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

D P

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

19 75

19 77

19 79

19 81

19 83

19 85

19 87

19 89

19 91

19 93

19 95

19 97

19 99

20 01

20 03

20 05

20 07

20 09

% G

D P

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 suicide Health 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 Response In 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 economy Demonstrate performance!!!

WealthWealthHealthHealth

SocietalSocietal WellWell--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 Services Coverage dimensionsCoverage dimensions

12

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. Belgium Mladowsky, 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%

C yp

ru s

B u lg

ar ia

L at

vi a

G re

ec e

P o la

n d

L it h u an

ia

P o rt

u g al

S lo

va ki

a

H u n g ar

y

S p ai

n

R o m

an ia

B el

g iu

m

S lo

ve n ia

F in

la n d

A u st

ri a

G er

m an

y

It al

y

M al

ta

E st

o n ia

F ra

n ce

Ir el

an d

N et

h er

la n d s

S w

ed en

D en

m ar

k

U n it ed

K in

g d o m

C ze

ch R

ep u b lic

L u xe

m b o u rg

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 predict who these 5 or 10% are?

50

3,4

10

2,5 4

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,