«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»
The management of health systems in
the EU Member States - The role of
local and regional authorities
The study was written by Progress Consulting S.r.l. and Living Prospects Ltd.
It does not represent the official views of the Committee of the Regions.
More information on the European Union and the Committee of the Regions is available
online at http://www.europa.eu and http://www.cor.europa.eu respectively.
Catalogue number : QG-30-11-072-EN-N
ISBN : 978-92-895-0717-2 DOI : 10.2863/83500 © 2012, European Union Partial reproduction is allowed, provided that the source is explicitly mentioned.
Table of Contents
2.2 Country profiles
3. Typology of health care systems
3.1 Some of the main existing models or classifications
3.1.1 Health care funding
3.1.2 Public/private financing and types of health care providers......... 101 3.1.3 Institutional features of health systems
3.1.4 Hospital governance
3.2 Methodological approach
3.2.1 Criteria considered
3.2.2 Outlining types
3.3 A new typology of health management systems
4. Conclusions and recommendations
Appendix I – List of references
1. Summary Health systems across the European Union (EU) are managed in very different ways. This report focuses on the role of local and regional authorities (LRAs) within these systems in terms of power and responsibility, from the issuing of legislation to policy development, implementation and funding.
LRAs play a significant role with regard to health issues. This role often reflects the constitutionalstructure of the country in question. However, there are several factors which complicate this simple relationship, such as the prevailing type of hospital governance or the LRA’s competence for raising the financial resources to be invested in health locally.
The study has three aims: (i) compiling an inventory outlining the type of prevailing management within health systems across the EU; (ii) proposing a typology of health management systems on the basis of some key competences held by LRAs within the systems; and (iii) highlighting, on the grounds of the evidence gathered, those health-related policy areas where local and regional inputs may potentially add value to EU policy development processes.
Chapter 2 includes the health management system profiles of 27 EU Member States (MS). The profiles outline the structure of the health systems, main actors and responsibilities; modalities for the delivery of health care services; financing mechanisms; and main types of expenditure. Although focussing on the role of LRAs, setting the institutional scene upstream (national level) and briefly describing the recipient catchment downstream (beneficiaries of the services and types of services) were necessary steps for understanding the framework in which LRAs intervene. The profiles are the result of the desk review of existing and publicly available literature and of information made available online by the relevant national authorities. Therefore, there may begaps in the information provided and it is not possible to present the same information systematically for all countries, although efforts are being made in this direction.
Some major sources deserve a special mention as being among the most important and comprehensive references: these are the health system profiles prepared by the European Observatory on Health Systems and Policies and published by the World Health Organization, in particular with regard to countries recently reviewed.
A number of health systems are undergoing reform. Reforms often address funding mechanisms and the purchaser/provider relationship. Some of these reform processes started some time ago and face evident difficulties in being implemented; others are a direct consequence of increasing health expenditure, driven, among other things, by the economic downturn and related occupational crisis (several systems have an occupation-based mechanism for contributing to statutory health insurance) as well as by important demographic changes (ageing population). In other cases, the constitutional structure of countries could allow for a deeper participation of LRAs in health management but this is not the case yet, largely due to financial constraints. All these situations make the inventory a snapshot that will change in the near future.
In Chapter 3, a typology of existing health management systems across the EU is outlined. Classifications of health care systems have traditionally been articulated around the types of funding mechanism for health care or on the basis of the prevailing contractual relationships between health care service providers and payers. These elements allow an analysis of the financial sustainability of the systems, and corresponding classifications are aimed at supporting decisions on the efficiency and effectiveness of expenditure.
However, in the last Joint EPC/EC Report on health systems it was highlighted how the understanding of drivers of health expenditure and of overall performance also requires an understanding of the organisational features of the systems. Research efforts in this area are acknowledged to be limited, with the survey undertaken by the OECD in 2008 among its member countries representing the most systematic and recent effort in this sense.
The dimensions to be considered for a classification are determined by the scope of the classification. In this study, the proposed typology was therefore built on a number of dimensions directly or indirectly correlated to the traditional classifications but all characterised by a clearly distinguishable regional and/or local contribution. In addition, as the types of hospital governance were found to be significantly related to the level of decentralisation of health management systems, ownership and management of health care facilities were also considered in the clustering process.
The proposed typology was outlined with respect to the following criteria: (i) presence/absence of LRA responsibility in health funding and level of health funding at the sub-national level, as a percentage of total sub-national public sector expenditure; (ii) presence/absence of power/responsibility of LRAs with regard to the following functions: health-related legislation, planning of health care services, and delivery (implementation) of health care services; and (iii) ownership and/or management of health care facilities, in particular hospitals, by LRAs.
The clustering process has outlined five main types of health management systems across Europe with respect to the role played by local and regional actors. Type 1 (decentralised systems) includes de facto ‘regional health management systems’, i.e. management systems whose regulation, operation and also co-funding are delegated to regional authorities (Italy and Spain) or States (Austria). Within this type, funding through sub-national budgets is well above the EU27 average of 12.9% of sub-national budget contributed to health1 and sub-national authorities also own and manage health care facilities. Type 2 includes those health management systems where local and regional governments are responsible for several planning and implementation functions, besides co-funding; in this type LRAs also own and manage health care facilities. A further distinction of the type into sub-types is possible on the basis of the level of co-funding from sub-national budgets (above or below the EU average). Type 2 may be referred to as partially decentralised systems.
Type 3 refers to health management systems where local and regional authorities have operational (implementation) functions, including as a consequence of owning health care facilities; co-funding from sub-national budgets is limited. There are two unusual situations in type 3: the Netherlands and the United Kingdom. In the Netherlands, hospital governance is centralised but LRAs have a role in planning and implementation, and provide a limited funding contribution from the sub-national budget. As the ‘operative’ function Council of European Municipalities and Regions & Dexia (2009) of Dutch local authorities is evident, their health management system has been categorised within this type (operatively decentralised systems). In the UK, each of the four constituent countries (England, Scotland, Wales, and Northern Ireland) has its own ‘National Health Service’ managed at the level of constituent country and thus falling into type 3, even if within each constituency a ‘centralised but structured at the territorial level’ system applies.
Types 4 and 5 are characterised by health management systems that are centralised (type 5) or centralised but structured at the territorial level (type 4); in type 4, most of the responsibilities lie with the central government even if implementation is at the territorial level through bodies or agencies representing the central administration; additionally, with the exception of Portugal, LRAs of type 4 systems may also manage health care facilities.
In the light of the important role played by LRAs in health care development and delivery of services across the EU, additional input from the local and regional level within relevant EU committees, working parties or expert groups would be beneficial to discussions feeding health policy development, as it would bring policy-making closer to real needs and make it more demanddriven.
Chapter 4 focuses on highlighting specific areas where local and regional input could add value in terms of policy development. These highlights are based on the evidence gathered through the inventory compiled in Chapter 2 and through other recent investigations by the Committee of the Regions, and do not enter into the merit of feasibility of, or modalities for, a higher degree of participation by LRAs in EU processes. However, since the topics are usually relevant for more than one type of health management system, a structured representation of LRAs by means of existing bodies, such as the Committee of the Regions or associations of regions, is recommended.
There is scope for input by LRAs through their representing bodies in the
following policy domains:
(i) Nutrition and Physical Activity, in particular with regard to: the enrichment of the knowledge base with experiences from the local and regional level; the proposal of new policy ideas; the acceleration of the creation of PPP through direct involvement of LRAs with the private sector.
(ii) Social Determinants of Health and Health Inequalities, in particular with regard to: monitoring the impact of the crisis at the local and regional level, including indicator development and modalities for streamlining data and indicator-based evidence into the policy-making process; developing integrated regional strategies to reduce health inequalities or ‘local care approaches’; promoting telemedicine;
partnering across border regions to reduce access inequalities by making facilities and personnel available across borders; determining the requirements for the enhancement of public health capacity at the local and regional levels through training on equity in health approaches across policy sectors.
(iii) Cross-border Health Care, in particular with regard to: monitoring respect of the subsidiarity principle and of the social, economic and financial impact of the EU Directive on patients’ rights in cross-border health care on health systems at the local and regional level, including the effect on patient inflows and outflows and reduction of health inequalities.
(iv) Implementation of the European Health Strategy as well as the shaping of Europe 2020 health objectives and making health a thematic priority for investment, along with better use of EU cohesion policy and structural funds.
(v) Data Protection, in particular by providing input on specificities related to health data on the basis of experiences made by LRAs.
2.1 Introduction This chapter includes the health management system profiles of 27 EU Member States. Profiles outline the structure of the health systems, main actors and responsibilities; modalities for the delivery of health care services; financing mechanisms; and main types of expenditure. This inventory is intended to provide a snapshot of the main features of health management systems across Europe. Even though the focus of the report is on the role of local and regional authorities (LRAs) with regard to health matters, from policy and regulation to planning, implementation and funding of health care, it was nevertheless necessary to set the institutional scene upstream (national level) and briefly describe the recipient catchment downstream (beneficiaries of the services and types of services) in order to understand the framework in which LRAs intervene.
Profiles have been developed on the basis of desk research. The most important sources of information are the health system reviews prepared by the European Observatory on Health Systems and Policies and published by the World Health Organization.2 Other good references, mainly for gathering an indication of latest developments, are the 2009 or 2010 annual national reports on pensions, health and long-term care prepared by the Analytical Support on the SocioEconomic Impact of Social Protection Reforms (ASISP).3 Hospital governancerelated information was gathered through the European Hospital and Healthcare Federation (HOPE) country profiles, available on-line and related to information updated to 2007, and through the 2009 report by HOPE and Dexia on hospitals in the EU. 4,5 All profiles are available at: http://www.euro.who.int/en/home/projects/observatory/publications/health-systemprofiles-hits/full-list-of-hits The Analytical Support on the Socio-Economic Impact of Social Protection Reforms (ASISP) is a network of independent experts established by the European Commission. The network prepares annually 34 country reports on pensions, health, and long-term care evaluating latest developments and reforms undertaken in these policy areas.