1. The impact of the Financial Crisis on Health and Health Systems What we do and don’t know? www.healthobservatory.eu Brussels, 21 st February 2013 Brussels, 21 st February 2013 Josep Figueras

2. Outline 0. What impact? Health expenditure trends Health system response Health levels: from crisis & health system response 1.Protect the health budget: Health & Wealth? 2.Raise extra statutory revenues: Sin taxes? 3.Ration coverage: Shifting to private expenditure? 4.Improve performance: Squeeze efficiency? 5.Strengthen Prevention: Public Health & HiAP

3. Impact of austerity on growth? Fiscal multiplier: larger impact than thought Explains damaging impact of austerity

4. What is happening to health expenditure? Source: Health at a Glance: Europe 2012 (based on OECD Health Data 2012; Eurostat Statistics Database: WHO Global Expenditure Database) Data quality Timeliness

5. WealthHealth Health Systems 1. Protect the health budget? ‘Health is Wealth’ Effects of ill health on economic growth Direct contribution to the economy Cost effectiveness Figueras J, McKee M 2011 ???

6. 2. Raise extra statutory revenues? Mladovsky P. Thomson S. Evetovits T. Cylus J. Karanikolos M. McKee M. Figueras J. 2012 SIN TAXES ?? Effectiveness of sin taxes Substitution Income effects Feasibility of implementation Subsidies

7. Source: WHO 2010 Public / Private mix funding in the EU 7 3. Ration coverage Shifting to private expenditure? R. Busse Coverage Dimensions Population (breadth) coverage Overall universal access maintained Some exceptions CZ, HU & ES (migrants) Service (benefits) coverage Limited (explicit) rationing: specific services  IVF (DK, NL), Ambulance (FR, SI) GP Home Visits (RO) Dental care, Cosmetic Surgery,... Significant (implicit) rationing  Waiting lists increases in several countries Cost (user charges) coverage Increased user charges in 13 countries  New charges: EE, FR, IE, IT, LT, NL, PT, RO, ES  Raising charges: CZ, DK, FI, FR, GR, IE, PT Services targeted  Drugs (8) Hospital (5) Ambulatory (3) A&E (2) But decrease in some (vulnerable populations)  AT, BE, GR, HU, IE, IT, LT Health Technology Assessment Priority Setting / Benefit Packages User charges evidence Cost control Access / equity

8. 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

9. Reduced / freeze professional salaries & pensions  CY, FR, GR, IE, LT, ROM  EN, PT, SI  Hospital closures, mergers,.. DK, GR, LT, PT, SI Reform provider payment methods  Reduce price for services EE, IE, RO, SI  Introduce DRGs in BG, CZ  Pay for Performance & Capitation in PHC Mladovsky P. Thomson S. Evetovits T. Cylus J. Karanikolos M. McKee M. Figueras J. 2012 4. Improve performance Squeeze efficiency Cost effectiveness ICT, Ehealth Integrated care P4P, incentives Skill mix Knowledge brokering Evidence to policy Implementaiton

10. Outline 0. What impact? Health expenditure trends Health system response Health levels: from crisis & health system response 1.Protect the health budget: Health & Wealth? 2.Raise extra statutory revenues: Sin taxes? 3.Ration coverage: Shifting to private expenditure? 4.Improve performance: Squeeze efficiency? 5.Strengthen prevention: Public Health & HiAP?

11. 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