Building sustainable and resilient health care systems: how ERA-NETs in Horizon 2020 can help

Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 BUILDING SUSTAINABLE AND RESILIENT HEALTH CARE SYSTEMS: HOW ERA-NETS IN HORIZON 2020 CAN HELP By: Johan Hansen, Judith de Jong, Peter Groenewegen and Walter Ricciardi Summary: Currently, a European Research Area network (ERA-NET) research programme – within Horizon 2020 – is being developed in the area of health services and systems research. It focuses on two meta-questions 1) under what conditions can health care innovations be effectively transferred to other countries and 2) how can this enhance health systems performance? In terms of substantive topic areas, ERA-NET will focus on the organisation of services throughout the entire chain of care, ranging from public health and prevention to hospital and long-term care. This article identifies the programme’s focus and how it can build on existing initiatives. Keywords: Health Systems Research, Sustainability, Health Care Delivery, Transferability, ERA-NET, Horizon 2020 Johan Hansen is senior researcher at NIVEL, The Netherlands Institute for Health Services Research, Utrecht, The Netherlands and project coordinator of HRS Europe; Judith de Jong is programme coordinator at NIVEL and President of the EUPHA Section on Health Services Research; Peter Groenewegen is director at NIVEL and Lead of the Research Pillar, EUPHA; Walter Ricciardi is Past President, EUPHA and Professor of Hygiene and Public Health, Catholic University of the Sacred Heart, Rome, Italy. Email: J.Hansen@nivel.nl ERA-NET as a tool to foster cross- country learning In 2015, Europe is still struggling to find its way out of the economic and financial crisis. Consequently, resilience and sustainability will remain key priorities for European countries and their health care systems for years to come. 1 This continuing focus is in part reflected in the ambition of the European Commission’s (EC) flagship programme for research and innovation, Horizon 2020, 2 which should contribute to boosting competitiveness and innovation to meet the (health care) demands of the European Union’s (EU) ageing populations. Challenges such as the growing burden of chronic diseases, the declining workforce to provide for our wealth and health, and increasing financial and political pressures call for innovative solutions on how to organise health care in an equitable and efficient manner. Within Horizon 2020 there is only limited room for fundamental research on the comparability between health systems as its focus is mostly on the implementation of (biomedical) innovations. 3 At the same time, there is a strong need for cross-border policy learning, in order to understand and value whether good practices and innovative solutions in health care delivery can be transferred from one country to the other. A European Research Area network (ERA-NET) can provide that opportunity, as it is 28 Eurohealth SYSTEMS AND POLICIES Eurohealth SYSTEMS AND POLICIES Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 29 a tool within Horizon 2020 to support more coordination and collaboration among countries. Through an ERA-NET, research funding bodies from inside and outside the EU can jointly set up calls for trans-national research and innovation in a joint research programme. Within selected areas with high European added value and relevance for Horizon 2020, these programmes can be topped up with additional funding from the EC. ‘‘ redesigning care models to face the common challenges of EU health systems Currently, an ERA-NET is being developed, focusing on the conditions under which successful innovations in the organisation and provision of services can transfer from one health system to another. It deals with the interaction of, on the one hand, substantive priority areas, such as models of integrated care, and on the other hand, the meta-questions of transferability, absorptive capacity and the contribution of innovations to health system performance. Below, we will elaborate on both dimensions to clarify the exact focus of the ERA-NET and its linkage to existing initiatives. Substantive questions: key priorities in European health systems A key step in the development of any research programme is to determine the main priorities. The exact focus of this ERA-NET will depend on the priority areas in the countries that will join the ERA-NET. To provide a first indication of policy issues high on countries’ agendas in Europe we looked at the reports produced as part of the European Semester. The European Semester is a yearly cycle of economic policy coordination, described in greater detail by Azzopardi Muscat et al. 4 We analysed the country responses to the European Semester’s Country Specific Recommendations (CSR’s). In their responses, EU Member States describe what actions and/or health care reforms they have initiated or are contemplating in order to meet the requirements as set out by the European Council. A word cloud of all texts relating to health care is shown in Figure 1. It shows that overarching system goals are important EU-wide, including how to safeguard accessibility and quality within the budget constraints that countries are facing. Many countries also place particular emphasis on equity, by protecting vulnerable groups, such as children, older people and those with mental health problems or Roma populations across Europe. In order to balance these goals, many countries are considering measures to achieve a better design of services throughout the entire chain of care, including public health and prevention. It implies, among others, strategies for strengthening community and primary care in relation to social care and prevention, redesigning hospital care and de-institutionalising long-term care with more care provided closer to home, thus also placing more emphasis on self-management of patients, new ways of linking health with social care and changing the role of regional or local government. 5 It is exactly these common priorities that will be explored by the funding bodies involved in setting up an ERA-NET. Meta issues: performance enhancement, transferability and absorptive capacity The similarity between countries, as highlighted in Figure 1, shows that there is great potential for countries to learn from each other’s health systems and service provision. This is exemplified by the mission letter of EC President, Jean-Claude Juncker, to the Commissioner for Health and Food Safety, Vytenis P. Andriukaitis, asking him to focus during his mandate on developing expertise on performance assessments of health systems, thus building up country- specific and cross-country knowledge which can inform policies at national and European level. 6 In this ERA-NET, the focus is not so much on comparing the level of performance of health systems, but mostly on the question of how the performance of the system as a whole or parts of it, such as hospitals or primary care centres, can be enhanced by learning from successful health care models in other countries. A key element for this is whether such models are transferable from one country to another. Often, this transferability is hampered by contextual differences in the political, cultural and institutional arrangements of health systems. This often makes direct copying of policy or services arrangements impossible. In addition to transferability, it is also important to address the absorptive capacity of recipient countries. Taking integrated care as an example, it is far more difficult to organise this effectively in a health care system in which most primary care physicians work in single- handed practices than in countries which mostly have larger multidisciplinary practices. The latter have far more opportunities to bring the right expertise together around specific patient groups. Therefore, an international research programme should focus on the transferability of and absorptive capacity for innovative solutions in service provision. Under what circumstances and to what extent can a programme that is effective in one place transfer to another? 7 So far little is known about what works where, when and why. The proposed ERA-NET should help determine what the required preconditions are that make an innovation work, in order to accurately and appropriately predict how a proposed policy may work in a new setting. 8 When identifying such lessons, we hardly need to start from scratch. In the past, many comparative studies have been conducted, e.g. by the European Observatory on Health Systems and Policies as well as others, which combined together, will provide an important starting point for this ERA-NET. 9 The programme should also provide room for methodological advancement for new calls of research, e.g. on how to deal with small-sample country comparisons, on comparing smaller and larger countries, or the regional health systems within those countries. Interestingly, as ERA-NETs can Eurohealth SYSTEMS AND POLICIES Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 30 also involve regional authorities, they may use Europe’s variation in health systems to its fullest, as a natural laboratory setting. 3 Building up country-specific and cross-country knowledge: linkage to other EU-initiatives Both at EU and national level, there is a clear window of opportunity for this type of research. It is not only illustrated by the above-mentioned mission letter to the Commissioner for Health and Food Safety, but also by the EC communication in 2014 on effective, accessible and resilient health systems. 10 An ERA-NET on health care models has the potential to contribute to this overarching goal, while providing added value to other EU-level and national level initiatives. To name a few examples: • EU-level health information and knowledge systems, such as the HIS ERIC (Health Information System European Research Infrastructure Consortium), ensure the availability of comparative data for assessing performance, while an ERA-NET provides the potential to use such data to identify innovations in the organisation and provision of services, including the conditions needed to transfer these. • The Joint Action on Workforce can identify strategies to avoid future health care personnel shortages, while an ERA-NET can assess whether the organisational conditions are present to help transfer these strategies to other settings, e.g. in terms of the available recruitment mechanisms and division of tasks between health professionals. • The Joint Programming Initiative ‘More years, better lives’ strengthens research collaboration in relation to demographic change and includes projects that investigate appropriate and effective models of care for people near the end of their lives. An ERA-NET can make use of these insights when evaluating the transferability of health care models for similar or different age and patient groups. • The European Innovation Partnership on Active and Healthy Ageing showcases business models which may contribute to better integrated care solutions, while an ERA-NET can determine whether the contribution to performance of these solutions depends on the division of responsibilities between care providers. Joining forces across all regions of Europe The ERA-NET initiative is currently being developed by the Istituto Superiore di Sanità in Italy and The Netherlands Organisation for Health Research and Development (ZonMw), supported by an international scientific working group (see acknowledgements). In February 2015, plans were addressed at a meeting of Horizon 2020’s Programme Committee for Health. In March 2015, an invitational meeting will be held among interested parties, in order to refine their specific plans. Other national or regional level governmental and research funding institutes will be able to join the collaboration. To indicate their interest, they can contact the authors of this article. Joining forces across all of Europe’s Figure 1: Word Cloud of texts in country responses to Country Specific Recommendations within the European Semester, year 2014 (n=26 countries)* Note: * Countries that provided a response report in English, either for 2014 or the latest available year Eurohealth SYSTEMS AND POLICIES Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 31 regions should contribute to fostering long-term collaboration between countries, all with the same ambition to organise health care in a more sustainable manner. References 1 Maresso A, Wismar M, Greer S, Palm W. What makes health systems resilient and innovative? Voices from Europe. Eurohealth 2013;19(3):3 –7. 2 European Commission. Horizon 2020 – The Framework Programme for Research and Innovation. COM(2011) 808 final. Brussels, 30.11.2011. Available at: http://ec.europa.eu/ research/horizon2020/index_en.cfm 3 Walshe K, McKee M, McCarthy M, et al. Health systems and policy research in Europe: Horizon 2020. The Lancet 2013;382(9893):668-69. 4 Azzopardi-Muscat N, Clemens T, Stoner D, Brand Helmut H. EU Country Specific Recommendations for health systems in the European Semester process: Trends, Discourse and Predictors. Health Policy, 2015. Available at: http://dx.doi.org/10.1016/j. healthpol.2015.01.007 5 Thomson S, Figueras J, Evetovits T, et al. Economic crisis, health systems and health in Europe: impact and implications for policy. Policy Summary 12. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies, 2014. Available at: http://www.euro.who.int/__data/assets/pdf_ file/0008/257579/12-Summary-Economic-crisis,- health-systems-and-health-in-Europe.pdf?ua=1 6 European Commission. Mission Letter of President of the European Commission, Jean-Claude Juncker to the Commissioner for Health and Food Safety, Vytenis P. Andriukaitis. Sent on 10 September 2014. Available at: http://ec.europa.eu/about/juncker-commission/ docs/andriukaitis_en.pdf 7 Rose R. Lesson Drawing in Public Policy: A Guide to Learning Across Time and Space. Chatham, N.J: Chatham House, 1993. 8 Figueras J. Transferring health reform innovation. How to ensure effective cross fertilisation? Presentation at Preconference meeting on Health Systems Research, European Public Health Conference, Glasgow, 19 November 2014. Available at: http://tinyurl.com/pb74h9t 9 Nolte E. Transferability of health services and policies. Learning from international experience. Presentation at Preconference meeting on Health Systems Research, European Public Health Conference, Glasgow, 19 November 2014. Available at: http://tinyurl.com/pb74h9t 10 European Commission. Communication from the Commission, On effective, accessible and resilient health systems. COM(2014) 215 final. Available at: http://ec.europa.eu/health/healthcare/docs/ com2014_215_final_en.pdf New HiT on Uzbekistan By: M Ahmedov, R Azimov, Z Mutalova, S Huseynov, E Tsoyi, B Rechel Copenhagen: WHO Regional Office for Europe Number of pages: 168, ISSN: 1817-6119 Freely available for download at: http://www.euro.who. int/__data/assets/pdf_file/0019/270370/Uzbekistan-HiT-web. pdf?ua=1 Since the country’s independence in 1991, Uzbekistan has embarked on several major health reforms, which included changes to health financing and the primary health care system. The country has also retained some features of the Soviet period, as most health care providers are still publicly owned and administered and health workers are government employees. Health expenditure is comparatively low when compared to the rest of the WHO European Region. The government has increased public expenditure on health in recent years, but private expenditure in the form of out-of-pocket payments remains substantial. The government has implemented a basic benefits package, but, for most people, this does not include secondary or tertiary care and outpatient pharmaceuticals. Uzbekistan Health system re view Vol. 16 No. 5 2014 Health Systems in T ransition Mohir Ahmedov • Ravshan Azimov Zulkhumor Mutal ova • Shahin Hus eynov Elena Tsoyi • Ber nd Rechel This new health system review (HiT) on Uzbekistan examines the changes and reforms that have taken place and the challenges that still remain.