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By Martyna Giedrojć, Policy Officer for Health Systems

European health systems are challenged with increasing costs of healthcare, a rise in chronic diseases associated with multi-morbidity, an ageing population and life expectancy that now exceeds 80 years in most EU countries, confirmed a joint report by the European Commission/Organisation for Economic Co-operation and Development. Health authorities work to improve health systems in the context of these challenges but often they have to operate with limited financial resources.

Public health expenditure has been decreasing steadily since the onset of the financial crisis and patients’ out of pocket expenditure has increased. Concerns about deteriorating health access are well-founded and the exclusion of some groups from health coverage will dramatically worsen public health. How to adjust health systems to the growing needs of the population? how to tackle health inequalities? how to decide which health technology is best? and finally, which problem should be prioritised?

Since the 2008 Tallinn Charter on Health Systems: Health and Wealth, many national governments on  the WHO European Region have made a commitment to increase transparency in the management of their health systems, and to monitor and measure them by using the Health System Performance Assessment (HSPA). HSPA is a tool to collect information and data and identify areas in health systems that need improvements. It is based on statistical indicators that monitor the system continuously and link health outcomes to the strategies and functions of the health system. It is a country-owned process, i.e. each national government is responsible for their own way of applying HSPA, for which there is no single accepted template, although there are many generally accepted principles of best practice. Each country’s assessment needs to capture and take into account all aspects of health systems, especially indicators on workforce, health information systems, health determinants, socio-economic and environmental factors in order to have a complete picture of health systems performance.

One indicator focuses on the health system as a whole, including health promotion and public health as well as health services.  Belgium, which hosted the first HSPA in 2008, prepared a Peer Review   focusing on the methods and tools needed for further HSPA development within the EU. Austria, the United Kingdom and the Netherlands include public health aspect in their HSPA. In Austria, public health is integrated into a broad range of other health-related outcomes (in particular life styles). The framework does not include health determinants outside the scope of the health care system, which are usually addressed by a Health in All Policies (HiAP) approach and other public health frameworks. By contrast, in the Netherlands the focus is on the full health system, including all aspects of public health.  The review also found the most desired outcomes from public health in the UK are increased healthy life expectancy and reduced differences in life expectancy and healthy life expectancy between communities.

In 2014, an Expert Group on Health Systems Performance Assessment  was established by the European Commission to provide national governments with a forum to exchange their experience on the use of HSPA at national level, and to support national policy-makers by identifying tools and methodologies to better develop HSPA. It provides the 28 EU Member States and Norway with the opportunity to strengthen their cooperation with three major international organisations – the OECD, World Health Organisation and the European Observatory on Health Systems and Policies.

The group intends to define a shared understanding among stakeholders of the priorities for strengthening European health systems, support evidence-based policy-making and priority-setting, and provide a platform to share experience and good practices that could improve health systems performance.

European countries use a benchmarking method to set their HSPA criteria. Creation of meaningful international comparisons on diverse indicators such as value cost or clinical trials, can help to define criteria for selecting priority areas for HSPA at EU level. “The EU needs granularity in comparison of indicators because there are still enormous variations between Member States,” stated Francesca Colombo Head of the Health Division, OECD at the event “Improving Health System Performance. Sharing Experiences and Tackling Challenges,” organised by the European Policy Centre in Brussels.

In April 2016, the report entitled “SO WHAT? Strategies across Europe to assess quality of care” produced by the EU’s Expert Group identified quality of care as the issue that deserves immediate attention. Over the decades all national governments have acquired some knowledge on the enhancement of quality of healthcare, but the identification of quality strategies that can positively impact health systems remains a challenge for national policy makers.  Even for well-developed health systems, where spending is up to seven times higher than in other countries, quality remains a serious concern. Often politicians and patients are confronted by health systems that cannot easily achieve the expected outcomes. Wide diversity in the quality of healthcare, both between and within countries also presents an opportunity for improvements and to make the best use of resources to meet the needs of the population in a sustainable way.  The report, concluded that European health systems should envisage making improvements in the following areas:

  • Accessibility – healthcare that is timely, reasonable in terms of geographic distribution, and supplied with appropriate tools and skilled staff;
  • Effectiveness – healthcare delivery, based on population needs;
  • Efficiency in delivering health services, to maximise results and avoid waste;
  • Equity – healthcare delivery should not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socio-economic status;
  • Patient-centredness;
  • Safety.

In the near future, the feasibility and effectiveness of HSPA will depend on the existence of extensive comparable and reliable data sources, collected on a consistent basis in each country and the ability to compare the results amongst as many other countries as possible.

The next goals to be achieved across Europe will focus on improvement of availability of indicators and making better use of data. In the end, taking into account healthy life expectancy and providing access to high-quality healthcare for those in need, should be the principles of every HSPA process.

Martyna Giedrojć

Policy Officer for Health Systems

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