Health system response to Covid-19: Experience from European countries

Reinhard Busse, Prof. Dr. med. MPH

Dept. Health Care Management, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management)

&European Observatory on Health Systems and Policies

Equity

Access(ibility)incl. financial protection

Quality (for those who

receive services)

Populationhealth outcomes(system-wide effectiveness)

Responsiveness

How good are health systems? A performance assessment framework I

Access(ibility)incl. financial protection

Quality (for those who

receive services)

Populationhealth

outcomes(system-wide effectiveness)

Responsiveness

Costs/ expenditure, physical inputs and/or physical outputs

System efficiency/ cost-

effectiveness(i.e. population health

and/ or responsiveness per cost/

input/ output unit)

Equity

Equity

Equity

PCosts/ expenditure

Physical outputs

Technical efficiency

OR▲population health and/

or responsiveness per

▲cost unit

How good are health systems? A performance assessment framework II

From “normal” utilization rates (seen as [in]efficiency) to health system usage in COVID times

Both a big ambulatory and hospital sector making the right decision to de facto focus on the first

Initially used almost only hospitals (80% of tests!)

Often hospital focusedbut lots of regional variation

Simplified visualisation of health care usage at the peak of the epidemic (early April) in Germany

14 : 1Test In-fected

Hospita-lised

Intensive Care3 : 1

7 / 100.000= 6.000 / day

1,4 / 100.000= 1.200 / day

0,5 / 100.000= 400 / day

1 : 0,3Died

0,3 / 100.000= 270 / day

1 : 0,045

5 : 1

40% in ICU90% in hospitals

14 : 1Test In-fected

Hospita-lised

Intensive Care3 : 1

1,4 / 100.000= 1.200 / day

0,5 / 100.000= 400 / day

1 : 0,3Died

1 : 0,045

5 : 1

40% in ICU90% in hospitals

600 / 100.000beds

in 1.350 hosp.

35 / 100.000ICU beds

in 1.150 hosp.

Only care for inambulatory care

How does this compareto Germany‘s available health care resources?

Early flowchart (late February): home care until test result, hospitalisation

for all patients with positive tests

Later flowchart: continued care at home for test-positive persons

unless hospitalisation necessary

How did this compare to other countries?

2 : 1

1 / 100.000 0,5 / 100.000

1 : 0,3Died

7 / 100.000

ES 17AT 10IT 9

(Lombardy 21)UK 8NL 7FR 7

DK 6NO 5

IT 4 : 1FR 4 : 1

ES 4,5 : 1AT 5 : 1NL 5 : 1DK 9 : 1

NO >20 : 1

ES 10 : 1IT 8 : 1DK 7 : 1UK 5 : 1FR 5 : 1NL 4 : 1

Everywhere fewer than in DE

14 : 1Test In-fected

Hospita-lisation

Intensive Care3 : 15 : 1 1 : 0,3

FR 3 : 2ES 2 : 1NL 5 : 2IT 3 : 1UK 3 : 1DK 5 : 1

CH 8 : 1AT 9 : 1

Almost everywhere fewer than in DE Often higher

than in DE Lombardy2 : 1

Emilia-Romagna

3 : 1Veneto

5 : 1

Currently hospitalised patients in relationship to total incidence (both per 100 000 population) over timeLombardy

BelgiumFrance

Emilia-Romagna

Italy

Currently ICU-treated patients in relationship to total incidence (both per 100 000 population) over timeLombardy

BelgiumFrance

Emilia-Romagna

NetherlandsICU capacity Lombardy

ICU capacity Netherlands

Outcomes: excess mortality – probably the ultimate indicator

+63%

+49%

+60% +63%+47%

+28% +24% +16%+17%

+39%

+6%

+10% +2%+5% +2%

Conclusions

• We will not need to re-invent our Health System Performance Assessment framework

• But certain interpretations and emphasis need to change, e.g. a strong primary care system might not be good if no testing exists and people still go directly to hospital

• In the crisis, keeping people out of hospitals was the key to success• Coordination and cooperation between public health services,

ambulatory care and inpatient care needs to be re-assessed