Tessa Richards: Paying for health in Europe

Tessa RichardsTwo years ago health ministers in the Czech Republic decided to focus on the financial sustainability of health systems during their six months at the EU presidency helm. Was this foresight? Did the ministers know what the bankers did not- that economic Armageddon was round the corner? Either way, the financial crisis was certainly concentrating minds at their recent conference on how countries can continue to meet their rising healthcare costs.

Prague’s main square was thronged with people, threaded by runners, and littered with green plastic water bottles; the familiar post Marathon scene. Inside the conference hall, we embarked on our own marathon. The backdrop was bleak. Expenditure on health has been outstripping growth in GDP in all EU member states. By 2050 it’s set to consume a further 1-2%, as a result of population ageing, new technology and increasing consumer expectation.

But as the economic crisis bites and unemployment rises, tax revenues fall and there is less money in the pot . The rising old age dependency ratio is another spectre to grapple with. “Currently there are 4 people of working age for each one over 65, but by 2050 there will only be 2,”warned Androulla Vassiliou, the EU’s regal commissioner for health. Longevity has it points, she admitted, “but only if the extra years are spent in good health;” to achieve this, “member states must increase the 3% they spend on disease prevention and health promotion.”

It’s always interesting to listen to health policy makers and health economists debate. Among the former there is a view that given the link between health and wealth, expenditure on health care should be seen as an investment, there should be no ceiling on the percentage of GDP a country spends on it; provided its citizens are willing to pay for it. (Average EU spending as a percentage of GDP is around 7%, with eastern countries spending a lot less than western ones.) Given this premise, the way to deal with unemployment and an ageing, shrinking medical workforce, speakers suggested, is to train the unemployed and put them to work them in the health sector.

Economist Christian Baeza from McKinsey had other views. He argued that the economic crisis should been seen as “an opportunity to unwind the [bloated} health sector.” Health professionals needed to recognise their limitations and acknowledge that improving health and tacking rising health inequalities depended on action outside the health sector. Within it the focus should be on “increasing efficiency and moving from grading inputs to grading outcomes.”

Casting around for an example of low efficiency he alighted on the hapless UK.

“GPs in the UK can spend less than 30% of their contracted hours actually seeing patients,” he said, “we have to improve behaviour like this.”

No one was about to dispute the need to reduce inefficiency and waste. The new Czech minister for health, Dana Juraskova, was the first among many to say that Europe’s health systems had to become more cost effective. Health technology assessment was essential and processes which don’t deliver should be abandoned.

Outside the conference hall, journalists had other concerns. Given the cuts to the health budgets, “how can you avoid increasing co-payments and users fees?” the lady from Czech radio wanted to know. “And shouldn’t smokers and those who don’t go for medical check-ups pay more for health insurance?”

Watch this space, was the reply. Meanwhile, expect a conference on financial sustainability of health systems somewhere near you soon. Global debate on this issue is hotting up.

Presentations from the meeting will be available from http://czpres.mzcr.cz/Categories/558-Downloads.html

Tessa Richards, BMJ