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Brief analytical summaries or syntheses #55

Re-orienting health systems :

Towards modern, responsive and sustainable health promoting systems


This position paper from EuroHealthNet is the culmination of a policy dialogue process with stakeholders, experts and European Union (EU) institutions to identify key contributions to sustainable health systems across Europe. The paper frames its findings in the context of the EU 2020 Europe strategy for continental growth.


The sustainability of national health systems is a core concern of the European Member States, the European Commission, and the World Health Organisation. As early as 2001, the European Commission identified ‘financial viability’ as one of three long-term objectives for national health systems, along with accessibility and quality. Since then, the development of high-quality, accessible and sustainable services has been in the spotlight of different EU policy agendas: social protection, public health, and economic and financial affairs. Initially, the issue was incorporated in the EU social protection and inclusion processes.

Health ministers addressed the issue of health systems for the first time in 2006. Stressing the importance of safeguarding overarching values of universality, access to good quality care, equity, and solidarity, they also acknowledged the challenge of reconciling individual needs with available finances. The Economic and Financial Affairs Council discussed financial sustainability of health and long-term care for the first time in 2003.

The economic and financial crisis has put pressure on public spending, including health system expenditure. In the opinion of the EU Social Protection Committee (SPC), tackling health inequalities through addressing social determinants of health can alleviate this pressure, and greater attention to health inequalities can improve healthcare efficiency. They advised accordingly, suggesting a shift of resources towards health promotion and preventive measures.

Against this backdrop, the EC Directorate for Economic & Financial Affairs (DG ECFIN) and the Economic Policy Committee (EPC) zoomed in on health systems, aiming to understand the drivers of health expenditure. In the quest for policies that strengthen financial sustainability as well as access to and quality of services, one of the most important challenges in the coming years is to get more value for money out of health sector resource allocation. The report identifies several policy challenges that need to be addressed ‘resolutely’ given the current system strengths and weaknesses. These include improving health through more effective health promotion and disease prevention in and outside the health sector.

Social innovation in health systems should push for investment in health and health equity, advocating health promotion approaches and incorporating these within the other elements of the system. As the best measure of health system performance is its impact on health outcomes, planned health system reforms should also be pre-assessed for health and health equity impact. This will provide policy makers with clearer insights into one of their key concerns: are they investing wisely and really getting the best value for money out of health sector resources.

Analysis and results

Previous work led by EuroHealthNet has illustrated the cyclical relationship between health, poverty and social inclusion. There are a many pathways via which poverty and social exclusion can lead to ill health and vice versa: ill health leading to poverty and social exclusion. Indeed, poor health and mental well-being may even be more prominent predictors of social exclusion than low income or paid employment. Public health and health promotion have a crucial, ‘upstream’ role to play in breaking this cycle.

Evidence suggests that ageing per se is not a key driver of health care costs, but accounts for only 10% of increased spending. Economic growth, higher income, new technologies and medical progress are much more powerful cost driving factors.

Comprehensive health promotion programmes, focusing on diet and physical activity offer cost-effective solutions. They would avoid tens of thousands of premature deaths (an estimated 75,000 in Italy and 70,000 in England). The cost of a comprehensive prevention strategy per life year gained, as calculated by OECD for five OECD countries is less than $20,000. Examples of preventive approaches to counteract obesity and improve health equity in children can be found in a recent overview by EuroHealthNet.

Vulnerable groups experience disproportionate amounts of morbidity and mortality. Equitable access to healthcare is therefore essential to minimise their disadvantage. Evidence gathered through cross-national and national studies strongly suggest, however, that horizontal and vertical inequities are persistent features across EU health systems. People in equal need do not receive equal treatment at all income levels, not even in EU countries with a longstanding reputation in providing rather universal and comprehensive health services coverage arrangements for their population. In addition, the relative financial burden of health systems finance is not always fairly distributed which has serious consequences for overall health.

Concern for financial sustainability and public health service budgets were identified as major policy hurdles in abolishing access barriers such as cost sharing or culturally sensitive services. Given the aspiration of Europe 2020 — two additional healthy life years for Europeans — there is, however, a world to win via targeted measures to improve health service access for disadvantaged communities. To achieve maximum impact on Europe 2020 targets, health system innovations should focus on dismantling access barriers and improving health literacy. This also includes a revision of co-payment arrangements. More traditional incentives aiming to reduce service uptake by introducing financial barriers may well have adverse effects in the longer term.

Implications and recommendations

Action on social health determinants requires involvement from other sectors as well a political commitment. But health systems and those responsible for health system stewardship do have an essential and pivotal role to play: both in advancing efforts from other sectors as well as in delivering all other functions of health systems and services. As such, health systems are a powerful social determinant of health.

In primary care, shifting service provision away from vertical, disease-oriented programmes towards horizontal community-oriented programmes promises to yield results. There is also great potential for healthcare professionals to support and empower communities and individuals taking more control over their health and well-being, especially when they join forces with local health trainers, community health champions and community development work. Until now, none of the peer reviews have been addressed to health promotion per se, but many have focused on social health determinants. Initiatives aiming to improve access to health and social services have also been subject to peer review. This is an area for potential improvement.


Re-orienting health systems : towards modern, responsive and sustainable health promoting systems

Gouvernement du Québec
© Gouvernement du Québec, 2018