · Financial Crisis in the EU...
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Financial Crisis in the EU countries Financial Crisis in the EU countries Health impact Health impact Health Systems Response Health Systems Response A framework for decision making A framework for decision making www.healthobservatory.eu www.healthobservatory.eu Lisbon, 11 Lisbon, 11 th th January 2012 January 2012 Josep Figueras Josep Figueras
Transcript of Financial Crisis in the EU countries Health impact Health ... · Financial Crisis in the EU...
Financial Crisis in the EU countriesFinancial Crisis in the EU countries
Health impact Health impact Health Systems ResponseHealth Systems Response
A framework for decision makingA framework for decision making
www.healthobservatory.euwww.healthobservatory.eu
Lisbon, 11Lisbon, 11thth January 2012 January 2012
Josep FiguerasJosep Figueras
8
9
10
11
% G
DP
Austria
Belgium
Czech Republic
Denmark
Finland
France
Germany
Greece
Hungary
Ireland
Total Total HealthHealth ExpenditureExpenditure % GDP (1975% GDP (1975--2010)2010)
4
5
6
7
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
% G
DP
Ireland
Italy
Luxembourg
Netherlands
Poland
Portugal
Slovak Republic
Slovenia
Spain
Sweden
United Kingdom
Source OECD HEALTH DATA 2010, October
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”A. Greenspan
• Threat to health and health systems?– E.g. Indiscriminate cross cutting– E.g. Further ration health budgets – 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
Outline Outline
• Impact on Health
• Social protection response
• Health services response
• Protect health budget
• Health for economic productivity• 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
Falling road deaths and increasing suicideHealth impact? Health impact?
In short....Health impact? Health impact?
• Contradictory evidence • Effects on alcohol, tobacco, diet?
• Negative health impact of recovery?
• Increase in psychiatric disorders and suicide
• Decrease in traffic accidents
• Decrease in access in some countries / services
• Increase health service utilisation in others
• Shifting from private to public sector
• Strengthen Social Protection
• Labour protection and unemployment policies
• Family & housing benefits
• Anti-poverty measures
• Foster Social Support Networks
Social Spending and Mortality
Stuckler, Basu & McKee, BMJ 2010
Health System ResponseHealth System ResponseIn short ....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• 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
Health SystemsHealth Systems
SocietalSocietal
1.1. Protect the health budget Protect the health budget Health Impact on Economic ProductivityHealth Impact on Economic Productivity
Direct contribution
to the economyDemonstrate performance!!!
WealthWealthHealthHealth
SocietalSocietalWellWell--beingbeing
Effects of ill health on economic growth
to the economy
Figueras J, McKee M 2011
• Component of stimulus packages:
• Hospitals (France, Denmark)
• Health employment
1.1. Protect the health budget Protect the health budget Invest on HS as component of economyInvest on HS as component of economy
• Retraining (Germany)
• But in most countries cuts in capital investment
Mladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
2. 2. Reduce (or raise) statutory resources
• How much to spend vs other sectors?• Decrease tax base in most countries• Increase tax baseonly Italy and Czech Republic.• Increased SHI contribution rates: Bulgaria, Czech
Republic, Greece, Portugal, Romania and SloveniaRepublic, 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
3. Rationing Health Services3. Rationing Health ServicesCoverage dimensionsCoverage dimensions
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R. Busse
3. Rationing Health Services3. 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. BelgiumMladowsky, P, Srivastava, D Cylus J, KaranikolosM, Thompson S & McKee M Forthcoming, 2011
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, 2007
60%
70%
80%
90%
100%
0%
10%
20%
30%
40%
50%
Cyp
rus
Bulg
aria
Lat
via
Gre
ece
Pola
nd
Lithuan
ia
Port
ugal
Slo
vaki
a
Hungar
y
Spai
n
Rom
ania
Bel
giu
m
Slo
venia
Fin
land
Aust
ria
Ger
man
y
Ital
y
Mal
ta
Est
onia
Fra
nce
Irel
and
Net
her
lands
Sw
eden
Den
mar
k
United
Kin
gdom
Cze
ch R
epublic
Luxe
mbourg
Public VHI OOP Other
10
10
10
5
5
5
5
53,2
60%
70%
80%
90%
100%
The well-known 20/80 distribution –actually the 5/50 or 10/70 problem
How can we predictwho these 5 or 10% are?
50
3,4
10
2,54
6,9
5,6
8,8
15,6
0%
10%
20%
30%
40%
50%
% of population % of expenditure
Where the cost of seeking care is lower, the reduction of utilization is also lower
Source: Lusardi et al. The economic crisis and medical care usage 2010. Harvard Business School
“Reductions in routine care today might lead to undetected illness tomorrow and reduced individual health and well-being in the more distant future.”
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 • 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
5. Improve performance5. 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 – 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
5. Improve performance 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 SpainRomania, 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
5. Improve performance5. 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 – Improving evidence/base/medicine
• Enhancing integrated care
• Skill mix optimisation
• Market ‘like’ mechanisms / New public management e.g Hospital Self Governance
In conclusion...In conclusion...
• Fiscal sustainability: constraint, not policy objective
• Cost containment ≠ efficiency
• (Extra) spending should demonstrate value
• Be transparent & explicit about trade offs• Be transparent & explicit about trade offs
• Don’t forget the other sectors (social)!
• Learn to communicate the case for Health & Wealth
In conclusion......In conclusion......
• Coverage (two dimensions) largely unaffected – Benefits package and population – Increase coverage targeted at low-income groups
• Increased user charges• Increased user charges– If substantial: likely to decrease equity and efficiency
• Few public health policies: missed opportunity
In conclusion...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• 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
