health gaps in europe: eu’s old and new members albena arnaudova who/europe representation to the...
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Health gaps in Europe:EU’s old and new members
Albena Arnaudova
WHO/Europe Representation to the EU
WHO European Region: WHO European Region: 53 countries53 countries
EU 15 MS – EU MS before 2004
New EU MS after 2004Accession/Candidate CountryEEA MS
ENP Country
Source: HFA database
We compare because we know there exist:
Consistent patterns of differences in health status between these groups of countires
Consistent lack of awareness about these differences
Crosscountry comparisons, in groups or per individual countries, are an essential tool for
policy making.
N.B. Sometimes the picture is mixed – some east European countries perform equally or better than some western European countries, especially if one compares the financial resources available.
Poor and rich? REAL GDP GROWTH: the trends
0
5000
10000
15000
20000
25000
30000
1980 1985 1990 1995 2000 2005
EU15 average EU10 average N12 average
Real gross domestic product, PPP$ per capita
Some demographic essentials:Life expectancy at birth: the trends
65
70
75
80
1980 1985 1990 1995 2000 2005
EU15 average EU10 average N12 average
Life expectancy at birth, in years
<= 75
<= 70
<= 65
<= 60
<= 55
No data
EU-15: 71.7 (2002)EU-15: 71.7 (2002)
Slovenia, Poland – 65; Baltics - 62Slovenia, Poland – 65; Baltics - 62Russia, Ukraine, Moldova: 58.6 - 59.8 (2002)Russia, Ukraine, Moldova: 58.6 - 59.8 (2002)
Disability-adjusted life Disability-adjusted life expectancy, menexpectancy, men
Source: WHO/HFA database
The new EU members group is not uniform:
Probability of dying before age of 5
5,1 - EU15; 9,9 – new members
19,7 Romaina
8 Poland, 7,5 Hungary, 4,4 Cyprus
Life expectancy at birth:
79,7 EU15; 74 – new members
78 Slovenia 76 Czech Republic
72 Bulgaria
70 Latvia, Lithuania
What do people suffer from?
The 10 health questions books present comparable data on:
Cardiovascular diseases – the leading cause of death
Cancer Mental disorders Intentional and untentional injuries Repiratory diseases Infectious diseases
What do people suffer from?
Cardiovascular diseases: the trends
0
100
200
300
400
1980 1985 1990 1995 2000 2005
EU15 average EU10 average N12 average
Deaths from ischaemic heart disease per 100 000
What do people suffer from?
Cancer: the trends
200
250
300
350
400
450
500
1980 1985 1990 1995 2000 2005
EU15 average EU10 average N12 average
Cancer incidence per 100000
The new EU members group is not uniform:
Deaths from malignant neoplasms
173 - EU15; 201 – new members
230 Czech Republic, 211 Poland
156 Bulgaria, 123 Cyprus
Deaths from diabetes, all ages
13, EU15; 12,7 – new members
22 Malta, 18,7 Slovenia
15,6 Estonia, 12 Slovakia
7,8 Latvia
The new EU members group is not uniform:
Mental disorders and disease of the nervous system
31 - EU15; 15 – new members 29,8 Estonia, 22 Hungary
11 Romania, 12 Slovakia Smoking related causes of death
200, EU15; 390 – new members548 Lithuania, 509 Romania407 Bulgaria, 477 Hungary283 Poland, 215 Slovenia
Some causesThe socio-economic determinants of health have
different pattern in different parts of the Region.
N.B. The present situation is a result of 15 years accumulation of these factors.
In societies in transition:
Reforms shake the whole society and its support systems. Increasing number of people fall under the poverty line. Access to services is constrained. Quality and appropriateness of health services Increasing pockets of population with high vulnerability Lifestyle patterns, environmental risks Governance and health systems
The underlying factorsThe underlying factors
Lifestyle and socioeconomic context- traditional risk factors: alcohol, tobacco, diet- men with poor education especially vulnerable: mortality
much higher among men with the least education compared to the well educated (link with alcohol)
- possible impact of low levels of social support and lack of control over one’s live
- direct effects of factors linked to material deprivation and poverty
Health care – health systems dimension
Is it only about rich and poor?
The economical situation explains many of
these results… but not all!
Can anything be done to accelerate health gain?
Or should countries wait
until they get richer, as the
only alternative…
Health has to do with
economic development
democracy and values
health system effectiveness
“Health Systems Constraints
are impeding the
implementation of major global
initiatives for health and the
attainment of the Millennium
Development Goals”
Lancet, 2004
While little can be done to accelerate the
economic growth, a lot can be done to
improve the performance of health
systems.
Strengthening Health Systems
aims at helping Member States
overcome such challenges
Not such a thing as a EU new member health system
Common challenges (transition, pre-accession…) but diversity: • Varying political & socio-economic
contexts • Differing speed and pendulum effect for
some countries
Health systems in the EU’s new members
Health system challenges Health system challenges
in the new EU membersin the new EU members
1. Strengthening health financing2. Reconfiguring the continuum of care3. Improving the quality of health services4. Investing in public health5. Stepping up the stewardship role of the
Ministry of Health
• Cost pressures against insufficient resources• Most new EU members neighbours adopted
Social Health Insurance• Challenges to the new health insurance systems
• Ability to raise taxes, unemployment, informal economy• Commitment to universal coverage but access problems • Low compliance and burden on labour costs • Significant (informal) out of pocket payments • Financial sustainability improved with economic growth
• Moving towards performance related payment• But major implementation constraints
(skills, information systems)
StrengtheningStrengthening health health financingfinancing
• Restructuring hospitals• Political obstacles to hospital closure but some success• Reduction in bed numbers is not enough• Developing cost effective alternatives: substitution
• Improvement of hospital performance• Further investment in facilities and equipment• Further management autonomy• Decentralization of ownership to municipalities • But poor capacity and skills
• Strengthening primary care - Progress with the introduction of family
medicine - GP privatisation / self contracted - But lower income and professional recognition - Limited gate keeping effectiveness - Step up training programmes, setting of
professional bodies and incentive policies
Reconfiguring the continuum of Reconfiguring the continuum of carecare
men
Age-standardised death rates(0-74) from Age-standardised death rates(0-74) from treatable causes, 1990/91 & 2000/02treatable causes, 1990/91 & 2000/02
0 50 100 150 200 250 300
SwedenNetherlands
FranceSpain
ItalyUK
GermanyIrelandFinlandAustria
SloveniaLithuaniaPortugal
PolandCzech Republic
EstoniaLatvia
HungaryBulgariaRomania
deaths / 100,000
1990/91
2000/02
Source: Newey, Nolte, McKee & Mossialos, 2004
Improving the quality of Improving the quality of services services
• Strengthening quality improvement systems• Evidence base medicine is still a challenge, widespread use of
ineffective interventions• Some progress with accreditation systems
• Increased use of guidelines and protocols • Improving the quality of health
professionals• Addressing over supply and skill mix
imbalances e.g. public health, nursing, family practitioners
• Strengthening professional standards, retraining
• Incentives and motivation• Addressing ‘Brain drain’ and ‘Domino
effect’
Investing in public healthInvesting in public health
• Restructuring public health services• Fragmentation and under investment
• Strengthening intersectoral action / Health in All Policies• Blocks to intersectoral action: medicalization, lack of
collaboration, obstacles enforcing legislation
• Advocacy: `Health is Wealth`• The contribution of health to the economy• Human capital and economic productivity
Central in implementation of reforms• Pluralism of provision, privatisation, market
competition,.... • Advocacy, information transparency & regulation
More difficult to `steer than to row`• Feasibility, credibility and capacity issues• Difficult change in culture ´command and control‘
Weak status of MoH against SHI, MoF,....
Stepping up stewardship Stepping up stewardship role of Ministries of Healthrole of Ministries of Health
Strengthening Health Systems
in support to Member States
Our message:
Beyond health care: health systems for health and wealth (Health Systems)
Invest in health, invest in the future (Wealth)
Strengthened health systems save more lives (Health)
WHO European Ministerial Conference on Health WHO European Ministerial Conference on Health Systems: Health Systems, Health and Wealth”Systems: Health Systems, Health and Wealth”
Tallinn, June 2008Tallinn, June 2008
Key objectives of the WHO European Ministerial Key objectives of the WHO European Ministerial Conference on Health SystemsConference on Health Systems
- Better understanding of the impact of health systems on people’s health and on economic growth in the WHO European Region;
- Take stock of recent evidence on effective strategies to improve the performance of health systems, given the increasing pressures on them to ensure sustainability and solidarity.
- Explore the dynamic relationship between health systems/health/ wealth.
Global health indicators keep improving …
But not in all places, not for all social groups and not at the same speed.
Globally: we know a lotGlobally: we know a lotdistribution of income and wealthdistribution of income and wealth
Richest 20% of the Richest 20% of the world’s population hold world’s population hold 75% of the world’s 75% of the world’s wealthwealth
Poorest 40% holds 5% Poorest 40% holds 5% of the world’s wealthof the world’s wealth
Corresponds approx to Corresponds approx to 2 billion people living 2 billion people living on less than $2 a dayon less than $2 a day
Human Development Report 2005
Between social groups: we know a lotBetween social groups: we know a lotMortality according to level in the Mortality according to level in the
occupational hierarchyoccupational hierarchy
0
10
20
30
40
50
60
70
80
40-64yrs 65-69yrs 70-89yrsAll
cau
se m
ort
alit
y (p
er 1
000
per
son
yrs
)
Admin Prof/Exec Clerical Other
Between social groups: we know a lotBetween social groups: we know a lot The widening mortality gap between the The widening mortality gap between the
social classes: England and Walessocial classes: England and Wales
Source: Tackling Health Inequalities: a programme for action Dept of Health 2003
Is there a gap in knowledge then?
The Regions of Europe
How does health status differ between Regions?
How to improve knowledge and make it available to regional policy makers?
What can be done to bring health gains equally to all Regions?
How can WHO help do that?
www.euro.who.int