The impact of the Financial Crisis
on Health and Health Systems
What we do and don’t know?
Brussels, 21st February 2013
Josep Figueras
www.healthobservatory.eu
Outline
0. What impact?
•
•
•
1.
2.
3.
4.
5.
Health expenditure trends
Health system response
Health levels: from crisis & health system response
Protect the health budget: Health & Wealth?
Raise extra statutory revenues: Sin taxes?
Ration coverage: Shifting to private expenditure?
Improve performance: Squeeze efficiency?
Strengthen Prevention: Public Health & HiAP
Impact of austerity on growth?
• Fiscal multiplier: larger impact than thought
• Explains damaging impact of austerity
What is happening to health expenditure?
• Data quality
• Timeliness
Source: Health at a Glance: Europe 2012 (based on OECD Health Data 2012; Eurostat Statistics Database: WHO
Global Expenditure Database)
1. Protect the health budget?
‘Health is Wealth’
Health Systems
Cost effectiveness
???
Health
Direct contribution
to the economy
Wealth
Effects of ill health on economic growth
Figueras J, McKee M 2011
2. Raise extra statutory revenues?
SIN TAXES ??
• Effectiveness of sin taxes
• Substitution
• Income effects
• Feasibility of implementation
• Subsidies
Mladovsky P. Thomson S. Evetovits T. Cylus J.
Karanikolos M. McKee M. Figueras J. 2012
3. Ration coverage
Shifting to private expenditure?
Coverage Dimensions
100%
Cost
(user
charges)
coverage
•
Health
Technology
Assessment
80%
•70% Increased
user charges
13 countries
• Priority
Setting in
/ Benefit
Packages
60% New charges: EE, FR, IE, IT, LT, NL, PT, RO, ES
• Service
User charges
evidence
(benefits)
coverage
50% Raising charges: CZ, DK, FI, FR, GR, IE, PT
•targeted
Cost control
• •40%Limited
(explicit)
rationing: specific services
Services
30%
 IVF
(DK,
Ambulance
(FR, SI) GP
• NL),
Access
/ equity
Drugs
(8)
Hospital
(5) Ambulatory
(3) Home
A&E (2)
20% Visits
(RO) Dental
care, Cosmetic
Surgery, ...
Population
(breadth)
coverage
•10% But decrease in some (vulnerable populations)
Public
/ Private
mix
funding in the EU
Significant
(implicit)
rationing
•• Overall
universal
access
maintained
0% AT, BE, GR, HU, IE, IT, LT
 Waiting
lists increases
in several
• Some
exceptions
CZ, HU
& ES countries
(migrants)
CY
BG
CH
LV
EL
SK
PT
HU
PL
SI
ES
LT
BE
FI
AT
DE
IT
MT
EE
FR
RO
IE
SE
NL
UK
NO
CZ
DK
LU
Source: WHO 2010
90%
Public
PHI
OOP
Other private
7
R. Busse
4. Improve performance
Squeeze efficiency
•
Restructuring care delivery
 Hospital closures, mergers,.. DK, GR, LT, PT, SI
 Shifting to outpatient settings IR,GR, LT
 Strengthen primary care LT,NL
•
•
Restructuring Admin. SHI & MoH - 8 countries
Pharmaceuticals & medical devices -18 countries
 Price reduction, procurement reforms
 Strengthening prescribing, promoting generics
 Positive lists, public awareness campaigns
Mladovsky P. Thomson S. Evetovits T. Cylus J.
Karanikolos M. McKee M. Figueras J. 2012
4. Improve performance
Squeeze efficiency
•
Reduced •/ freeze
professional salaries & pensions
Cost effectiveness


CY, FR, GR,•IE,ICT,
LT, ROM
Ehealth
EN, PT, SI
• Integrated care
 Hospital closures, mergers,.. DK, GR, LT, PT, SI
• P4P, incentives
• Reform provider
methods
• Skillpayment
mix
 Reduce •price
for
services
EE,
IE,
RO,
SI
Knowledge brokering
 Introduce DRGs
in
BG,
CZ
• Evidence to policy
 Pay for •Performance
&
Capitation
in
PHC
Implementaiton
Mladovsky P. Thomson S. Evetovits T. Cylus J.
Karanikolos M. McKee M. Figueras J. 2012
Outline
0. What impact?
•
•
•
1.
2.
3.
4.
5.
Health expenditure trends
Health system response
Health levels: from crisis & health system response
Protect the health budget: Health & Wealth?
Raise extra statutory revenues: Sin taxes?
Ration coverage: Shifting to private expenditure?
Improve performance: Squeeze efficiency?
Strengthen prevention: Public Health & HiAP?
Concluding
• Crisis an unprecedented opportunity for change
• Yet ...
•
•
•
•
Focus on cost containment regardless of efficiency
Not enough emphasis on long term structural reform
Public health: a missed opportunity
‘Cutting the lower branches rather than pruning’
• Lessons
•
•
•
•
Fiscal and policy preparedness
Governance, vision and leadership
Political economy /implementation
Transparency, communication and involvement