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«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»

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The inventory provides the following evidence:

Ownership of health care facilities by LRAs is common in 19 countries.

Ownership always implies the management of health care facilities that may be direct or indirect through contractors.

In three countries LRAs are responsible for the management of health care facilities without owning them.

In four countries LRAs do not own health care facilities, nor do they manage them.

3.2.2 Outlining the types The types were outlined following a simple labelling exercise of countries with respect to the criteria presented under 3.2.1.

When LRAs contribute to the funding of health care and raise financial resources locally through, for example, taxation, the corresponding countries have been labelled ‘max’; if funding is only channelled through LRAs but provided by the state or if LRAs do not handle health-related financial resources at all, the corresponding countries were labelled ‘0’. With respect to the level of funding, three categories were distinguished: (i) countries where LRA funding is above the EU27 average of 12.9% of sub-national budget contributed to health (labelled ‘max’); (ii) countries where LRA funding is below the EU27 average (labelled ‘min’); (iii) countries where LRAs do not fund health through a subnational budget (labelled ‘0’).

Legislative power on health matters was given high relevance as it affects the way health management systems are structured and operated. Where LRAs have legislative power, the reference may, in fact, straightforwardly be to ‘regional health systems’: corresponding countries were labelled ‘max’. Countries where there is no evidence of legislative power by LRAs for health-related matters were labelled ‘0’.

With respect to planning and implementation functions, countries were distinguished into three groups: (i) countries where LRAs have both planning and implementation functions (labelled ‘max’); (ii) countries where LRAs exercise only one of the two functions (labelled ‘min’); and (iii) countries where LRAs have no planning and implementation functions with respect to health (labelled ‘0’).

Finally, with regard to the ownership and management of health care facilities, countries were also distinguished into three groups: (i) countries where LRAs own and manage (directly or indirectly) health care facilities (labelled ‘max’);

(ii) countries where LRAs only manage health care facilities but do not own them (labelled ‘min’); and (iii) countries where LRAs do not own or manage health care facilities (labelled ‘0’).

3.3 A new typology of health management systems Table 4 summarises the proposed new typology according to the criteria and approach presented in sections 3.2.1 and 3.2.2.

Five types of health management systems at the local and regional level are distinguished within the proposed typology.

Type 1 includes ‘regional health management systems’, i.e. whose regulation, management, operation and partially also funding is delegated to regional authorities or States. Funding through sub-national budgets is above the EU average 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 funding; further, they own and manage health care facilities. Within this type, sub-types are distinguished on the basis of the level of funding from subnational budgets (above or below the EU average).

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; funding from sub-national budgets is limited. The Netherlands are in a peculiar position; they are centralised with respect to hospital governance, but LRAs have a role in planning and implementation, including limited funding contribution from the sub-national budget. As the ‘operative’ function of Dutch local authorities is evident, their health management system has been attributed to this type. Another particular case is that of the United Kingdom, as each of its four constituent countries (England, Scotland, Wales, and Northern Ireland) has its own ‘National Health Service’ but within each constituency the prevailing type refers to a system that is ‘centralised but structured at the territorial level’. The UK has been attributed to type 3 according to the ‘operative’ function of the four constituencies.

Types 4 and 5 are characterised by health management systems that are centralised in full (type 5) or to a great extent (type 4); in type 4, most of the responsibilities lie with the central government even if implementation is at the territorial level through bodies representing the central administration;

additionally, with the exception of Portugal, LRAs of a type 4 system may also manage health care facilities.

Table 4 – Proposed new typology of health management systems

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4. Conclusions and recommendations

4.1 Conclusions LRAs commonly implement tasks related to public health. Notably, these tasks are a prerogative of LRAs also when the actual delivery of services is partially or fully centralised. Consequently, LRAs are affected by decisions related to health promotion and disease prevention, several of which fall under Objective 1 ‘Fostering good health in an ageing Europe’ of the EU Health Strategy.24 Additionally, LRAs are often specifically responsible for the provision of services to the youth and the elderly. For the latter, these services also include long-term care.

In particular, ageing is a process that is affecting Europe in different ways.

There are ‘old’ and ‘relatively young’ regions that will face diverse challenges according to the dynamics of their population. Population ageing is expected to impact public expenditure for health and long-term care, the demand for health services, and the need for health professionals and workforce (Committee of the Regions, 2011b). Thus, the existence of very diverse situations across the EU and the important role played by LRAs in fostering the healthy ageing of the population make it imperative to take into account experiences and trends occurring at the territorial level while shaping health policies.

LRAs from 21 MS are involved in the territorial management of health systems, from a highly decentralised level where policy and regulatory issues are handled locally, to an operatively decentralised management level. LRAs significantly25 involved in the funding of health care are found in ten MS, in most cases generating resources through local taxation. Further, LRAs from 19 MS own and manage health care facilities for the delivery of primary or secondary care, or of long-term care services. As a logical consequence of this Among the issues related to the fostering of good health are, for example: nutrition, physical activity, consumption of alcohol, drugs and tobacco, environmental risks, and accidents i.e. above the EU27 average of 12.9% of sub-national budget contributed to health, according to data from the Council of European Municipalities and Regions & Dexia (2009) evidence, it seems important for the views and interests of LRAs to be systematically taken into account while shaping and implementing policies affecting health management systems, as these systems, in several MS, are under the direct responsibility and power of territorial administrations.

Health management systems-related topics that are relevant to LRAs fall both under Objective 1 of the EU Health Strategy, for example with regard to health inequalities, and under Objective 3 ‘Supporting dynamic health systems’ with regard to health workforce, cross-border health care, patient safety and quality of care. On the other hand, patient safety and quality of care are both relevant to the development of ICT applications for health. Since there is the evidence of an important level of involvement by LRAs in the development of regional and/or hospital information systems (Committee of the Regions, 2011a), data protection is also an issue to be considered when fostering local and regional input into health decision-making processes at the EU level.

Considering 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 committees, working parties or expert groups would be beneficial to discussions contributing to health policy development. Such input would, among other things, bring policy-making closer to real needs and make it more demand driven. Therefore, rather than the sporadic participation of individual administrations, a more structured participation by LRAs, either through their associations or consultative body, is needed.

It is acknowledged that detailed procedures already exist for assisting the Commission in drafting legislation and identifying measures for its implementation. Thus, suggestions for involvement do not enter into the merit of feasibility of, or modalities for, a higher degree of participation by LRAs.

Instead, they point to the level of representation that should be fostered within existing committees or working/expert groups, on the basis of the relevance to LRAs in general or to the type of health management system, as identified under chapter 3, in particular, of the topics handled by these committees and working/expert groups.

Types of formal cooperation mechanisms Comitology committees assist the Commission by providing formal opinions on measures intended to implement EU legislation. Members of these committees are EU MS representatives. These committees are set up by the Council or by the Council and the European Parliament.

Commission expert groups are forums for discussion and provide high-level input to the Commission for the preparation of legislation or implementation of legislation, programmes and policies. Input is provided in the form of

opinions, recommendations and reports. Members of these expert groups are:

individuals in a personal capacity, individuals representing common interests, organisations, and authorities (including at the local and regional level).

4.2 Recommendations There are several committees and working/expert groups at the EU level that are dealing with health-related topics partially or totally falling under the power and/or responsibility of LRAs. Some of these committees and groups where a structured participation of LRAs, through the appropriate bodies, is considered to be beneficial, are highlighted below.

The committees/groups highlighted are not to be regarded as exhaustive.

Recommendations point to an opportunity for participation based on evidence, i.e. on the basis of information gathered through the inventories compiled in this report, and in other recent investigations carried out by the Committee of the Regions, all of which testify to an increasingly important role played by LRAs in health-related matters.26 The reference to the types of health management systems has been made with respect to the new typology outlined in Chapter 3.

Committee of the Regions (2011a), Dynamic health systems and new technologies: eHealth solutions at local and regional levels; Committee of the Regions (2011b), Active ageing: local and regional solutions.

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Added value Providing input to the revision process of the Directive, by through specificities related to health data on the basis of local/regional experiences made at the regional level, especially in http://ec.europa.eu/justice/policies/privacy/workinggroup/index_en.htm

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Committee of the Regions (2011a) Appendix I – List of references Analytical Support on the Socio-Economic Impact of Social Protection Reforms (ASISP), 2010 Annual Reports, all downloadable from the network website.

Busse R., Schreyögg J., Gericke C. (2007), Analyzing Changes in Health Financing Arrangements in High-Income Countries: A Comprehensive Framework Approach, Health, Nutrition and Population (HNP) Discussion Paper, World Bank.

Committee of the Regions (2009), Opinion of Committee of the Regions on ‘Cross-border healthcare’ (CdR 348/2008 fin), 78th plenary session, 12-13 February 2009.

Committee of the Regions (2010a), Opinion of the Committee of the Regions on ‘Solidarity in health: reducing health inequalities in the EU’ (CdR 47/2010 fin), 84th plenary session, 14 and 15 April 2010.

Committee of the Regions (2010b), own-initiative Opinion of the Committee of the Regions on ‘The role of local and regional authorities in the implementation of the Health Strategy 2008-2013’(CdR 260/2010 fin), 87th plenary session, 1 and 2 December 2010.

Committee of the Regions (2011a), Dynamic health systems and new technologies: eHealth solutions at local and regional levels, written by Progress Consulting S.r.l. and Living Prospects Ltd.

Committee of the Regions (2011b), Active ageing: local and regional solutions, written by Progress Consulting S.r.l. and Living Prospects Ltd.

Council of European Municipalities and Regions & Dexia (2009), EU subnational Governments 2008 Figures, Brussels, CEMR Council of the European Union (2010a), Joint Economic Policy Committee – European Commission Report on Health Systems (16940/10). ECOFIN 768 SAN 274.

Council of the European Union (2010b), Council conclusions on Equity and Health in All Policies: Solidarity in Health. 3019th Employment, Social Policy, Health and Consumer Affairs Council meeting, Brussels, 8 June 2010.

European Commission, DG Economic and Financial Affairs (2010), Projecting future health care expenditure at European level: drivers, methodology and main results, written by Bartos Przywar. European Economy: Economic Papers 41.

European Observatory on Health Systems and Policies, Health System Profiles,

available at:

http://www.euro.who.int/en/home/projects/observatory/publications/healthsystem-profiles-hits/full-list-of-hits European Parliament and the Council of the European Union (2011), Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare.

Hope & Dexia (2009), Hospitals in the 27 Member States of the European Union, Dexia Editions.

Joumard, I., André C. and Nicq C. (2010), Health Care Systems: Efficiency and Institutions, OECD Economics Department Working Papers, No. 769, OECD Publishing OECD (2010), Health at a glance: Europe 2010. OECD Publishing.

Oireachtas Library & Research Service (2010), Spotlight: Financing Local Government. No.1, 2010.

Paris V., Devaux M., Wei L. (2010), Health Systems Institutional Characteristics: A Survey of 29 OECD Countries, OECD Health Working Papers, No. 50, OECD Publishing.

The Commonwealth Fund (2010), International Profiles of Health Care Systems

- Australia, Canada, Denmark, England, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States.

Thomson S. et al. (2009), Financing health care in the European Union:

challenges and policy responses. World Health Organization on behalf of the

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