November 2013

Improve governance to build resilient health care for the future

Building on the latest evidence of the impact of the economic crisis on health, the World Health Organisation has formulated ten policy action points to strengthen health systems by making them people-centred, equitable and sustainable for the future. The key to implementation lies in good governance, says Hans Kluge

There may be less money than before the financial crisis, but health care remains one of the biggest items of public expenditure across Europe. “No one wants cuts, but it is necessary to face up to the impact of the financial crisis and reflect on how to use this considerable resource to build resilient health systems for the future,” says Hans Kluge, Director of the Division of Health Systems and Public Health at the World Health Organisation (WHO) Regional Office for Europe.

The major health challenge for citizens and patients has been the increase in inequity, both within countries and between the 53 member countries of the WHO European Region. Increasing co-payments, for example, is a “policy sledgehammer” that has most impact on the poor and unemployed and which reduces  the use of both necessary and unnecessary services alike. Similarly, across the board cuts in hospital services and primary health care take no account of the quality of, or need for, those services.

What is now needed is a more nuanced, thoughtful and evidence-based approach, in which a focus on improving efficiency goes hand-in-hand with a prudent fiscal policy. “The aim is to ensure responsible management of public resources,” Kluge says.

This could mean that services are cut – if they are shown to be ineffective or inappropriate. It is also likely to result in a rationalisation of  hospital care, with resources more balanced towards public health, primary care and specialist outpatient services. In parallel, there needs to be investment in infrastructure that is less costly to run.

These “painful reforms” will have more credibility and legitimacy if there is evidence they will make for greater efficiency, if patients are involved and if health care workers are engaged more in these changes, says Kluge. “This is the way to build trust in health services.”

Facing the new financial realities

Over the past two – three years the WHO Regional Office for Europe has worked closely with the European Observatory on Health systems and Policies to generate evidence of the impact on health and the health policy responses to the economic crisis. The WHO, together with the OECD and the World Bank, has also brought together health and fiscal policy makers and other stakeholders to assess the evidence and extract the lessons. The number of EU countries benefitting from WHO’s direct technical assistance has also increased sharply since the onset of the crisis (Greece, Cyprus, Ireland, Portugal, Hungary, the Baltic States). From this work, ten principles have been formulated to steer policy makers as they face up to the new financial realities.

After the knee-jerk budgets cuts dictated by the crisis, the first of these principles states there must be a long-term approach to health system sustainability. “This speaks to the need to spend money on prevention,” Kluge says. The three per cent of health expenditure currently devoted to this area is “incredibly low”.

For the most efficient use of the total health budget, preventative measures must take a more prominent role, with strengthening of the public health elements of health systems and the promotion of health in all policies. “This calls for a whole-of-government approach: some of the most powerful determinants, for example, speed limits, are outside the responsibility of health ministers,” Kluge notes. This whole-of government and whole-of-society approach is at the heart of the WHO Health Policy, Health 2020.

Innovation in disease prevention

The WHO’s Health 2020 policy, adopted by the WHO Regional Committee for Europe in September 2012, has the overall ambition of significantly improving health and well-being of populations, to reduce health inequities and to ensure sustainable people-centred health systems. Within this, a key aim is to promote the paradigm shift needed to move health systems from a sole focus on disease, and put more emphasis on health and well-being.

This highlights the need for innovation in health promotion and disease prevention. It is heartening to see more involvement of the social sciences in the European Union’s Horizon 2020 R&D programme, which will run from 2014 – 2020, says Kluge. However, it remains the case that most of the health-related research is biomedical.

It is also necessary to see research outputs translated through to improve health. “The results must be fostered into policy, we need more knowledge translation,” Kluge says.

Alongside a long-term approach to health care sustainability and a greater emphasis on public health, the WHO principles call for fiscal policies to improve the overall performance of health systems, a safety net for the poor, efficiency gains, structural reforms, and better monitoring of, and information on, performance.

The key to enshrining these principles is good governance. The European Observatory on Health Systems and Policies has set out a framework on good health system governance to guide in its implementation, covering aspects including transparency; integrity; participation in decision-making; and planning, implementing and monitoring of reforms.

“All the evidence is that cost-effective, resilient health systems primarily result from good governance,” says Kluge. “This is the way to protect health and equity.”