Health policy responses to the financial crisis in Europe

The global financial crisis that began in 2007 can be classified as a health system shock – that is, an unexpected occurrence originating outside the health system that has a large negative effect on the availability of health system resources or a large positive effect on the demand for health services. In 2009, WHO’s Regional Committee for Europe adopted a resolution (EUR/RC59/R3) urging Member States to ensure that their health systems would continue to protect and promote universal access to effective health services during a time of economic crisis. To date, there has been no systematic cross-country analysis of health policy responses to the financial crisis in Europe, although some overviews of health system responses to the crisis have been published. This policy summary aims to address a gap in the literature by presenting a framework for analysing health policy responses to economic shocks; summarizing the results of a survey of health policy responses to the financial crisis in the European Region’s 53 Member States; and discussing the potential effects of these responses on health system performance.

Health system performance comparison: an agenda for policy, information and research

Individual nations are increasingly seeking to introduce more systematic ways of assessing the performance of their health systems and of benchmarking performance against other countries. Policy-makers recognize that without measurement and comparison, it is difficult to identify good and bad delivery practice or good or bad practitioners (“what or who works”), to design health system reforms, to protect patients and payers, or to make the case for investing in health care. Measurement is also central to promoting accountability to citizens, patients and payers for health system actions and outcomes. This focus on assessment coincides with the enormous increase in the capacity for measurement and analysis of the last decade, driven in no small part by massive changes in information technology and associated advances in measurement methodology. However, notwithstanding major progress by organizations such as the European Commission, the OECD, the Commonwealth Fund, WHO and individual countries, performance comparison efforts are in their early stages, and there are many challenges involved in the design and implementation of comparison schemes. This policy brief seeks to summarize the current “state of the art” of health system comparison, identifying data and methodological issues and exploring the current interface between evidence and practice. It also draws out the priorities for future work on performance comparison, in the development of measurement instruments, analytic methodology, and assessment of evidence on performance. It concludes by presenting key lessons and future priorities policy-makers should take into account.

How can telehealth help in the provision of integrated care?

Telehealth, the provision of care at a distance, is certain to be a key component in future ICT infrastructure for integrated care. It has already raised high hopes among policy-makers with regard to its potential for delivering solutions forgrowing capacity problems. For integrated care, today's segregated telehealth applications still require linking into more comprehensive eHealth strategies, in which clinical pathways and service delivery processes are fully coordinated andpatient data safely shared. Although few instances of routine application have yet emerged in Europe or elsewhere – in contrast with an enormous breadth of research activities – anincreasingly solid evidence base is emerging indicating that telehealth can be used effectively to help support better integrated care, in particular for those with long-term chronic conditions.

Wie lassen sich Voraussetzungen schaffen, um die Qualifikationen von Ärzten an neue Anforderungen und lebenslanges Lernen anzupassen?

Dieses Grundsatzpapier untersucht die wichtigsten Maßnahmen, die erforderlich sind, um die Voraussetzungen zu schaffen, die Ärzten gestatten, ihre Qualifikation im Kontext von beruflichem Bedarf und lebenslangem Lernenanzupassen. Er umreißt die Gründe, warum die Praktiken des lebenslangen Lernens in Europa auf verschiedenen Ebenen (z. B. Lernender, Einrichtung und System) neu überdacht werden müssen, und er erforscht die politischen Optionen, Bedingungen und Anreize, die ins Spiel kommen, wenn Wissen und Fähigkeiten gleich welchen Gesundheitspersonals auf den neuesten Stand gebracht werden sollen. Hier liegt der Schwerpunkt zwar auf den Ärzten, aber viele der Konzepte lassen sich auf andere Gesundheitsberufe übertragen. Dieses Grundsatzpapier untersucht die Möglichkeiten der länderübergreifenden Zusammenarbeit auch bei Strategien zur Förderung der Weitergabe von Lerninhalten, Fortbildungsmaßnahmen und neuen Wissensformen über die europäischen Ländergrenzen hinweg (unter besonderem Bezug auf die EU-Mitgliedsstaaten).

How to create conditions for adapting physicians’ skills to new needs and lifelong learning

This Policy Brief examines the key measures necessary for creating the conditions that allow physicians to adapt their skills in the context of professional needs and lifelong learning. It outlines the reasons why a reconsideration of lifelong learning practices in Europe is needed at various levels (i.e. learner, organization and systems) and it explores the policy options, conditions and incentives involved in updating the knowledge and skills of any health workforce. While the focus here is on physicians, many of these concepts are transferable to other health professionals as well. This Policy Brief specifically examines the options for collaboration across countries, including strategies for promoting thetransmission of learning, training and new forms of knowledge across national boundaries within Europe (with particular reference to the EU Member States).

Wie lässt sich ein attraktives und unterstützendes Arbeitsumfeld für Fachkräfte des Gesundheitswesens schaffen?

Die europäischen Länder stehen vor der gemeinsamen Herausforderung, in Zeiten bestehender und prognostizierter Personalknappheiten einen gut funktionierenden Fachkräftebestand im Gesundheitswesen sicherzustellen. Von den vielen Aspekten, die Versorgung mit entsprechenden Fachkräften undderen Leistung bestimmen, spielt das Arbeitsumfeld eine entscheidende Rolle. Dieses Grundsatzpapier betrachtet politische Ansätze, die zur Schaffung eines positiven Arbeitsumfelds eingesetzt werden können, und die auf diese Weise die Rekrutierung und Bindung von Fachkräften im Gesundheitswesen verbessernund zum Erreichen hochwertiger Gesundheitsdienstleistungen beitragen. Fragendes Arbeitsumfelds betreffen im Allgemeinen alle Arbeitnehmer in allen Arten von Gesundheitsdienstleistungen – mit Abweichungen, die von den Merkmalen der beruflichen Funktion oder Arbeitssituation abhängen. Dieses Grundsatzpapier beschäftigt sich schwerpunktmäßig mit Ansätzen für Ärzte und Pflegepersonal, da diese den größten Teil der Beschäftigten im Gesundheitswesen ausmachen,ohne dass damit die Relevanz für andere Berufsgruppen ausgeschlossen wird.

How to create an attractive and supportive working environment for health professionals

European countries face common challenges in ensuring a well-performing health workforce in times of existing and projected shortages. Among the multiple aspects that determine the supply and performance of health workers, the work environment plays a critical role. This policy brief considers policy approaches that can be employed to help create positive work environments, thus improving the recruitment andretention of health professionals and contributing to the achievement of high-quality health services. Work-environment issues generally apply to all health workers in all types of health services – with variations according to the characteristics of professional functions or work settings. Without excluding their relevance for other professional groups in the health sector, this policy brief focuses on approaches for physicians and nurses, as they represent the largest constituents of the health workforce.

Audit und Feedback für Gesundheitsfachkräfte zur Verbesserung von Qualität und Sicherheit der Gesundheitsversorgung

Es gibt heute umfassende Erkenntnisse aus jedem Land, das nach ihnen gesucht hat, die besagen, dass es eine Lücke zwischen der empfohlenen Praxis und der Gesundheitsversorgung gibt, die Patienten erhalten. In Primär- und Sekundärversorgung gibt es nicht gerechtfertigte Variationen in der Praxisund in ihren Ergebnissen, die sich nicht durch die Eigenheiten des Patienten erklären lassen. Es ist zwar schwierig, festzustellen, in welchem Umfang in allen 53 Mitgliedsstaaten der Region Europa der Weltgesundheitsorganisation Maßnahmen ergriffen werden, um etwas daran zu ändern, aber in jedem der 27 Mitgliedsstaaten der Europäischen Union lassen sich konkrete Beispiele feststellen. Insbesondere wächst das Interesse am Einsatz von Audit und Feedback für Fachkräfte im Gesundheitswesen. Das Material dieser Themenübersicht beruht weitgehend auf einer systematischen Bewertung der Effektivität von Audit und Feedback in einer sich verändernden klinischen Praxis und einer Bewertung von Erfahrungen, wie Audit und Feedback in der klinischen Praxis eingesetzt worden sind. Die in diesem Themenüberblick vorgestellten Studien zeigen, dass Audit undFeedback in beinahe allen Umfeldern im Gesundheitswesen genutzt werden können. Die Einführung von Audit und Feedback setzt klare Ziele und eine gründliche Analyse des fraglichen Umfelds voraus, insbesondere dann, wenn dieser Ansatz mit Anreizen oder Sanktionen kombiniert oder zur Pflicht erklärt wird. Auch in diesem Fall gibt es keine belastbaren Erkenntnisse, ob dieseKombinationen die Ergebnisse und damit die gewährte Gesundheitsversorgung deutlich verbessern. Die Erfahrungen einiger bedeutender Initiativen in bestimmten europäischen Ländern können in Zukunft einen Teil der erforderlichen Erkenntnisse liefern.

Analyse des zukünftigen Personalbedarfs im Gesundheitswesen

Viele Länder haben Probleme mit dem angemessenen Einsatz der Beschäftigten im Gesundheitswesen. Die Mobilität dieser Beschäftigten innerhalb der Länder Europas macht eine Planung auf nationaler Ebene schwierig, zum Teil auch deshalb, weil die Migrationsströme nur schlecht dokumentiert sind. Ziel dieser Zusammenfassung ist es, Politiker und Entscheidungsträger darüber zu informieren, wie der zukünftige Personalbedarf im Gesundheitswesen nach aktuellem Wissensstand am besten analysiert werden kann und wie diesem Bedarf bestmöglich Rechnung getragen werden kann. Zunächst wird erörtert, welcher Art die Herausforderungen bei der Analyse des zukünftigen Fachkräftebedarfs im Gesundheitswesen sind. Dann werden verfügbareInstrumente und Strategien vorgestellt, deren Stärken und Schwächen diskutiert, die Lehren aus den Erfahrungen maßgeblicher Länder präsentiert und die Kernaussagen zusammengefasst, die sich aus der Bewertung des aktuellen Stands der Dinge ergeben.

Assessing future health workforce needs

Many countries face difficulties in adequately deploying the health workforce and the mobility of health personnel between countries in Europemakes planning at national level difficult, in part, because migratory flows are poorly documented.The aim of this policy summary is to inform policy- and decision-makers of the state of knowledge about how best to assess and respond to future health workforce needs. It first discusses the nature of the challenge in assessing the future health workforce. It then introduces available tools and strategies; discusses their strengths andweaknesses; presents lessons learned from relevant country experiences, and summarizes the key messages from the review of the state of the art.

Using audit and feedback to health professionals to improve the quality and safety of health care

There is now extensive evidence from every country in which it has been sought that there is a gap between the health care that patients receive, and the practice that is recommended. In both primary and secondary care there are unwarranted variations in practice and in the resulting outcomes, and which cannot be explained by characteristics of the patients. While it is difficult to ascertain the extent to which measures for tackling this exist in all 53 Member States of the World Health Organization’s European Region, concrete examples can be identified in each of the 27 European Union Member States. In particular, there is growing interest in the use of audit and feedbackfor health professionals. The material in this policy summary is largely based on a systematic reviewof the effectiveness of audit and feedback in changing clinical practice, and a review of experiences of how audit and feedback have been used in clinical practice. The studies presented in this policy summary show that audit and feedback can be used in almost all health care settings. Implementation of audit andfeedback requires clear goals and a thorough analysis of the health care environment in question, especially if this approach is combined with incentives or penalties, or is made mandatory. No strong evidence has been identified indicating that these combinations significantly improve outcomes and thus the health care delivered. The experience arising from some major initiatives taking place in certain European countries may provide some of therequired evidence in the future.

Каким образом системы здравоохранения могут содействовать достижению гендерной справедливости?

В данном кратком аналитическом обзоре показано несколько возможныхподходов, следуя которым системы здравоохранения (европейские) моглибы решать гендерные проблемы. Некоторые из этих подходов легче, чемдругие, с точки зрения требуемых ресурсов и имеют больше вероятностибыть положительно воспринятыми как лицами, формирующимиполитику, так и лицами, осуществляющими эту политику. Для другихтребуется больше ресурсов и может потребоваться больше времени нареализацию. Некоторым странам Европы при нынешней ситуации вэкономике и культуре рассмотренные в данном обзоре меры могутпоказаться слишком трудными, чтобы ставить вопрос об ихосуществлении. Однако необходимо учесть, что даже таким странам, какНорвегия, Швеция и Шотландия, которые приняли множество мер длядостижения гендерной справедливости, потребовалось несколькодесятилетий, чтобы придти к этому, и в течение этого времени ониосуществляли целый ряд небольших изменений, которые помогали имвыявлять потребности и разрывы в отношении здоровья идемонстрировать положительный эффект от обеспечения гендернойсправедливости с точки зрения здоровья населения и рациональногоиспользования ресурсов. Эти изменения также позволилисоздать организационно-кадровый потенциал на различных уровняхминистерств здравоохранения, необходимый для выработки пониманиятого, как гендерные различия влияют на здоровье. Кроме того,благоприятным фактором для этих стран стал дополнительный импульск переменам, который был дан под влиянием международных инаднациональных организаций, таких как Организация ОбъединенныхНаций, ВОЗ и ЕС. Описанные подходы открывают ценные возможностидобиться гендерной справедливости в деятельности системздравоохранения на благо как мужчин, так и женщин.

Addressing financial sustainability in health systems

The question as to whether health systems will be financially sustainable in the future is frequently raised in health policy debate. The problem is often phrased in terms of the ability of governments and others adequately to finance health care in the face of growing cost pressures, with population ageing, new technologies and consumer expectations around health care coverage and quality being the three most commonly cited challenges. Although the notionof ‘financial sustainability’ appears to be central to health policy debate, it does not form part of most health system objectives, including those of the World Health Organization’s health system performance framework. Moreover, there is little clarity or consensus about the term's meaning, beyond it having something to do with ‘ability to pay’ or ‘affordability’. Nevertheless, the underlying ‘sustainability’ issue – balancing rising cost pressures against limited resources – is a concern across countries, all the more so in the context of the current financial crisis. Inevitably, this means addressing trade-offs, both within the health sector itself and more broadly between the health sector and the rest of the economy. This policy summary, prepared for the Czech European Union Presidency Ministerial Conference on the Financial Sustainability of Health Systems(Prague, 10–12 May 2009), aims to shed light on the notion of financial sustainability and to examine its policy relevance in practical terms.

How can gender equity be addressed through health systems?

There is a considerable volume of research on differences between women and men in terms of their experiences of ill health and how well health services meet their needs. National and international data show that men experiencehigher mortality and lower life expectancy than women around the world, while women tend to experience more ill health than men, although this varies across the lifespan and in relation to specific conditions. In most countries, women also experience a better healthy life expectancy than do men but spend more years living with a disability. This policy brief provides an account ofthe key issues in the delivery of appropriate, accessible and evidence-informed health care to women and men, and considers how public policies might improve these experiences and health outcomes for both sexes. The benefits, costs and barriers involved in different approaches are also identified. It is clear that health systems can make important contributions to gender equality and gender equity by addressing gender in a variety of ways.

How can European states design efficient, equitable and sustainable funding systems for long-term care for older people?

Across Europe data suggest that an ageing of the population, coupled with changes in the availability of informal family support, increasing costs of care and raised expectations on the quality, intensity and flexibility of services mayraise major challenges for policy-makers contending with maintaining or extending coverage and support for long-term care systems. To be sustainable long-term care systems need to be affordable, fair and flexible. In a given context, public consensus needs to be achieved aroundany mechanism of long-term care funding. National governments, as part of their stewardship of the health system, can consider steps to: (i) ensure that comprehensible information and advocates to help individuals navigate long-term care systems are in place; (ii) assure quality standards, provide support for informal carers and facilitate flexibility in care package choices (such as through cashpayments); and (iii) pursue measures to improve coordination between the long-term care and associated sectors. With many countries facing similar challenges, member states of the European Region may be able to draw on lessons from international experience in long-term care systems, both from Europe and beyond.

How can health systems respond to population ageing?

One of the most important demographic trends facing Europe is the ageing of its population. This policy brief considers the implications of this process for health and long-term care, including the funds available for health care and the expenditure required. It discusses a series of policy options that can be considered when responding to the challenge of an ageing population. Without making specific recommendations, it is noted that on the basis of the available research evidence, a promising option is to promote healthy ageing. When elderly people are in good health, it is shown that they will need fewer health care resources and are also more likely to remain in the labour force.Policies that allow a healthy ageing of the population include a better coordination of health and long-term care services and enhanced prevention services.

How can the impact of health technology assessments be enhanced?

Growth in the diffusion of new health technologies has led to remarkable improvements in health and quality of life. These benefits, however, also bring challenges in ensuring value for money and concerns over the willingness of third party payers and patients to pay for expensive treatments, devices and drugs. As policy-makers seek to obtain maximum benefit from limited resources, and do so in legitimate and transparent ways that reflect the values underpinning health systems, health technology assessment (HTA) is a tool increasingly used to support this aim and encourage the efficient use of health technologies. This brief examines selected issues in the application and uptake of HTA in Europe.

Where are the patients in decision-making about their own care?

Patients can play a distinct role in protecting their health, choosing appropriate treatments for episodes of ill health and managing chronic disease. Considerable evidence suggests that patient engagement can improve their experience and satisfaction and also can be effective clinically and economically. This policy brief outlines what the research evidence tells us about the effects of engaging patients in their clinical care, and it reviews policy interventions that have been (or could be) implemented in different health care systems across Europe. In particular, it focuses on strategies to improve health literacy, treatment decision-making and self-management of chronic conditions.

How can the settings used to provide care to older people be balanced?

The optimum balance between institutional, home-based and community care for older adults requires an effective mix of organizational, funding and delivery mechanisms for target populations. This policy brief assesses at least three dimensions of care for older people: first, health and social care; second, within health care (the balance between preventive care, curative care and health maintenance); and third, within social care (the balance between formal andinformal care). This brief examines how an appropriate balance of care for older people may be developed, assesses the alternative methods that may be used to bring about change in the provision of care for older people and considershow such models need to be adapted flexibly to meet local circumstances.

When do vertical (stand-alone) programmes have a place in health systems?

Few issues related to the organization of health systems and service delivery have attracted as much attention as the debate on vertical versus integrated health programmes. The literature has focused on the comparative effectiveness of vertical (disease- or service-specific) versus more systemic approaches since the 1960s, and both approaches have been widely implemented in low- and middle-income countries and in high-income countries. In vertical approaches (also referred to as stand-alone, categorical, disease management or disease control programmes), interventions are provided through delivery systems that typically have separate administration and budgets, with varied structural, funding and operational integration with the wider health system. In the integrated model (also known as horizontal approaches or programmes), services do not have separate administration orbudgets and are typically delivered through health facilities that provide routine or general health services. This policy brief has three objectives and is structured accordingly: to unpack what is meant by a vertical programme versus an integrated one; to assess the available evidence and lessons on when vertical programmes have a role to play in health systems; and to indicate under what circumstances vertical programmes have a role to play in health systems and to note the factors policy-makers need to take into account when considering implementing vertical programmes.