What is the EU’s contribution to health system performance?

Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 21 WHAT IS THE EU’S CONTRIBUTION TO HEALTH SYSTEM PERFORMANCE? By: Matthias Wismar, Scott L Greer and Nick Fahy Summary: Countries throughout Europe are striving to improve the performance of their health systems, and their impact on public finances is increasingly important. The European Union is playing a stronger role than hitherto in this area, with specific recommendations to countries on reforming health systems, and investment into health systems available from European funds, alongside its broadly positive but fragmented impact on health as a whole. As Europe emerges from the financial crisis and the strategic agenda of the Juncker Commission is developed, understanding the potential impact and contribution of Europe to health is more important than ever. Keywords: Health Policy, Public Finances, Financial Crisis, European Union Matthias Wismar is Senior Health Policy Analyst, European Observatory on Health Systems and Policies, Brussels, Belgium. Scott L. Greer is Associate Professor, Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA and Research Associate at the European Observatory on Health Systems and Policies, Brussels, Belgium. Nick Fahy is an independent consultant and PhD student at Queen Mary University of London, United Kingdom. Email: mwi@obs.euro.who.int The policy context All countries in Europe are striving to improve the performance of their health systems. Policy-makers are aiming at better returns from time, effort and monies invested in health systems. They are also seeking to eliminate or reduce the waste in health systems caused, for example, by over- and mal-treatment or the use of ineffective or overly expensive procedures and products. Needless to say, that in times of austerity many countries are confronted with growing health demands and dwindling public budgets, putting extra pressures on them to get more value for money. It is easy to postulate the quest for efficiency, but it is harder to define and agree on desired outcomes vis-à-vis the investment. The Council of Ministers has provided some orientation as it established specific health systems values in 2006 that can serve as goals for performance. The Council emphasised the “overarching values of universality, access to good quality care, equity, and solidarity” and “operating principles” of quality, safety, evidence and ethics, patient involvement, redress, and privacy and confidentiality. In other words, health system performance would be assessed against the ability to serve the whole population, to extend life expectancy and improve health-related quality of life, to do so regardless of social status and to distribute the burden of health care funding in a fair manner. These Council conclusions have no binding character. They were developed in the context of a wider debate on cross- border patient mobility in which Ministers of Health were eager to clarify that health systems objectives are separate from other sectors’ policies and objectives. 1 ➤ #EHFG2014 Forum 6: Health System Performance Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 22 Efficiency and health system performance increasingly play an important role for the European Commission. In 2010 the EU started to send Member States country-specific recommendations (CSR). These CSRs are part of the European Semester, a form of fiscal governance, designed to contribute to fiscal discipline and economic recovery in a crisis- ridden Europe. The recommendations made on health systems focus largely on financial sustainability and are pushing for structural reforms to improve efficiency. Within the Commission, the Directorate-General for Economic and Financial Affairs (ECFIN) is leading the development of the CSRs, but the conceptual basis of the assessment is not entirely clear. Recently, as mandated by the Social Protection Committee, the Directorate-General for Employment, Social Affairs and Inclusion (EMPL) has started developing a Joint Assessment Framework for health systems in the context of the Open Method of Co- ordination (OMC) but also with relevance to the CSR. This framework focuses on access, quality, efficiency and contextual factors, including equity-related factors, 2 and is therefore not so dissimilar from the values and principles suggested by the Council of Ministers. In the context of the social investment package designed to contribute to economic recovery in Europe, the Commission is also aiming to address the needs of health systems. It is making the case for investment in health and pointing at various areas where Member States can improve the efficiency of health systems. Among the suggestions are many examples for raising health systems performance: “using financial incentives to encourage patients to register with a general practitioner (GP) or family doctor, […] introducing activity- and/or quality- based payment for diagnosis-related groups, […] ensuring a more balanced mix of staff skills, […] reducing unnecessary use of specialists and hospital care, […] better health promotion and disease prevention in and outside the health sector, […] improving data collection, [… ] using health technology assessment more systematically, [… and] the use of less expensive equivalent (generic) drugs”. 3 What is the European Union’s contribution to health systems performance? The EU is not just making recommendations on how to improve health system performance. The EU has in some policy areas exclusive or shared competencies allowing for legislating and adopting legally binding acts. It is therefore shaping–or helping to shape– policies that impact on health and health systems and their performance. And this impact is bigger than one may think. There are several health-related articles in the Treaty on the Functioning of the EU (art. 168 public health, art. 169 consumer protection, art. 191 environment, art. 153 working environment). These articles provides the legal mandate for Community action on tobacco, alcohol, environmental determinants, climate changes, diet, nutrition and physical activity, health and safety in the workplace, consumer protection and communicable diseases. It also includes information, comparison and benchmarking and actions on substances of human origin. The intensity and instruments chosen to tackle these areas vary greatly, but the actions are very relevant with regards to unburdening health systems from diseases amenable to prevention and health promotion – one way to strengthen health system performance. 4 ‘‘ The EU is helping to shape policies that impact on health A more indirect but often more substantial impact on health system performance is caused by the internal market, the coordination of social security systems, and fiscal governance. The so-called four freedoms – the free movement of goods, services, people and capital within the EU’s internal market – is also the free movement of pharmaceuticals, medical devices, diagnosis and therapy and patients. This includes a plethora of specific issues like procurement, competition law, cross-border collaboration, European reference networks, e-health, European prescription, just to name a few, which have, undoubtedly, an impact on health system performance. The EU has various instruments to implement these policies, programmes and actions. Directives: The Directives on the recognition of professional qualifications (health professional mobility), the Directive on patient rights in cross-border health care and the tobacco products Directive are examples of key legislation with major impact on health and health systems. Agencies: There are plenty of agencies working in health-related fields: the European Centre for Disease Prevention and Control (ECDC), the European Food Safety Authority (EFSA), the European Medicines Agency (EMA), the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the European Environment Agency (EEA) and the European Agency for Safety and Health at Work. (With a slightly different legal status, there is also the Consumers, Health and Food Executive Agency (CHAFEA). Joint action (JA): JAs are a way of collaboration between Member States, their competent authorities and the Commission. Examples under the health programme are the JA on Health Inequalities, 5 JA on Health Workforce Planning and Forecasting 6 and the JA on Comprehensive Cancer Control. 7 Budgets: There is the health programme budget, although this is rather seed money in comparison with the more substantial budgets of the Cohesion policy. In addition, the health-related funds of the Horizon 2020 research programme contribute to health. Fiscal governance: The European Semester, an annual review cycle, holds together a host of surveillance, assessment, benchmarking and recommendation Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 23 mechanisms based in a consciously expanding base on economic policies aimed at controlling public budgets. Clearly, the EU has the mandate and instruments to impact on health and health system performance. But is there really sufficient policy consistency and is it focusing on the key issues? ‘‘ The fragmented nature of EU action on health makes it difficult to gain an overall picture Electing health – electing performance? With the recent European Parliament elections, fundamental discussions on the future direction of European Integration entered the political centre stage sometimes resulting in strictly opposing positions. Big themes like peace, economic growth, sovereignty and democracy were brought forward in the debate. These are certainly key themes; however, if we want to do justice to health systems and their specific goals, if we are to ask what benefits health systems performance, we would look at the EU and health from a more functional, if not technocratic angle: what can the EU add that Member States have difficulties to achieve by themselves? Reviewing past contributions, the EU has clearly helped to improve health by addressing environmental determinants; European citizens are amongst the best protected in the world in terms of exposure to chemicals or pollution, for example. The EU has made progress in addressing key social determinants, such as health and safety at work, but the impact of wider social inequalities on health remains. This cannot be blamed on a lack of legal powers to act (unlike health, the social powers in the Treaty are wide-ranging), but rather on a clear preference by national governments to address social issues domestically, rather than at European level, and likewise to keep the overwhelming weight of financial tools under national control. The EU has also made some progress in addressing the behavioural determinants of health, but most strongly for smoking. For diet and exercise or the particularly European issue of alcohol, European action has been broadly limited to providing information and leaving choices to individuals. This broadly positive impact is not widely understood, though. The fragmented nature of the EU’s action on health – being taken across a wide range of legal bases, many of which do not have health as an objective – makes it difficult to gain an overall picture. This consequently makes it difficult for health stakeholders to be part of shaping the EU’s health- related discussions, when so much of the discussion and decision-making takes place in forums which are not primarily focused on health. The qualitative nature of much European health cooperation – building networks, providing comparable data for benchmarking, sharing good practice – has done a great deal to improve health, too, but works in ways that are hard to quantify and demonstrate. Often, EU activity based on internal market, competition, or trade law has received the attention – justly, as in the cases of EU action on trade in essential medicines or cross-border patient mobility. Meanwhile, the development of EU fiscal governance is potentially important but it is difficult to say how much, or what, it will mean for health services. In response to the fiscal crises of various EU Member States after 2008, the EU strengthened its existing fiscal governance regime in order to more effectively monitor Member States’ fiscal policies, economic situation, and policies that might in the future lead to imbalances. Given the public expenditure of health systems, it is no surprise that fiscal governance mechanisms start to make recommendations about health system reform. It remains to be seen how effective the fiscal governance system, notably the European Semester, is at changing health policies or stabilising economies for growth, but it is worth following. It is therefore overdue to have an informed debate on the achievements and prospects of the EU in health and health systems and on the appropriate areas of, and instruments for, action. Only if we are prepared to asked these questions on the linkages between EU and health can we make informed decisions on electing health and improving health system performance at European and Member State level. References 1 European Council. Council Conclusions on Common values and principles in European Union Health Systems (2006/C 146/01), 22 June 2006. 2 Social Protection Committee. Developing an assessment framework in the area of health based on the Joint Assessment Framework methodology: final report to the SPC on the first stage of implementation, 19 November 2013. Available at: file:///H:/JAF%20 health%20document.pdf 3 European Commission. Social Investment Package. Investing in Health Commission Staff Working Document SWD (2013) 43 final. Available at: http://ec.europa.eu/health/strategy/ docs/swd_investing_in_health.pdf 4 Greer SL et al. Everything you always wanted to know about European Union Health Policies but were afraid to ask. Copenhagen: European Observatory on Health Systems and Policies, 2014 (forthcoming). 5 Equity Action was the EU-funded Joint Action on Health Inequalities (February 2011– February 2014). Available at: http://www.health-inequalities.eu/ HEALTHEQUITY/EN/projects/equity_action/ 6 Joint action on health workforce planning and forecasting web site. Available at: http://www. euhwforce.eu/ 7 European Commission. Kick-off meeting of the Comprehensive Cancer Control Joint Action (CANCON), Luxembourg, 11 – 13 March 2014. Available at: http://ec.europa.eu/dgs/health_ consumer/dyna/enews/enews.cfm?al_id=1461