ACCESS TO HEALTHCARE IN EUROPE

Transcription

1 ACCESS TO HEALTHCARE IN EUROPE Sponsored by:

2 CONTENTS 2 About this report 3 INTRODUCTION 5 CHAPTER 1: Geographical disparities and economic gaps 7 CHAPTER 2: The role of primary care 9 CHAPTER 3: Value-based healthcare: A work in progress 11 CONCLUSION 1

3 ABOUT THIS REPORT Access to healthcare in Europe is an Economist Intelligence Unit report, commissioned by Gilead, which examines the challenges and opportunities health systems in the region face as they attempt to improve access to high-quality care that meets the needs of their populations. It is based on the findings of a global index measuring how healthcare systems across 60 countries are working to fulfil the health needs of their populations. This report is part of a regional series of a wider programme that includes a global report which summarises the global results and implications. 1 The 15 European countries included in the index are as follows: Azerbaijan, Belarus, France, Germany, Italy, Kazakhstan, the Netherlands, Poland, Romania, Russia, Spain, Turkey, the UK, Ukraine and Uzbekistan. In addition to the index findings, this report includes insights from additional desk research and five in-depth interviews with senior healthcare practitioners, academics and policymakers. Our thanks are due to the following for their time and insight (listed alphabetically): Rafael Bengoa, co-director, Institute for Health & Strategy, Bilbao, and former minister for health and consumer affairs, Basque government, Spain Francesca Colombo, head of health division, Organisation of Economic Co-operation and Development (OECD), Paris, France Johan Hjertqvist, president and owner, Health Consumer Powerhouse, Stockholm, Sweden Martin McKee, professor of European public health, London School of Hygiene and Tropical Medicine, UK; and research director, European Observatory on Health Systems and Policies Robin Osborn, vice-president and director, international health policy, Commonwealth Fund, New York, US The report was written by Andrea Chipman and edited by Martin Koehring of The Economist Intelligence Unit. June The Economist Intelligence Unit, Global Access to Healthcare. Available at: www. accesstohealthcare.eiu.com 2

4 INTRODUCTION The two domains that comprise The Economist Intelligence Unit s Global Access to Healthcare Index accessibility and healthcare systems include a number of sub-categories, all of which contribute to the ranking of the 60 countries included in the index (see chart 1). The index ranks 15 countries from each of the four broad regions of the world: Africa/Middle East, the Americas, Asia-Pacific and Europe. Within each region, countries with the largest populations were selected, representing a diversity of income levels. Population and income criteria were established in order to compare countries facing similar organisational challenges owing to their size, and to highlight achievements across income levels. 2 The accessibility domain provides a country-level snapshot of current access to prevention and treatment services across a set of disease areas: child and maternal health services; infectious diseases, such as malaria, HIV/AIDS, tuberculosis and viral hepatitis; and non-communicable diseases, such as cardiovascular diseases (CVDs), cancer and mental health. The index evaluates these areas according to a series of key performance indicators, focusing on health outcomes. The index evaluates progress within these sub-indices considering current global policy agendas, such as the Sustainable Development Goals (SDGs). In the case of the healthcare systems domain, the index measures the conditions that allow for good access to effective and relevant healthcare services, such as policy, institutions and infrastructure. The index takes a forward-looking approach to the category, namely, is the country implementing the right mechanisms today for optimal access tomorrow? Chart 1 The components of the Global Access to Healthcare Index Access to healthcare Accessibility Healthcare system Child and maternal health Coverage Infectious diseases Political will Non-communicable diseases Reach of infrastructure Access to medicines Efficiency and innovation 2 For a detailed description of the methodology, please refer to the accompanying methodology paper: The Economist Intelligence Unit, Global Access to Healthcare Index: Methodology, May Available at: methodology/ 3 Equity of access Source: The Economist Intelligence Unit, Global Access to Healthcare Index. Europe s healthcare systems generally get top marks for both their quality of care and the extent of their infrastructure, with fewer gaps in access than in most other parts of the world. This is reflected in the index, where the Netherlands, France and Germany occupy the top three places (see chart 2).

5 Chart 2 Ranking of countries from Europe in the Global Access to Healthcare Index (score out of 10) Rank in Europe (of 15) 1 =2 = =9 = Global rank (of 60) 1 Netherlands =2 France =2 Germany =4 UK =8 Italy =10 Spain =16 Kazakhstan 19 Poland =20 Romania =20 Turkey =23 Russia =30 Belarus =33 Uzbekistan =38 Azerbaijan 44 Ukraine Note: The index includes 60 countries from each of the four broad regions of the world Africa/Middle East, the Americas, Asia-Pacific and Europe representing a diversity of income levels. Source: The Economist Intelligence Unit, Global Access to Healthcare Index But there are also clear areas for improvement. Most obvious is the disparity in care provision, affordability and access to innovation between wealthier and poorer parts of the continent, with a particularly sharp divide between western and eastern Europe (see chapter 1). In addition, there are disparities in the quality of primary care between different regions of Europe (see chapter 2) Fit for purpose? The very advanced nature of the continent s health systems has led many experts to begin to question not whether the kind of care that European consumers are getting is sufficient, but whether it is fit for purpose. While patients in most European countries are less likely to fall through the affordability gap, they say, there remains sufficient disparity in quality and, in some cases, safety. One of the things that is most important is not that there is universal health coverage, but that the services are most effective and deliver the most health, says Francesca Colombo, head of the health division of the Organisation of Economic Co-operation and Development (OECD). You can have financial protection, but if health services are of poor quality, not available and not safe, then access is an issue. Yet Europe is increasingly focusing more closely on healthcare outcomes and is, to varying degrees, making progress in introducing value-based measures to evaluate care. This development, as well as increasing discussions about how to avoid expenditure on treatments that are not evidence-based, holds the promise of reducing wasteful spending and improving healthcare quality (see chapter 3). 4

6 CHAPTER 1: GEOGRAPHICAL DISPARITIES AND ECONOMIC GAPS The health insurance systems in much of western Europe are roughly divided into two different models, according to Johan Hjertqvist, president of the European Health Consumer Powerhouse, a Swedish consultancy. On the one hand, there are the so-called Bismarck systems. Named after Otto von Bismarck, a 19th-century German chancellor, they are based on a social-insurance model in which employers and employees pay jointly for insurance coverage through payroll deductions. The so-called Beveridge healthcare models, on the other hand, named after the British social reformer who designed the UK s National Health Service (NHS), are financed through tax payments. Bismarck systems, which are comprised of compulsory or competing non-profit insurance systems, deliver better outcomes, Mr Hjertqvist notes, while Beveridge models have proven competitive in smaller countries, such as the Nordic ones. 3 West European countries have had comprehensive, developed universal health coverage systems in place for more than half a century, while their eastern neighbours remain in the transition period from socialist systems which, although nominally universal, provide a more limited set of services. Consequently, east European countries such as Kazakhstan, Ukraine, Russia, Uzbekistan and Azerbaijan are ranked considerably lower than their western and European neighbours in the index. However, Belarus gets a comparatively high score, while two central European countries, Romania and Poland, are also doing relatively well (see chart 3). 3 Physicians for a National Health Program, Health Care Systems - Four Basic Models. Available at: payer_resources/health_care_systems_ four_basic_models.php 5 Chart 3 Ranking of countries from Europe in the area of population coverage of the healthcare system (score out of 10) Rank in Europe Global rank (of 15) (of 60) 1 1 Netherlands =2 France 9.2 =3 =7 Germany 8.7 =3 =7 UK =10 Turkey =12 Romania 8.5 =7 =20 Italy 7.8 =7 =20 Poland Spain Belarus 7.2 =11 =36 Kazakhstan 5.9 =11 =36 Ukraine 5.9 =13 =38 Russia 5.8 =13 =38 Uzbekistan Azerbaijan 3.6 Note: The index includes 60 countries from each of the four broad regions of the world Africa/Middle East, the Americas, Asia-Pacific and Europe representing a diversity of income levels. The metrics evaluated in this sub-domain include: sustainable financial protection, and prevention and public health services as a percentage of total health expenditure. Source: The Economist Intelligence Unit, Global Access to Healthcare Index.

7 Limited access for certain groups Even in parts of the continent which nominally guarantee universal access, certain sectors of the population are increasingly falling through the cracks, including Roma populations and illegal immigrants. Western European countries essentially all achieve universal coverage, but there are some erosions at the edge, especially in the case of undocumented migrants, says Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine and research director of the European Observatory on Health Systems and Policies. The problem with talking about universal health coverage is: universal coverage of whom? In Greece, people are losing entitlement to health coverage because they are unemployed. Spain started out from a very good level of coverage, but the Spanish government has implemented new coverage to reduce access by undocumented migrants. In the UK, there is a progressive move to reduce eligibility and impose charges for foreigners. In eastern Europe, which is still struggling to catch up with the rest of the continent, levels of public investment in health systems still lag well behind those in western Europe. For example, in 2014 countries in central and eastern Europe spent on average US$953 per capita on health (up from US$199 in 1995), but this was much lower than the euro area average of US$4, Likewise, central and east European countries spent on average 6.8% of GDP on health in 2014 (up from 5.8% in 1995), well below the euro area average of 10.4%. 5 Investment gaps also exist between north European countries and those in southern Europe, which were disproportionately affected by the global financial crisis. Even in western Europe, different health and benefit systems mean different access. In Spain, 40% co-payments can limit access to some medicines, but most other services are offered at a high level. Spain is also well ahead of many of its neighbours in the development of electronic health records (EHRs), electronic medical prescriptions and telehealth. And even in the healthcare systems with the most equal access to services, other obstacles, such as waiting times, can impede availability of services. It may be that you have generous rights, such as in Sweden, but it might take a lot of time before you can see a doctor, says Mr Hjertqvist. Indeed, a 2016 EU report found that some 18m people living in the EU in 2013 (3.6% of the population) experienced unmet need for healthcare owing to cost, travel distance or waiting time. This was an increase from 15m people facing unmet need in World Bank, Global Health Expenditure database, Health expenditure per capita (current US$). Available at: worldbank.org/indicator/sh.xpd.pcap 5 World Bank, Global Health Expenditure database, Health expenditure, total (% of GDP). Available at: org/indicator/sh.xpd.totl.zs 6 Expert Panel on Effective Way of Investing in Health (EXPH), Access to health services in the European Union, May 3rd

8 CHAPTER 2: THE ROLE OF PRIMARY CARE A strong primary-care system is especially important for boosting access to healthcare as the number of patients with chronic diseases and complex conditions increases, says Rafael Bengoa, co-director of the Institute for Health & Strategy in Bilbao, Spain, and former minister for health and consumer affairs at the Basque government. Coverage to an acute-care model that we all want to get away from is unsustainable in a chronic-disease environment with the demographics we have, he says. An ideal approach to care delivery in Europe, he adds, would be largely preventive and populationfocused, with home care, community nursing and more preventive logistics. What s happening in Spain is that there are some autonomous regions moving forward in a much more proactive and clinical way to build that model. Yet many of the incentives remain with the acute-care model. He notes that in the US, accountable care organisations (ACOs) operating in some parts of the country are taking a harder look at the evidence behind care that is provided and targeting investment in treatments and care pathways that offer the greatest value for money. Until we build a model looking like the ACOs in the US, it is going to be hard to build the type of culture where the incentives are right, so doctors and nurses have the incentive to think about the health of the populations and not just wait for them when they are sick. Primary care is particularly strong in countries where you do have a national health system, because fee-for-service tends to encourage specialisation, Professor McKee says. Mr Hjertqvist agrees that good primary-healthcare systems have a strong connection with health outcomes and expenditure. Prevention is still underdeveloped in Europe. If you could keep obesity and smoking under control and help diabetics to control their condition, you could save a lot of money. Dutch focus on primary care In 2016 a US-based private foundation, the Commonwealth Fund, conducted a survey of 11 countries health systems and found the Netherlands to be the strongest overall performer. 7 With the Netherlands also coming on top in the Global Access to Healthcare Index, this highlights the importance of a strong healthcare system as the basis for providing good access to care. The Netherlands high ranking in the Commonwealth Fund s survey was largely attributable to its investment in primary care, according to Robin Osborn, the Fund s vice-president for international health policy. They have the best access to same-day or next-day appointments, after-hours care, the lowest use of the emergency room (ER) and fewer gaps in the doctor-patient relationship. Everyone is registered with the GP [general practitioner] of their choice in the Netherlands, and the doctor knows the patient s medical history. 7 The Commonwealth Fund, International Health Policy Surveys. Available at: current-issues/international-surveys 7

9 A 2002 law gave Dutch doctors statutory responsibility for providing after-hours care. In response, Dutch doctors set up designated after-hours GP co-operatives, covering anywhere from 100,000 to 500,000 people. Most are located in the community and increasingly also next to ERs, sharing the rota for on-call. The Commonwealth Fund survey found that 72% of Dutch respondents said it was easy to get after-hours care, compared with 42% of Americans and just 34% of Canadians. 8 GPs have been pleased with the changes, Ms Osborn says, because the amount of hours they spent providing out-of-hours coverage dropped from 19 to four hours a week, giving them greater satisfaction and a better work-life balance. GP co-operatives are staffed by a medical assistant and nurse equipped with detailed protocols for triage, with the primary-care doctor available as a backup. The new system also means fewer people going to the emergency department. Another factor helping such a system work smoothly is the fact that 88% of Dutch GPs make house calls regularly, compared with 84% in the UK, 19% in Canada and just 6% in the US. 9 For frail elderly patients, in particular, house calls make access to care much easier, Ms Osborn points out. Not only do people get good access, but they [the co-operatives] have access to the patients electronic medical record and can shoot a note to the primary-care doctor. Meanwhile, more than 70% of Dutch doctors can exchange information electronically, which leads to better care co-ordination. In addition, more than 92% of practices employ case managers or nurses to help manage complex patients with chronic conditions. 10 The Dutch example could be a model for neighbouring countries, notably the UK, where emergency services are struggling with increased demand and access to general practitioners is increasingly difficult, while the government has promised to offer seven-day-access to services through the NHS Ibid. 9 Ibid. 10 Ibid. 11 NHS 7 day services, UK Department of Health, October 30th Available at: collections/nhs-7-day-services 8

10 CHAPTER 3: VALUE-BASED HEALTHCARE: A WORK IN PROGRESS Providing access to healthcare requires governments to make the necessary investments, but it is not just about how much money is spent, but how well it is spent. Mr Hjertqvist s Health Consumer Powerhouse has surveyed 35 European countries, ranking national health systems on value for money, which compares performance outcomes with the money spent to achieve them. 12 He notes that middle-income countries, such as Estonia and the Czech Republic, do well in promoting valuebased expenditure, demonstrating that there are better and worse ways of using resources. Even pay for medical staff should be evaluated on a cost-effectiveness basis, he says. If you have US salary levels, it takes away from resources. OECD health ministers are also increasingly looking at patient-reported outcomes measures, says Ms Colombo. In the case of hip replacement surgery, for example, these might involve whether patients are still in pain and whether or not they are able to walk, rather than whether the surgery was an ostensible success. All of those aspects really change the way you view accessibility. Health systems are all structured around what providers are able to do in terms of survival etc, but from an individual perspective, have particular interventions made a difference to them? We need to measure performance differently. Redefining the delivery of healthcare services to make a difference in patients lives means a wholesale reassessment of the way in which the effectiveness of health systems is evaluated, Ms Colombo adds. A major element of the OECD health ministerial meeting in January 2017 was the reinvention of health systems that are people-centred, not just provider-centred, something that the OECD has measured poorly in the past, according to Ms Colombo. Part and parcel of this transformation is not just measuring those interventions that make a difference but also those that do not, Ms Colombo says. Hence, the Global Access to Healthcare Index sub-domain for efficiency and innovation includes an indicator for the existence of mechanisms for identifying interventions for de-adoption. 12 Health Consumer Powerhouse, Euro Health Consumer Index Available at: publications/euro-health-consumerindex-2016/ 13 R Collier, Choosing Wisely concept has universal appeal, CMAJ, September 6, 2016, Vol. 188, No. 12. Available at: short?rss=1 9 Both France and Germany have recently adopted the Choosing Wisely approach to healthcare, in an effort to improve quality and reduce waste in health systems. 13 Based on an approach adopted by the US in 2012, Choosing Wisely encourages physicians to co-operate on measuring which interventions make a difference and which are provided without delivering improvements in healthcare. Growing importance of health technology assessment The increased use of health technology assessment (HTA) by European countries is also attributable to a growing emphasis on the need to target scarce health budgets carefully. There is a lot of discussion about whether the current metrics used in HTA to identify cost-effectiveness of treatment provide the right metrics and whether budget impact should be taken into account, Ms Colombo observes.

11 Institutions such as the UK s National Institute for Health and Care Excellence (NICE), Germany s Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWIG Institute for Quality and Efficiency in Healthcare) and France s Haute Autorité de Santé (HAS National Authority for Health) have been refining their systems for evaluating health technologies to determine which ones are most effective and, increasingly, which ones offer value for money. These three countries, along with the Netherlands, are leaders in efficiency and innovation not just in Europe but also globally. Thus, they top this particular sub-domain of the Global Access to Healthcare Index (see chart 4), which includes, for example, measures on the existence and independence of HTA and the existence of performance-based payment models in hospital remuneration and primary care. Chart 4 Ranking of countries from Europe in the area of efficiency and innovation of the healthcare system (score out of 10) Rank in Europe (of 15) =5 = Global rank (of 60) =6 = =25 33 =36 =41 =55 Germany France Netherlands UK Italy Spain Turkey Kazakhstan Poland Russia Romania Belarus Ukraine 2.3 Uzbekistan 2.1 Azerbaijan Note: The index includes 60 countries from each of the four broad regions of the world Africa/Middle East, the Americas, Asia-Pacific and Europe representing a diversity of income levels. The metrics evaluated in this sub-domain include: expenditure on research and development (R&D) as a percentage of GDP; existence and independence of Health Technology Assessment (HTA); existence of mechanisms for identifying interventions for de-adoption; existence of performance-based payment models in hospital remuneration; and existence of performance-based payment models in primary care. Source: The Economist Intelligence Unit, Global Access to Healthcare Index T Bochenek et al, The transparency of published health technology assessment-based recommendations on pharmaceutical reimbursement in Poland, Expert Review of Pharmacoeconomics & Outcomes Research, 2016, December, 5: At the same time, European HTA agencies are also increasingly co-operating through organisations such as the European Network for Health Technology Assessment (EUnetHTA), a process that will increase the scope for sharing data and conclusions. Multi-stakeholder co-operation will be increasingly important as more European countries are attempting to develop HTA, including in eastern Europe. Strong levels of public and patient participation, transparency and codes of conduct are crucial in this regard. 14

12 CONCLUSION European countries have some of the most extensive, highly developed and universally accessible health systems in the world. Yet health policymakers need to confront gaps in access. In particular, more investment and co-operation will be needed to get east European health systems up to the level of their western neighbours, as well as to help improve access in poorer parts of the EU, such as Greece. More work is also needed to improve primary care and preventive care in areas where they are especially weak; this area of healthcare is likely to provide the greatest value for money as health systems grapple with the rise in chronic diseases. Finally, European countries will have to develop their increasingly important HTA infrastructures to help them make better decisions about where to direct limited budgets, and also to identify money that is being spent unwisely. 11

13 While every effort has been taken to verify the accuracy of this information, The Economist Intelligence Unit Ltd. cannot accept any responsibility or liability for reliance by any person on this report or any of the information, opinions or conclusions set out in this report.

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