ESI Funds for health investmentsesifforhealth.eu/pdf/National workshops_compilation.pdf · ESI...

ESI Funds for health investments

Compilation of topics reflected during national

workshops

Topics

I. Introduction of the project and project output

II. Principles of strategic management

III. 2014-2020 PP principles and mechanisms

IV. Health funding potential in 2014-2020 PP

V. ESIF investment critical success factors

VI. Specifics of complex project management

and implementation

VII. Principles of effective project application assessment

and relevant indicators

VIII. Principles of effective coordination

IX. New concepts in health

X. Discussion on specific EC regulations

I. Introduction of the project and outputs (i) Project and its context

[Project introduction and disclaimer]

Project objectives

► The project is aimed at providing assistance in the area of

healthcare to EU Member States in the programming and

implementation of European Structural and Investment Funds

(ESIF) in the new programming period 2014 - 2020, more

concretely:

► To support the Member States and their efforts to tap into the potential

of ESIF 2014 - 2020 for health investments and to manage ESIF

support for health in a better and more effective way

► To promote effectively implemented actions in the health sector which

will have a major positive impact on the wider population’s access to

quality and sustainable healthcare in EU Member States

► To build knowledge of the implementation of ESIF for health in the new

programming period 2014 - 2020

Project background

► The project builds on two key documents:

► Toolbox for effective structural funds investments in health

2014-2020 as developed by Subgroup 2 of the Reflection Process

on modern, responsive and sustainable health systems that was

conducted in the Council of the EU under the auspices of the

Working Party on Public Health at Senior Level

[Electronic version in various languages available at the website of the Council of the European

Union]

► Policy Guide for Health Investments by European Structural

and Investment Funds 2014-2020, developed by the European

Commission (DGs SANCO, REGIO, EMPL)

[Electronic version in English available at the DG REGIO website]

Disclaimer

► Please be aware that the workshop (as well as the project itself) are NOT

part of the negotiations between the Commission and the Member

States

► EY has been contracted by DG SANCO, not DGs directly involved into negotiations

► EY provides consultations based on its professional judgment, analysis of documents

and analysis of situation in all Member States

► Information provided in the project outputs and in this presentation should serve as

supportive material for discussion and reflection

► Suggestions presented further do not reflect the Commission's position, but EY’s

professional opinion and good practice examples gathered during this project

The presentation does not reflect the Commission's position and the way

implementation of ESIF will be finally delivered is still being negotiated with

the European Commission

II. Introduction:

(ii) Project outputs

[EY outputs introduction]

I. Introduction of the project and outputs (ii) Project outputs

[Project scope]

Project outputs

WP 1: Mapping report

Implementation of SF in

health in all EU Member

States

► Overview of 2007 - 2013

period

► Planned implementation

of ESIF for funding health

priorities in 2014 - 2020

based on Partnership

Agreements and OPs

WP 2: Guide

Guidance on effective

health investment from

ESIF

► Recommendations for

Ministries of Health and

managing authorities on

practices that lead to

efficient health investment

funded from ESIF

► Roles of MoH and MA and

ways of their cooperation to

achieve effectiveness

► Lessons learned (Do’s and

Don’ts)

WP 3: Toolkit

Set of technical and

managerial tools to

accompany the Guide

► ESIF instruments and

mechanisms in 2014-2020

► Calls for proposal

management

► Set of indicators

► Sustainable and efficient

models & concepts in HC

► Manual on capital investment

► Investment appraisal methods

► Additional issues raised by

Member States

WP 4: Roll out to Member States: Website, country visits, regional workshops

WP1 Mapping report

Mapping report

WP1

►Objective:

► Give a complete picture of health investment under Structural Funds / ESIF in EU Member States for the period

2007 – 2013 and the period 2014 – 2020 (planned actions)

► Provide entry information for the Guide, the Toolkit and the Roll-out phase

►Activities:

►Collect information on health investment under SF made in 2007 – 2013 in individual Member States, including total

allocations of SF for health investment and examples of concrete projects

► Interviews with MAs / Ministries of Health representatives on past investment as well as future priorities

►Analysis of draft Partnership Agreements when available

►Analysis of draft operational programmes when available

►Deliverable:

► Report summarizing areas of health investment under SF / ESIF, identifying main categories of investment

in 2007 – 2013 and main priorities for 2014 – 2020

► Country sheets describing health investment in individual Member States

WP2 Guide for effective ESIF investments in health

Guide

►Objective:

► Elaborate a practical Guide for Member States’ authorities that will enhance effectiveness of investment in health

in the programming period 2014-2020

►Activities:

► Analysis of a set of case studies on health investment

► Interviews with managing authorities and Ministries of Health on successful and even unsuccessful projects and

their experience

► Identification of critical success factors

► Summary of lessons learned (Do’s and Don’ts)

► Design of a set of recommendations

►Deliverable:

► Recommendations on practices that lead to efficient setup of actions in health area financed from ESI Funds under

the new programming period 2014 - 2020

WP2

Guide for effective ESIF investments in health Structure

Part I:

Theoretical background

► Today’s EU health systems

► Challenges

► Sustainable concepts

► Health funding

in 2014 - 2020 PP

► Funding principles

► Health actions under

thematic objectives

Part II:

ESIF programming

& implementation

► Models of MoH involvement in

the operational programmes

► Intermediate body

► Subject matter expert

► MoH involvement in OP

delivery:

► Calls for proposals

► Projects preparation and

delivery

► Evaluation & monitoring

Part III:

Lessons learned

► Main causes of investment

inefficiency

► Recommendations in areas

considered as critical success

factors based on case studies,

interviews and EY’s experience

► Case studies

WP2

WP3 Technical toolkit

Technical toolkit

► Objective:

► Develop a set of tools supporting the national authorities in achieving sustainable and effective investments in

health under ESI Funds, which accompany the Guide

► Deliverable:

► Set of documents providing a technical advice on key issues related to investments in health under ESI Funds

► Technical areas covered by the Toolkit:

► Introduction of 2014 – 2020 instruments & mechanisms and evaluation of their relevance for health area

► Reference checklist on calls for proposals for officials involved in managing 2014 – 2020 funding in health

► Useful indicators for objective evaluation of projects/actions in healthcare

► Compendium of new concepts and models in healthcare

► Capital investment management manual

► Appraisal techniques and evaluation of their relevance for health investment evaluation

► Reflection of additional issues raised by Member States during national visits

WP3

WP3 Technical toolkit 1/6 Categorization of instruments and mechanisms for 2014-2020 PP

WP3

Instruments

► Forms of support under ESIF

► Grants and prizes

► Financial instruments

► Specific territorial approaches to

development under ESIF

► Integrated approach to territorial

development

(CLLD, ITI, Integrated Sustainable Urban

Development)

► European Territorial Co-operation

► Community programmes

► Horizon 2020

► Health Programme

Mechanisms

► Funding mechanisms

► Delivering the Europe 2020 strategy

goals

► Synergies, coordination and

complementarities

► Thematic concentration

► Strong result orientation

► Performance reserve based approach

► Cohesion policy principles

► Concentration

► Programming

► Partnership

► Additionality

WP3 Technical toolkit 2/6 Reference checklist: Success factors for calls for proposals

WP3

Management of calls for proposals

► Preparation of an indicative timetable

for calls ► OP Performance framework, milestones values

► Absorption capacity

► Synergies and complementarities

► Set-up and public announcement of

individual calls ► Use targeting on specific health themes

► Raise awareness among heath entities about

funding possibilities

► Evaluation of calls ► Reassessment and update of calls timetable

and their focus

Project applications assessment

► Assessment process ► administrative check

► eligibility check

► quality assessment

► Design of quality assessment criteria ► Impact on cost-efficiency and sustainability

► Capacity to reduce inefficiencies in access to

care and health status

► Need for the project (relevance)

► “Value for money”

► Feasibility

► Risk analysis

► Selection of projects for funding

► Award of funding

WP3 Technical toolkit 3/6 Set of indicators for final evaluation of action

WP3

Indicators in ESIF context

► Operational Programmes indicators ► Financial indicators

► Output indicators

► Result indicators

► Requirements on Output indicators ► Common output indicators

► Programme specific output indicators

► Requirements on Result indicators ► Responsive to policy

► Normative

► Robust

► Data collection possible in timely manner

Indicators to evaluate ESIF health action

► Indicators per main categories of health

actions eligible for ESI funding* ► eHealth

► Health infrastructure & community based care

► Access to healthcare

► Health workforce

► Prevention, promotion and healthy aging

► Health status

* Indicators based mainly on existing indicators monitored

by:

► Eurostat

► DG Sanco (European Community Health

Indicators - ECHI)

► National statistical offices

WP3 Technical toolkit 4/6 Compendium of (new) concepts and models

WP3

Use of information

technologies

Clinical and prescription

guidelines and models

Population-oriented

concepts Other

► eHealth concepts

► Electronic health

records

► ePrescription

► Telehealth

& mHealth

► Networking and

knowledge sharing

► DRG model

► Cost-effective use of

medicines

► Deinstitutionalization

► Cost-effective path

of care

► Community-based

care, personalized

medicine and long-

term care

► Active and healthy

ageing

► Health promotion

and prevention

► Patient

empowerment

► Medical tourism

► Cross border care

WP3 Technical toolkit 5/6 Manual on capital investment

WP3

Strategic investment guide

► Capital investment planning ► Strategy identification

► Financial planning

► Project definition

► Risk management

► Capital investment implementation ► Ministry as an Intermediate Body

► Preparing Project Requests and Call for

Proposal

► Reviewing and Prioritizing Project Requests

► Implementation

► Ministry as a beneficiary

► Project request preparation

► Investment implementation

► Capital investment sustainability

Categorization of financial mechanisms

► Other sources of funding apart from

ESIF ► Loans / Guarantees

► Equity / Venture Capital

► Initiatives of EC

► JESSICA

► JEREMIE

► JASPERS

► JASMINE

► Combinations of the instruments

► PPP

WP3 Technical toolkit 6/6 Investment appraisal

WP3

General principles of economic appraisal

Key process steps:

1. Problem identification & definition

2. Definition of alternatives for problem solution

3. Assessment of costs and benefits

► List all the costs and benefits

► Quantify/describe all the costs and benefits

► Converse data into value of resources

4. Calculation which will strongly depend on

the type of economic appraisal

5. Decision-making

Investment appraisal techniques

► Quantitative assessment techniques

applicable to health investments

► Cost Benefit Analysis (CBA)

► Option Appraisal (OA)

► Cost Consequence Analysis (CCA)

► Cost Effectiveness Analysis (CEA)

► Qualitative assessment techniques

applicable to health investments

► Cost Utility Analysis (CUA)

► Health Impact Assessment

► Health Technology Assessment (HTA)

WP5 Online platform

Online platform (webpage)

►Objective:

► Develop an online platform supporting the roll-out phase by allowing widespread dissemination of the deliverables

and tools developed

►Deliverable:

► A single point providing all the necessary information about funding of health from ESIF in 2014-2020 and the most

up-to-date versions of project outputs

www.

.eu

WP5

WP5 Online platform Website content & structure

► News containing information about

workshops / updates or most up-to-date

issues

► Project introduction & background

information

► General introduction of EU Cohesion

Policy 2014-2020 principles & mechanisms

► Indicative list of health actions under

thematic objectives for the 2014-2020

programming period

► Downloadable project outputs:

> Guide

> Toolkit

► Frequently asked questions (FAQs)

► Mapping of implementation of ESIF in

health across EU Member States

► Useful contacts

WP5

I. Website content:

► Existing knowledge and other useful

links

► Information about national and

regional workshops

II. Principles of strategic management

[EY understanding]

Public strategies development 1/2 Principles

Based on our experience with strategy development we have defined ten principles related to public policies making:

1. Transparency and objectiveness of strategies preparation

► Wide range of stakeholders is involved into the preparation process

2. Responsible decision making

► Government (or approval authority) has to be able to make responsible decisions based on relevant information

3. Specific issues solving

► Strategies are aimed at solving specific and significant problems

4. Coordination of strategic projects

► Particular strategies are not prepared separately, but they are coordinated both horizontally and vertically

5. Standard procedures and project management approach

► Mandatory requirements on strategic documents quality are met and process structure is compliant with standard practice of project management

6. Clear source of financing

► Implementation financing is clearly defined

► Realization of approved strategies is reflected in budgeting on a regular basis

► Seeking the highest feasible level of efficiency; negative unintended effects are minimized

*the list continues on the next page

Public strategies development 2/2 Principles

Principles of public strategies development also include:

7. Strategies compliant with real needs

► Strategies development is evidence-based

► Both intended and real impacts of strategies implementation are monitored and evaluated

8. Particular measures and well-defined implementation structure

► Responsibility for objectives accomplishment is clearly defined

► Indicators and metrics of success and process of implementation are specified

9. Defined strategy owner

► Overall responsibility is assigned

10. Regular evaluation

► Effectiveness of implemented measures is evaluated on a regular basis

► Corrective mechanisms are proposed .

► Why is a given strategy being created?

► What is its purpose (which issue will be solved)?

► How will be the issue solved?

► When will be the issue solved?

► Who will solve the issue?

► For how long is the strategy valid?

► How much will a given solution cost?

Key questions to answer within the strategy development process

Public strategies development Methodology application scheme

1. Identification of strategy creation need

2. Project set-up

3. Analytics and forecasting phase (on a regular basis)

4. Strategic direction, priorities and variants determination

5. Strategy elaboration

6. Implementation, financing and evaluation set-up

7. Strategy approval

Strategy development (application of public strategies preparation methodology)

Preliminary vision formulation

(final strategic documents, long-term plans and vision, response to external forces etc.)

Strategy implementation

(realization of the strategy, its monitoring and evaluation on a regular basis, final evaluation)

Framework of strategic management

Strategic management in defined areas (public strategy)

Strategic management of public administration

organization (strategy of an office)

Application of public strategies preparation

methodology

Public strategies development Strategy development process

► 1. Identification of strategy creation need ► Organization of strategy creation preparation ► Data collection ► Current state analysis and future development

forecast ► Preliminary vision analysis ► Input report preparation and approval

► 2. Project set-up ► Organizational structure staffing ► Project plan of strategy creation preparation ► Plan of cooperation and communication preparation ► Risk management plan for strategy creation

preparation

► 3. Analytics and forecasting phase (on a regular basis) ► Data sources identification and primary analyses

elaboration ► Existing solutions analysis incl. international practice ► Current state analysis ► Future development forecast ► Analytical part of strategic document compilation

► 4. Strategic direction, priorities and variants determination

► Vision verification and options of objectives definition

► Options selection for further elaboration

► 5. Strategy elaboration ► Strategic objectives elaboration ► Set of indicators set-up ► Variant measures identification ► Measures assessment and selection ► Draft strategy finalization

► 6. Implementation financing and evaluation set-up ► Work breakdown structure creation ► Managing structure of strategy implementation set-

up ► Change management plan set-up ► Risk management plan set-up and assumptions

determination for successful strategy implementation ► Monitoring system of objectives attainment set-up ► Strategy evaluation set-up ► Communication plan of strategy implementation

creation ► Strategy implementation budget creation ► Strategy implementation schedule creation

► 7. Strategy approval ► Strategy approval plan revision and finalization ► Internal strategy revising and approval ► External strategy revising and approval ► Project closing

Public strategies development Strategy implementation

Essential condition: divisional and functional managers involved as much as possible in strategy-formulation and strategists involved as much as possible in strategy-implementation.

► Managers and employees are motivated more by perceived self-interests than by organizational interests

Basic management issues of strategy implementation:

► Establish annual (or other regular) objectives

► Devise policies

► Allocate resources

► Alter an existing organizational structure

► Restructure and reengineer

► Minimize resistance to change

► Match managers with strategy

► Develop a strategy-supportive culture

► Develop an effective human resources function

Phase of strategy review, evaluation and control:

► Examine the underlying bases of an organization’s strategy

► Compare expected results with actual results

► Take corrective actions to ensure that performance conforms to plans

Regular objectives serve as guidelines for action, and standards of performance

Policies clarify what work is to be done and by whom

Change must be viewed as an opportunity rather than as a threat by managers and employees

Adequate and timely feedback is the cornerstone of effective strategy implementation

Public strategies development Barriers and measures

► Absence of unanimous methodology of strategic documents making

► Absence of

► Compact strategic management system and planning

► Unanimous framework of strategy making and implementation

► Hierarchy of strategies

► Absence of strong political assignment

► Budgeting not directly connected to government’s priorities

► Absence of central capacities (departments) for strategic work

► Lack of personal capacities

► Unstable political environment

► Insufficient implementation and monitoring of strategy, unmeasurable objectives

Barriers

Lack of general coordination

Insufficient political support

► Creation and approval of public strategies preparation methodology

► Assembly of public administration workers having adequate knowledge of and experience with strategic work

► Development of strategic management on central level and closer connection of strategic management with budgeting

► Coordination of strategic management on government level

► Setting of prioritization process of strategic objectives on central level of public administration

► Seeking broader political agreement, or at least cooperation, in order to ensure process continuity

► Independence and transparency of strategies preparation

Key measures

III. 2014-2020 programming period principles and

mechanisms [Topic covered by the project outputs]

2014 – 2020 programming period Cohesion policy principles

ADDITIONALITY

► ESIF do not replace national sources, ESI funding is

complementary to it

► Based on national public health priorities

► Health funding shall be a combination of variety of

financial sources

CONCENTRATION

► Limited number of priorities to be supported

► Targeted on achievement of two underlying objectives:

► Cost-effectiveness and sustainability of health

systems

► Mitigation of inequalities in health status and in

access to health care

PROGRAMMING

► ESIF do not support individual projects

► Multiannual programmes aligned with EU objectives

and priorities

PARTNERSHIP ► Collective process involving partners throughout:

► Programme development

► Implementation

► Monitoring & evaluation

2014 – 2020 programming period Principal ESI funding principles

► Delivering the Europe 2020 strategy goals:

► Smart, inclusive and sustainable growth

► Delivery through contribution to thematic objectives

► Synergies, coordination, complementarities:

► Establish mechanisms to ensure coordination and

synergies to avoid overlaps

► Ensure effective coordination in order to increase the

impact

► Combine ESI Funds in a complementary manner

► Ex-ante conditionalities:

► Minimum requirements which need to be fulfilled prior to

the funding is started

► General / thematic – based on the investment priorities

► Existence of a national or regional strategic policy

framework for health with aim to:

► Improve access to quality health services

► Stimulate efficiency in the health sector through effective

innovative technologies

► Introduce monitoring and review system

► Provide cost-effectiveness and concentration of

resources on prioritized needs for health care

► Thematic concentration:

► Targeting of funds at key priorities

► Based on country-specific national, regional and local

context

► Minimum thematic concentration required depending on

the level of development of regions

► Strong result orientation:

► Result oriented approach rather than focus on the

financial means

► For each programme area desired improvement in the

situation should be identified

► Performance reserve based approach:

► Total amount of 6 % of the resources allocated to all ESI

Funds

► In 2018 MSs will submit performance reviews of

accomplished milestones

► Reserve will be allocated to OPs and priorities which

have achieved the milestones

2014 – 2020 programming period Funding instruments and financial mechanisms

► Grants & prizes

► Non-repayable public funding

► Main form of ESIF investments in a public

service such as health

► Financial instruments

► Loans, guarantees, equity

► Plan to use them for 10 % of projects

► Possible use to all thematic objectives covered

by OPs

► Clear rules to enable a better combination of

financial instruments with other forms of support

(grants)

Funding instruments Public Private Partnership (PPP)

► The use of PPPs as an alternative source of funding is

a widely discussed topic

► There are two dimensions to the application of PPP

strategies linked with Structural Funds investment

strategy:

► PPP as an integral part of a Structural Funds project;

► PPP as separate but complementing Structural Funds

projects and programmes, where there is no financial

relationship between the two.

► Issues considered as important in relation to PPPs:

► If the resources from ESIF for health might be relatively

restricted, MS might consider PPPs as a viable alternative

of funding for projects that more directly contribute to

economic growth

► Whole hospital PPP projects could be considered where

they form part of a wider Structural Funds strategy

programme [Slovakia]

► In any event Member States would be well advised to begin

to invest in competency training and development

paralleled by the establishment of some form of central /

coordinated expert PPP guidance and advisory service

paying specific attention to the complexity of the health

sector

What is your experience with PPP funding?

Have PPP funding been considered to be used as a complementary source of funding in the new programming period?

IV. Health funding potential in 2014-2020 programming

period (i) Health specifics in 2014-2020 programming period

[EY interpretation]

2014-2020 health context 1/2 ESIF level

► Health is eligible for funding under 2014 – 2020. However there is

no thematic objective exclusively dedicated to health.

► Health related issues could be identified in most of the 11 thematic

objectives

► Direct investments Investments directly targeted on health care (HC) issues and reforms;

within direct investments MoH is usually formally involved in

implementation.

► Indirect investments Investments not directly targeted on HC, but health care subjects might

apply for funding from them; MoH usually has no formal competencies in

implementation of this group.

2014-2020 health context Scheme of 2014-2020 health investment framework

TO 1

National strategic

framework

European strategic

framework

EUROPE 2020

EU policies TO 2 TO 3 … TO 10 TO 11 TO 9

Ministry of Health

Hospitals

General

practitioners

Medical

universities

Providers of

specialized care

Emergency

service

Medical R&D

institutions Medical staff

OP 1 OP2 OP 3 OP 7 OP 8 OP 6

TO 4 TO 5

MoH

Illustrative scheme

2014-2020 health context 2/2 ESIF level

The aim of the Ministries of Health (resp. of Ministries of Social affairs

where applicable) shall be to maximize utilization of ESIF

opportunities for health care under legal conditions (EC Guidelines,

3E) and with respect to Europe 2020 as well as national strategic

framework (incl. Partnership Agreement).

V. Principles of effective coordination: (i) Role of MoH as a coordinator of health care

[Topic covered by the project outputs]

IV. Health funding potential in 2014-2020 programming

period (ii) Health areas under thematic objectives


Health funding potential under specific thematic objectives in 2014 – 2020 programming period

TO 1 Strengthening research, technological development and innovation

► Innovation in health

► Research in development of new detection methods and treatments

► Collaborative research in rare diseases

► Support research and related IT infrastructures including support to health information systems

Potential health issues under TO 1?

► Enhancing research and innovation (R&I) infrastructure and capacities to develop R&I excellence, and

promoting centers of competence, in particular those of European interest

► Promoting business investment in R&I, developing links and synergies between enterprises, research and

development centres and the higher education sector, in particular promoting investment in product and

service development, technology transfer, social innovation, eco-innovation, public service applications,

demand stimulation, networking, clusters and open innovation through smart specialisation, and supporting

technological and applied research, pilot lines, early product validation actions, advanced manufacturing

capabilities and first production, in particular in key enabling technologies and diffusion of general purpose

technologies

Investment priorities under given thematic objective:


TO 2 Enhancing access to and, use and, quality of information and

communication technologies

► Strengthening ICT applications for e-Health (investment priority)

► e-Health solutions compatible with EU standards ensuring (cross-border) interoperability of IT systems

► Use of uniform electronic health care information system

► Creation of legal basis for e-Health

► Improvement of IT Tools for coordination of response to health threats

► Development of ICT based solutions and services for needs of an ageing population


► Extending broadband deployment and the roll-out of high-speed networks and supporting the adoption of

emerging technologies and networks for the digital economy

► Developing ICT products and services, e-commerce, and enhancing demand for ICT

► Strengthening ICT applications for e-government, e-learning, e-inclusion, e-culture and e-health



TO 3 Enhancing the competitiveness of SMEs

► Promote awareness among SMEs on “white sector” business opportunities and know-how

► Support SMEs' businesses addressing the needs of old people, or 'age-friendly' businesses (e.g.

providing personalised care, assisting in functional physical or cognitive decline, improving old people's

health literacy), including senior start-ups and entrepreneurship

► Encourage private and public enterprises to play a larger role in public-private partnerships in 'age-

friendly' areas


► Promoting entrepreneurship, in particular by facilitating the economic exploitation of new ideas and

fostering the creation of new firms, including through business incubators

► Developing and implementing new business models for small and medium-sized enterprises

(SMEs), in particular with regard to internationalisation

► Supporting the creation and the extension of advanced capacities for product and service development

► Supporting the capacity of SMEs to grow in regional, national and international markets, and to

engage in innovation processes



TO 4 Supporting the shift towards a low-carbon economy in all sectors

► Support energy efficiency of health care facilities

► Assisting low-income communities and the elderly with energy efficiency improvements

► Support actions to help reduce the use of domestic solid fuels (coal and wood) which create indoor

air pollution and negatively effects health


► Promoting the production and distribution of energy derived from renewable sources

► Promoting energy efficiency and renewable energy use in enterprises

► Supporting energy efficiency, smart energy management and renewable energy use in public

infrastructure, including in public buildings, and in the housing sector

► Developing and implementing smart distribution systems that operate at low and medium voltage

levels

► Promoting low-carbon strategies for all types of territories, in particular for urban areas, including

the promotion of sustainable multimodal urban mobility and mitigation-relevant adaptation measures

► Promoting the use of high-efficiency co-generation of heat and power based on useful heat demand

► Promoting research in, innovation in and adoption of low-carbon technologies



TO 5 Promoting climate change adaptation, risk prevention and management

► Increase investments in risk prevention and management, including protection, preparedness, response

and recovery that have positive impact on human health

► Creation of early warning systems and health care investments for disasters and climate-related

events and adaptation

► Support water efficiency in health care buildings to reduce water scarcity

► Investments to reduce flooding of health care facilities


► Supporting investment for adaptation to climate change, including ecosystem-based approaches

► Promoting investment to address specific risks, ensuring disaster resilience and developing disaster

management systems

Investment priorities under given thematic objective


TO 6 Preserving and protecting the environment and promoting resource

efficiency

► Investing in waste sector management to support protection from dangerous medical waste

► Increase actions that reduce potential health risks of contaminated sites


► Investing in waste sector to meet the requirements of the Union's environmental acquis and to address needs,

identified by the Member States, for investment that goes beyond those requirements

► Investing in the water sector to meet the requirements of the Union’s environmental acquis and to address needs,

identified by the Member States, for investment that goes beyond those requirements

► Protecting and restoring biodiversity, soil protection and restoration and promoting ecosystem services, including

Natura 2000 and green infrastructures

► Taking actions to improve the urban environment, revitalisation of cities, regeneration and decontamination of

brownfield sites (including conversion areas), reduction of air pollution and promotion of noise-reduction

measures

► Conserving, protecting, promoting and developing natural and cultural heritage

► Promoting innovative technologies to improve environmental protection and resource efficiency in the waste sector,

water sector and with regard to soil, or to reduce air pollution

► Supporting industrial transition towards a resource-efficient economy, promoting green growth, eco-innovation and

environmental performance management in the public and private sectors



TO 7 Promoting sustainable transport and removing bottlenecks in key

network infrastructures

► Improve connectivity (e.g. through infrastructure) and mobility to enhance access to health services

► Gain health benefits through enhanced safety levels of transport networks

► Support greener infrastructure to reduce obesity and create healthier lifestyles, particularly for the youth


► Supporting a multimodal Single European Transport Area by investing in the Trans-European Transport

(TEN-T) Network

► Developing and improving environmental-friendly (including low-noise) and low-carbon transport

systems, including inland waterways and maritime transports, ports, multimodal links and airport

infrastructure, in order to promote sustainable regional and local mobility

► Developing and rehabilitating comprehensive, high quality and interoperable railway systems, and

promoting noise-reduction measures

► Enhancing regional mobility by connecting secondary and tertiary nodes to TEN-T infrastructure,

including multimodal nodes

► Improving energy efficiency and security of supply through the development of smart energy distribution,

storage and transmission systems and through the integration of distributed generation from renewable

sources



TO 8 Promoting employment and supporting labour mobility

► Access to employment for job- seekers and inactive people, including the long-term unemployed and people far

from the labour market, also through local employment initiatives and support for labour mobility

► Sustainable integration into the labour market of young people, in particular those not in employment, education

or training, including young people at risk of social exclusion and young people from marginalised communities,

including through the implementation of the Youth Guarantee

► Self-employment, entrepreneurship and business creation including innovative micro, small and medium sized

enterprises

► Equality between men and women in all areas, including in access to employment, career progression, reconciliation

of work and private life and promotion of equal pay for equal work

► Adaptation of workers, enterprises and entrepreneurs to change

► Active and healthy ageing

► Modernisation of labour market institutions, such as public and private employment services, and improving the

matching of labour market needs, including through actions that enhance transnational labour mobility as well as

through mobility schemes and better cooperation between institutions and relevant stakeholders

► Supporting the development of business incubators and investment support for self-employment, micro-enterprises

and business creation

► Supporting employment-friendly growth through the development of endogenous potential as part of a territorial

strategy for specific areas, including the conversion of declining industrial regions and enhancement of accessibility

to, and development of, specific natural and cultural resources

► Supporting local development initiatives and aid for structures providing neighbourhood services to create job

► Investing in infrastructure for employment services



TO 8 Promoting employment and supporting labour mobility

► Supporting adequate and qualified health workforce in all areas through adaptation and training

and promotion of labour mobility

► Active and healthy ageing measures

► Health and human capital - supporting employment through healthy workers

► Promotion of healthy life style and disease prevention

► Health at the workplace

► Supporting healthy and safe working conditions and prevent work-related injuries



TO 9 Promoting social inclusion and combating poverty

► Active inclusion, including with a view to promoting equal opportunities and active participation, and

improving employability

► Socio-economic integration of marginalized communities such as the Roma

► Combating all forms of discrimination and promoting equal opportunities

► Enhancing access to affordable, sustainable and high-quality services, including health care

and social services of general interest

► Promoting social entrepreneurship and vocational integration in social enterprises and the social and

solidarity economy in order to facilitate access to employment

► Community-led local development strategies

► Investing in health and social infrastructure which contributes to national, regional and local

development, reducing inequalities in terms of health status, promoting social inclusion through

improved access to social, cultural and recreational services and the transition from institutional to

community-based services

► Providing support for physical, economic and social regeneration of deprived communities in urban

and rural areas

► Providing support for social enterprises

► Undertaking investment in the context of community-led local development strategies



► Active inclusion improving employability

► Integration into the labour market of people with disabilities, mental disorders, chronic disease

► Enhancing access to affordable, sustainable and high-quality services, including health care

(reducing inequalities in terms of health status)

► Equitable access to affordable care and medication

► Promote active involvement of patients and their empowerment

► Access to acceptable standards of housing and hygiene

► Investing in health and social infrastructure

► Contributing to cost-effectiveness and sustainability of health systems

► Supporting specialization and concentration of hospital care

► Transition of hospital based care to community based care

► Strengthening of primary and ambulatory care

► Deinstitutionalization of long-term care, after care and mental care / home care strengthening

TO 9 Promoting social inclusion and combating poverty



TO 10 Investing in education, skills and lifelong learning

► Reducing and preventing early school-leaving and promoting equal access to good quality early-childhood,

primary and secondary education including formal, non-formal and informal learning pathways for reintegrating

into education and training

► Improving the quality and efficiency of, and access to, tertiary and equivalent education with a view to

increasing participation and attainment levels, especially for disadvantaged groups

► Enhancing equal access to lifelong learning for all age groups in formal, non-formal and informal settings,

upgrading the knowledge, skills and competences of the workforce, and promoting flexible learning

pathways including through career guidance and validation of acquired competences

► Improving the labour market relevance of education and training systems, facilitating the transition from

education to work, and strengthening vocational education and training systems and their quality, including

through mechanisms for skills anticipation, adaptation of curricula and the establishment and development of

work-based learning systems, including dual learning systems and apprenticeship schemes

► Investing in education, training and vocational training for skills and lifelong learning by developing education

and training infrastructure

► Tertiary education delivering workforce sufficient in numbers as well as in qualification, reflecting the

shortages of certain specializations (i.e. General Practitioners)

► Adjustment of education system to deliver sufficient nursing staff (sufficient numbers as well as with

sufficient qualification to provide certain types of care independently)

► Lifelong training to adjust workforce skills – eHealth, new treatment and diagnostic methods




TO 11 Enhancing institutional capacity and ensuring an efficient public

administration

► Capacity building in health administration: actions to support institutional and management capacities of

health administration

► Actions to increase efficiency of health administration in particular to design and deliver health system

reforms and increase its efficiency, quality and sustainability

► Actions to enhance cross border cooperation of MS in health area


► Enhancing institutional capacity of public authorities and stakeholders and efficient public

administration through actions to strengthen the institutional capacity and the efficiency of public

administrations and public services related to the implementation of the ERDF, and in support of actions under

the ESF to strengthen the institutional capacity and the efficiency of public administration

► Enhancing institutional capacity of public authorities and stakeholders and efficient public administration

through actions to strengthen the institutional capacity and the efficiency of public administrations and public

services related to the implementation of the Cohesion Fund

► Investment in institutional capacity and in the efficiency of public administrations and public services at

the national, regional and local levels with a view to reforms, better regulation and good governance

► Capacity building for all stakeholders delivering education, lifelong learning, training and employment and

social policies, including through sectoral and territorial pacts to mobilise for reform at the national, regional

and local levels



V. ESIF investment critical success factors (i) ESIF investment effective lifecycle


ESIF investment effective lifecycle Critical success factors

Critical

success

factors

Strategy

development

Investment

sustainability

Capacity

building

Procurement

management

Financial

planning

Partnership

building

Monitoring

& Evaluation

01 07

02 06

05 03

04

WP2

Critical success factors Discussion topics

Q1: Based on introduction of critical areas, where do you think are your:

i. Strong areas, i.e. areas that could be shared with other Member States as a good

practice example.

ii. Weak areas, i.e. areas where would your country appreciate support in a form of a

good practice example from other Member States.

Q2: Would you name any other critical success factor that has not been mentioned here and

is worth mentioning?

V. ESIF investment success factors (ii) Practices and recommendations to various investment

life-cycle stages [Topic covered by the project outputs]

01. Strategy development

► Lack of real public health strategy

► Absence of clearly defined priorities

► Investments are not focused on achievement of

clear objectives (duplicities and overlapping of

funding)

► Investments do not generate any tangible results

(there are no health gains and no improved cost

efficiency of health sector)

► Unsustainability of the investments

► Lack of project progress or project disruption in

case of changes in political environment

► Lack of coordination in strategy development

► On various levels of public administration

► For different types of health care

(outpatient x hospital care;

primary x specialized care)

► On cross-regional and cross-border level

Problems

Inefficient use of public resources

Obstacles to systemic changes

► Develop an overarching public health strategy

based on evidence and centered around a patient

oriented approach [Ministry of Health]

► Coordinate the strategy-making process with

stakeholders to make the strategy broadly

accepted and relevant [Ministry of Health]

► Identify & involve stakeholders

► Know other existing and developing strategies

► Ensure balanced and complementary approach

to maximize investment effects [Ministry of Health]

► Infrastructure development

► Human resources development

► Prevention and health promotion campaigns

► Identify financial resources and select priorities

to be financed from ESIF [Ministry of Health,

Managing Authorities]

Recommendations

Example of insufficient strategy development Hungary, programming period 2007 - 2013

Context

► The implementation of ESIF for health infrastructure in Hungary in PP 2007-2013 was the largest of all

EU Member States (approx. 1,3 bn. EUR allocated over the 7 years, which represents 5,5 % of whole

ESIF allocation)

► Lack of strategic planning in the field of health and coordinative management of resources

► Political instability contributed to insufficient funding coordination

Consequences

► Spending driven approach in preference for project lacking evidence base, rather than a strategic

one taking into account sustainability considerations

► Insufficient attention given to health gains when deciding on where to direct the funding

► Lack of coordinative management function caused inefficiencies in a way that projects addressing

various levels of care provision are not complementary and loose (at least partially) their benefits

► Potential effects limited by insufficient coordination of Structural Funds projects and other

development efforts, on regional level no strategy planning:

► Investments into regional hospitals were not coordinated with investments in outpatient primary

care

► Infrastructure investments in specialized oncological centers were not coordinated with

development of regional hospitals

02. Partnership building

► Insufficient involvement of relevant partners in

development of strategies:

► Health care strategy

► Partnership Agreement

► Operational programmes

► Insufficient involvement of all relevant partners

► Public

► Experts

► Foreign partners

► Shortcomings in management of partners in

implementation of strategies, programs and

projects

► Insufficient consultation and information sharing

processes set-up

► Unclear roles and responsibilities

► Inflexible decision-making process

► Gain wide range of relevant partners in

preparation of key strategic documents through

their careful identification and invitation [Ministry of

Health]

► Introduce formalized system for cooperation

among partners, which will be consensually adopted

[Ministry of Health]

► Clearly delimit the roles and responsibilities

of individual partners

► Decide on the decision making process,

favouring flexible forms ensuring at the same

time wide acceptance

► All key decisions and changes consult with partners

and try to find consensus [Ministry of Health]

► Designate a responsible for stakeholder

management [Ministry of Health]

► Learn to understand individual partners’ and group

of stakeholders’ needs [Ministry of Health]

Problems Recommendations

High risk of delay or refusal of a program / project realization

Limitation or blocking of expected outcomes

03. Capacity building

► Lack of qualified human resources for efficient

programme implementation at the Ministry of Health,

especially when it plays the role of intermediate body:

► Inadequate knowledge of relevant OP(s)

► Inadequate skills in project and financial

management

► Lack of experience with health strategies

implementation

► High fluctuation rate of employees

► Lack of information and guidance for applicants

and beneficiaries

► Insufficient information about publishing a call

for proposals among potential health sector

applicants

► Insufficient support of applicants in the phase of

project preparation and implementation

► Secure qualified and skilled MoH capacities

capable to support managing authorities in the area

of health expertise [Ministry of Health]

► More extensive use of technical assistance

resources for education [Managing Authority,

Ministry of Health as an Intermediate Body]

► Standard staff education

► Preparation of standard educational plans for

capacities of Ministry of Health, MAs,

intermediate bodies in the field of: Structural

Funds, health policy, project and financial

management

► Exchange of experience and cooperation

with foreign partners

► More active role of MoH in building absorption

capacity among potential beneficiaries [Ministry of

Health]

► Personal contact with beneficiaries and the staff of

intermediate body/managing authority [Ministry of

Health]


Insufficient absorption capacity

Limited quality and value added of funded projects

Possible ineligibility of projects

04. Financial planning

► Insufficient detail of a project business case

► Inappropriate use of various techniques for financial

planning and investment appraisal

► Cost-benefit analysis, cost-effectiveness analysis

► Health technology assessment

► Health impact assessment

► Incorrect evaluation of project applications for

funding where even project applications with

insufficient detail and low value added of investments

were accepted for funding

► Project costs overruns which might seriously

threaten project sponsor’s ability even to finish the

project

► Problems with ensuring project sustainability in

case the operational costs during the sustainability

phase were not planned for or identified properly

► Require use of evidence-based approach:

► Put emphasis on detailed and evidence based

needs assessment

► Support benchmarking where possible

► Clearly set the main principles of financial

planning and investment appraisal [MA, possibly

MoH as an Intermediate body]

► Set criteria for project applications evaluation and

selection to ensure only financially realistic,

achievable and cost-efficient projects are

supported [MA, possibly MoH as an Intermediate

body]

► Monitor the financial performance data

periodically to be able to identify any possible

problems in time [MA, possibly MoH as an

Intermediate body]

► Ensure capacities with adequate knowledge and

expertise in the field of financial planning of health

projects and health investment appraisal methods

through the capacity building process [Ministry of

Health]


Failure to achieve expected benefits

Support of unsustainable projects

05. Procurement management

► Too complex and frequently changed procurement

laws, disparities across OP

► Erroneous procurement (typically in case of health

instrumentation / technology purchases):

► Discriminatory conditions

► Not enough specific conditions

► Unsuitable scope of the tender

► Too broadly defined contract, combining

unrelated items (excludes specialized suppliers)

► Subdivisions of contract

► Insufficient knowledge and experience with public

procurement of contracting authorities and suppliers

► Insufficient support of beneficiaries – contracting

authorities from the side of administrative capacities

of managing authorities / intermediate bodies

► Define clear, concise and easy-to-follow

programme-specific procurement rules, coordinated

across all country’s Ops [Managing Authority]

► Provide administrative support to beneficiaries

acting as a contracting authority in form of guidebooks,

templates, forms, tutorials and trainings [MA, possibly

MoH as an Intermediate Body]

► Set up sufficient administrative capacity Consider

ex-ante reviews of tender specifications if

sufficient expert capacities are available

► Engage health care experts (as well as IT experts,

engineers etc.) in preparation and/or review of the

technical specifications [MoH as beneficiary,

possibly even as an Intermediate Body, MA]

► Require estimated value in an evidence-based

manner, supported by market research and involve

experts to consider the usual market prices [MoH as

an Intermediate Body]

► Avoid subdivision of related items into separate

tenders, but do not link large contracts with various

components into one tender [MoH as an Intermediate

Body]


Delays in project implementation

Ineligibility of expenses

Disruption of project implementation

Loss of unrecoverable funds

Example of consequences of erroneous procurement Slovenia – „eZdravje“ Context of the project

► National eHealth project has been implemented in 2007-2015

► Procurement of technological implementation of eHealth portal funded from ESF

Main problems

► Procurement took significantly longer than expected

► Scope of the tender defined too broadly, which excluded potential smaller and specialized suppliers

► Scope of the tender was not specific enough, or on the contrary too discriminative with focus on a

single technology to deliver services

► Insufficient involvement of IT stakeholders in formulating procurement rules

► Preliminary checks of tender specifications delayed significantly procurement due to insufficient

capacities delayed significantly

► Main tenders were legally challenged

Implementation of the project of major national importance is delayed with increased costs.

06. Evaluation and monitoring

► Lack of data or their insufficient quality to monitor

progress made

► Unclear definitions of indicators and resulting

inconsistency in data makes it impossible to

evaluate the real impact of the intervention

► Untargeted support or support of measures, which

do not lead to objective achievements

► Inner inconsistency of supported measures

► Inexistent identification of causes of negative

consequences and of insufficient outcomes of

interventions

► Insufficient information for qualified decision-

making

► Involve Ministry of Health representatives and

other health care expert into the monitoring

committee [Managing Authority]

► Select relevant and unambiguous indicators for

monitoring [Managing Authority with MoH,

possibly MoH as an Intermediate Body]

► Use evaluation not only for OPs, but also for

assessment of:

► Health strategies

► OPs’ priority axes and calls for proposal

relevant for health

► Health programs and projects

[Managing Authority with MoH]

► Improve the quality of evaluators [MA, possibly

MoH as an Intermediate Body]

► Set up the objectives of each evaluation, relevant

timing and methods; evaluation should take place in

all stages of the investment process [Managing

Authority with MoH, possibly MoH as an IB]

► Design measures to take in reaction to the

evaluation results [Ministry of Health]


Lack of information for projects evaluation and for better results achievement of interventions in future.

07. Investment sustainability

► Higher operational costs than expected in

investment planning:

► Too high treatment costs for using the new

technologies and equipment

► Insufficient pool of patients requiring

treatment with the new thus more expensive

equipment

► Medical personnel not properly trained to

use new equipment, eHealth and treatment and

diagnostic methods

► Investments do not reflect the current mid-

and long- term trends in health care

► Little attention is given to health promotion

and prevention programs

► Measure and monitor sustainability of health

investment before its implementation [Managing

Authority with MoH]

► Assess future operating costs of

investment actions

► Prioritize investment actions according to their

sustainability - include “sustainability” into

project selection criteria [Managing Authority

with MoH]

► Assess sustainability in terms of availability of

qualified and adequately trained human

resources [Managing Authority, possibly MoH as

an Intermediate Body]

► Promote projects aimed at:

► Monitoring healthcare effectiveness

► Adopting healthcare guidelines and

standards (i.e. for prescriptions)

► Reduction of unnecessary use of

specialists

► Health prevention and promotion


Good practice example Sustainable investment in Finland

► Finnish population over 75 years is expected to double by 2030 causing the current health

system financially unsustainable

► With the help of ERDF funding, an innovative and far reaching health reform model has

been developed with following objectives:

► Save at least 10 % in current operating costs of the acute hospital service

► Double the numbers at present of the delivery of a ‘care for elderly’ service with no increase in

operating (staff) costs

► Key components of reform:

► Integrate special / acute and primary care and some social services

► Reorganize service structures within hospitals to improve effectiveness and efficiency

► Rebuilding age care residential accommodation to provide better support and promote healthy

ageing

► Improve rehabilitation services

► Invest in illness prevention wherever possible

Critical success factors Q&A

VI. Specifics of complex projects management

and implementation [Topic covered by the project outputs]

Areas for improvement

Complex projects Introduction

► Complex = integrated, interconnected, interdependent

► Complex projects are those that:

► Are characterized by uncertainty, ambiguity, dynamic

interfaces, and significant political or external influences;

and/or

► Can be defined by effect, but not by solution

Programmes implemented under national strategies

(eHealth, reforms etc.)

Regarding the characteristics of complex projects listed

above, complex projects require different management

approach


Complex projects management framework 5DPM approach introduction

► Cost = quantifying of the scope in monetary terms ► Project costs estimates

► Risk assessment

► Identification of cost drivers & constraints

► Schedule = time factors that needs to be managed to

deliver a complex project in time

► Time schedule addressing:

► Scope of work and sequence of work

► Project milestones

► Critical path and path of execution

► Risks identified regarding schedule

► Schedule change process

► Key procurement and submittals

► Quality = project overall design and set up ► Scope of work

► Form and composition of the project team

► Contracts & procurement set up

► Technical solution

► Context = identification of all external factors impacting the

project ► Stakehoders

► Other issues such as environmental, legal, global as well as

local

► Financing = identification of financing sources ► Public vs. private sources of funding

► Eligibility for funding under ESIF

Traditional three-dimensional project management

Five-dimensional project management

Schedule Cost

Quality / Technical

Schedule Cost

Quality / Technical

Context Financing


Implementation of complex projects Main principles

► Strategic context

► Framework for the programme set up and

financing

► Financial planning

► Funding scheme

► Long-term investments VS annual budget

requirements

► Tools such as cost-effectiveness analysis

(CEA), Data envelopment analysis (DEA),

HTA, sustainability analysis

► Proper project definition

► Action plan for each priority

► Introduction of risk management

► Project management framework &

capacities

► Project team selection & maintaining

► Management principles set up ► Project management structure (project

managers, working groups, Steering

committee)

► Coordination of activities ► Overall coordination of project activities

designated to one coordinator

► Relevant indicators for proper monitoring

► EU level indicators

► Specific indicators reflecting national

specifics

► Appropriate timing

► Periodical monitoring of project status

Capital investment planning Capital investment implementation

Complex projects implementation Lessons learned from Slovenia

► Research of previous projects

► Lesson learned from them

► Possible use of their components or follow-

up

► Project based on specific documentation

developed prior to its start (nation eHealth

strategy, feasibility study)

► Partnership principle

► Funding agreement as part of a long term

plan of needs put together by the main

stakeholders

► Special project management framework

designed to advance the project

► Project management framework developed to

feature consultation and decision-making

among key stakeholders

► Collaboration between ministries in operating

eHealth network

► Precise time framework

► Procurement process took much more time

than originally planned

► Attract stakeholders from all areas involved

► Lack of a fuller engagement with the IT

industry as a stakeholder

► Set project management priorities

► Create sufficient team

► Prepare realistic tenders not of too large scope,

with clear specification

► Secure qualified staff to manage the project and

subject matter experts

Areas for improvement Successful steps Areas for improvement

Complex projects implementation Lessons learned from Hungary

► Critical factor perspective applied

► Evidence based approach used in project

preparation

► Flexibility to improve project efficiency

► Broad scale assessment of projects

► Coordination tools introduced

► Need of a broadly accepted and well-known

health care strategy logged into the political

process

► Do not underrate sustainability studies,

quantitative modelling

► Capacity planning

► Coordination between the projects

addressing the various care provision levels

► Strategic planning should not be vulnerable

to disruptions caused by changes in political

direction

Successful steps Areas for improvement Successful steps Areas for improvement

VII. Principles of effective project application

assessment and relevant indicators in health

projects [Topic covered by the project outputs]

Project application assessment General background

► Assessment is a process in which submitted

applications are checked and evaluated against a

set of criteria in aim to select projects:

► Eligible for funding under a given call

► With sufficient certainty regarding the ability of

the recipient to implement the project

► Contributing to the OP’s objectives

► Four types of evaluation should be covered by an

assessment process:

► Administrative check (formal requirements)

► Eligibility check (compliance with the goals of

the call)

► Quality assessment (project necessity, cost

appropriateness, effectiveness, sustainability,

management capacities, relevance of indicators)

► Risk assessment (analysis and incorporation of

mitigation actions)

► Two types of assessment model taking into

account the size and type of a project:

► Single step assessment for small and easy-

to-assess projects (e.g. in case of a large

number of similar projects)

► Two- or multi-steps assessment which is

more demanding on time and expertise of

evaluators

► Expertise and quality of evaluators for assessment:

► Administrative and eligibility check to be done

by people skilled in specifics of the OP

(European Funds department of MoH)

► Quality and risk assessment shall be

conducted by experts with relevant

experiences with the field of the project

scope

► Exclusion, eligibility and evaluation criteria

could support evaluators in the whole process

► Selection of projects based on a degree of

fulfillment of each of the criterion. Their

importance should be projected into the weights.

Definition and types Important factors

► Put emphasis on properly conducted need

assessment:

► Introduce formalized practices how to prove

necessity of the project

► Require long/term prognoses of key factors to

ensure long-term sustainability of the project

(especially important in health care projects)

► Develop methodology on needs assessment

relevant for the field of investments (call) and

develop guideline for project applicants

► Assign relevant weight to this criterion in overall

scale

► Require detailed feasibility study proving

sustainability of the solution

► Expert assessment of quality of the study shall be

essential

► Assess competencies of nominated project team

► Project management, financial management, expert

knowledge etc.

► Sufficient knowledge and experience in relevant

areas

► Require risk analysis and assess detail of the

analysis conducted and mitigation actions suggested

by the analysis

► Improve evaluation of project sustainability:

► Especially in case of large and important

investments, consult experts from practice

► Formalize approach to project sustainability

assessment by developing methodology for

proving and assessing project sustainability

► Consider sustainability also from long term

point of view [five years horizon is not sufficient

especially in strategic health projects]

► Assign relevant weight to project

sustainability, so that it reflects importance of

this criterion

► Support applicants in the process of project

(application) development:

► Provide consultations to potential beneficiaries

► Review applications before submitting especially

procurement set up and financial adequacy

[applicable especially on large and strategic

projects]

Project application assessment Recommendations

► Fund-specific indicators

► Financial indicators relating to expenditure

allocated

► Output indicators relating to the operations

supported (per priority axes).

► Result indicators relating to the priority concerned

► Programme-specific indicators

► Should the fund-specific indicators be insufficient to

measure supported actions they can be completed

with programme-specific output indicators

► Common specific indicator for ERDF actions

specifically defined for health:

► Population covered by improved health services

[persons, no multiple counting]

► Specific indicators to monitor health care

actions to evaluate health investments in a more

focused way. They list can be developed based on:

► ECHI – European Core Health Indicators

(indicators aiming to create a comparable

health information and knowledge system to

monitor health at EU level)

► Eurostat database

► WP 3 (3): Set of indicators useful for final

evaluation of actions

Relevant indicators in health projects Types of indicators


► Limited set of indicators defined at fund level

► A list of common output indicators is defined for

both ERDF and ESF, and the indicators used in

OPs are to be chosen primarily from this list

► Programme-specific indicators designed by the

Member States and Managing Authorities


► Result indicators express the change sought by

a specific objective

► For each specific objective, one or a few result

indicators are defined

Indicators to monitor health care

actions

Indicators per main categories of health actions Access to healthcare

Category / Indicator Measurement unit

Hospital care

Proportion of people (all population) with self-declared unmet needs for healthcare services

due to either financial barriers, waiting times or travelling distances

% of population

Proportion of people whose highest level of education is ISCED 0, 1, or 2 with self-declared

unmet needs for healthcare services due to either financial barriers, waiting times or travelling

distances

% of population with highest level of

education is ISCED 0, 1, or 2

Proportion of people in the first quintile of equalized income (20 % lowest income group) with

self-declared unmet needs for healthcare services due to either financial barriers, waiting times

or travelling distances

% of population in the first quintile of

equalized income

Proportion of people (all population) with self-declared unmet needs for dental care services

due to either financial barriers, waiting times or travelling distances

% of population

% of women aged 50 - 69, whose highest level of education is ISCED class 0, 1 or 2 (lower

secondary), reporting a mammography in the past two years

% of women with highest level of education

is ISCED class 0, 1 or 2

Percentage of persons (aged 50-74), whose highest level of education is ISCED class 0, 1 or 2

(lower secondary), reporting a colorectal cancer screening in the past two years

% of population with highest level of

education is ISCED 0, 1, or 2

Waiting time for certain types of surgeries

Cancer treatment delay

Access to primary care Number of inhabitants per one general practitioner, by region Number of inhabitants

Number of women per one gynecologist, by region Number of women

Number of inhabitant per one dentist, by region Number of inhabitants

Indicators per main categories of health actions Health infrastructure & community based care


Hospital care

Standardized rate of hospitalization Number of hospital admissions per 100 000 inhabitants

In-patient average length of stay in days, all diagnosis Average duration in days of a single episode of

hospitalization in a hospital per discharged in-patient

In-patient average length of stay in days, for individual diagnosis groups Average duration in days of a single episode of

hospitalization in a hospital per discharged in-patient

Hospital care capacities

Hospital beds per 100 000 inhabitants Number of beds

Long-term hospital beds per 100 000 inhabitants Number of beds

Psychiatric hospital beds per 100 000 inhabitants Number of beds

Acute care hospital beds per 100 000 inhabitants Number of beds

Transition to community-based care, development of long-term care and after care

Persons, to whom care has been provided in a community / at home / in a nursing

house* Number of persons

Percentage of persons discharged from hospital who are readmitted within 30 days Percentage of discharged persons

Primary and ambulatory care

Percentage of ambulatory physicians on total number of physicians % of physicians

Percentage of general practitioners in outpatient care % of physicians

Percentage of ambulatory specialists in outpatient care % of physicians

Percentage of illness cases where the first point of contact is a general practitioner % of illness cases

* To monitoring of transition or change, also indicators expressing change in demand could be used.

Indicators per main categories of health actions Health workforce

Indicator Measurement unit

Practicing physicians Number per 100 000 inhabitants

Practicing nurses Number per 100 000 inhabitants

Percentage of physicians aged 35 years and younger % of physicians, all specializations

Percentage of physicians aged 55 years and older % of physicians, all specializations

Percentage of nurses aged 35 years and older % of nurses

Percentage of nurses aged 55 years and older % of nurses

Average age of general practitioners Average age in years

Number of jobs created in health care sector Equivalent of full time jobs

Number of jobs created in health care sector for qualified workforce holding post-

secondary degree

Equivalent of full time jobs

Shortage of physicians (nationwide, regional) Vacancy rate

Percentage of care not covered

Shortage of dentists Vacancy rate

Percentage of care not covered

Indicators per main categories of health actions Health status

Indicator Description / measurement unit

Life expectancy at birth

(total population, men / women) Average number of years of life remaining at birth

Life expectancy at 65 years of age

(total population, men / women) Average number of years of life remaining at the age of 65

Healthy life years Expected remaining number of years, lived from a particular age without long-term activity limitation

Infant mortality rate Ratio of the number of death of infants per 1000 live births

Diabetes incidence % of persons with diabetes diagnosed in the past 12 months

Cancer incidence Incidence per 100 000 inhabitants

Acute myocardial infarction incidence Incidence per 100 000 inhabitants

Depression incidence Proportion of people reporting diagnosed chronic depression in the past 12 months

General musculoskeletal pain Proportion of people reporting to experience general musculoskeletal pain

Long-term activity limitations Proportion of people reporting to have long term restrictions in daily activities

Self-perceived health Proportion of people who assess their health to be good or very good

Indicators per main categories of health actions eHealth


ICT infrastructure

Physicians using a computer % of physicians

Physicians using a computer during consultation (to display a patient's file, to get supporting information when

making treatment or medication decisions) % of physicians

Physicians with broadband connection with speed above

50 MBps % of physicians

Physicians having a website % of physicians

Physician using email to communicate with patients % of physicians

Use of eHealth applications

Physicians with an electronic appointment booking system % of physicians

Physicians using electronic storage of patient’s data % of patients

Use of electronic networks for transfer and exchange of patient medical data (i.e. exchange of clinical information,

laboratory results, medication information etc.) % of physicians / % of patients

Use of electronic networks for transfer and exchange of patient administrative data (i.e. for reimbursement

purposes between care providers and health insurance companies) % of physicians / % of patients

Physician with integrated system to send electronic discharge letters % of physicians

Physicians with an integrated system for tele-medicine (tele-radiology, tele-homecare/tele-monitoring services to

outpatients) % of physicians

Physicians monitoring patients remotely at their home % of physicians

Physicians using electronic networks to transfer prescriptions electronically to dispensing pharmacist

(ePrescribing) % of physicians

Data security

% of physicians using coded data to store and exchange information % of physicians

% of physicians using e-signatures % of physicians

Indicators per main categories of health actions Prevention, promotion and healthy aging 1/2

Category / indicator Description / measurement unit

Prevention

Brest cancer screening % of women aged 50 - 69 reporting a mammography in the past two years

Cervix cancer screening % of women aged 50 - 69 reporting a cervix cancer screening in the past two years

Colorectal cancer screening % of persons (aged 50-74) reporting a colorectal cancer screening in the past two years

Influenza vaccination in elderly Proportion of persons aged 65 and over reporting to have received one shot of influenza (flu) vaccine

during the last 12 months

Vaccination coverage in children

Percentage of infants reaching their first birthday in the given calendar year who have been fully

vaccinated against diphtheria, tetanus, pertussis, poliomyelitis, haemophilius influenza type b or

Hepatitis B and those reaching their second birthday in the given calendar year who have been fully

vaccinated against measles, mumps and rubella

Preventive health determinants

Regular smokers Proportion of persons aged 15+ reporting to smoke cigarettes daily

Alcohol abuse Liters of pure alcohol consumer per persons aged 15+ per year

Physical activity Proportion of persons aged 15+ reporting practice of daily physical activity

Obesity: Body mass index Proportion of adult persons who are obese, i.e. their body mass index is equal or bigger than 30.

Blood pressure Proportion of persons reporting diagnosed high blood pressure (hypertension) in the last 12 months

Occupational health

Work injuries Standardized incidence rate of accidents at work per 100 000 workers

Work-related health problems

Percentage of workers reporting work-related health problems in the past 12 months

Workers off work at least 1 month due to accidents at work and work-related health problems in the

past 12 months

Sick leave Number of sick leave cases per 100 000 workers

Average length of 1 episode sick leave in days

Work safety Number of employed persons who would stay longer at work if their workplace was healthier and/or

safer

Indicators per main categories of health actions Prevention, promotion and healthy aging 2/2

Category / indicator Description / measurement unit

Active and healthy ageing

Employment rate of workers aged 55-64 Proportion of people aged 55-64 in employment.

Population with health-related restrictions Proportion of people reporting to have long-term restrictions in daily-activities

Physical activity Proportion of persons aged 55+ reporting practice of daily physical activity

Dementia / Alzheimer incidence Incidence per 100 000 inhabitants

Influenza vaccination in elderly Proportion of persons aged 65 and over reporting to have received one shot of influenza

(flu) vaccine during the last 12 months

Promotion programmes*

Policies of healthy nutrition N/A, under development

Policies and practices on health lifestyles N/A, under development

Integrated programmes in workplace, schools, hospitals N/A, under development

* Indicators under this category are currently being developed as a part of the ECHI initiative

VIII. Principles of effective coordination (i) Role of MoH as a coordinator of health care


Roles of the MoH in health investments funding from ESIF

Ministry of Health in implementation structure of operational programmes

in 2014 - 2020 in three possible roles:

► Intermediate body (Delegated Act)

► Ministry of Health in the role of an intermediate body (responsible body) has a direct influence on the designing

and delivery of the OP (or more specifically its priority axis relevant for health) and funding of selected strategic

health priorities

► Being a responsible body is a complex task and impose a commitment on MoH to ensure/build sufficient

administrative capacities to be able to efficiently manage implementation of ESI Funds

► Subject matter expert (Memorandum of Understanding)

► Role of a subject matter expert is in place at areas that are not specifically devoted to health, but where health

entities could implement ESIF to contribute to achieving strategic health priorities

► Ministry of Health in the role of a subject matter expert could support MAs or relevant IBs during the whole

programming life-cycle

► Beneficiary of important strategic projects (Grant Agreement)

► In case of a large projects of a strategic importance, MoH might get in a position of a beneficiary from OPs not

managed by MoH

► Being a beneficiary responsible for implementation of important strategic projects impose a commitment on MoH

to ensure/build sufficient management capacities to be able to efficiently manage the investment

Possible roles of the Ministry of Health in 2014 - 2020

1. Subject matter expert in ESIF implementation structure

To ensure health care will utilize ESIF funding opportunities

2. Coordinator of strategic health investments in regions

To ensure equal access to appropriate health care services across

all regions

3. Intermediate body

To ensure proper performance of activities delegated by MAs

4. Beneficiary

To perform health care projects of a strategic importance

I. Coordination of health care system development

II. Coordination across implementation structure

Possible roles of the Ministry of Health in 2014 - 2020 Schematic overview

National health strategy

SP 1 SP 2 SP 3

Capacity building Energy efficiency eHealth

MoH as possible

Intermediate

Body

MoH as

possible

Beneficiary

OP Administrative

reform

Medical staff

development

Regional OP 1 Regional OP 2

Improve access to

health care Development of

specialized centers

SP 4 SP 5 SP 6

OPs

Strategic

priorities

Funding

areas

Implementation of strategic health priorities

Co

ord

inati

on

wit

h O

P M

As

Coordination with OP MAs

OP LLL & HRD OP technical

assistance

MoH as a subject matter

expert supporting

implementation

Illustrative scheme

OP Environment

I. Coordination of health care system development MoH as a subject matter expert

► Elaboration of health care strategy / strategies (ex ante conditionality)

► Identification of what investments in health are eligible under thematic objectives

and investment priorities supported under set Ops

► Cooperation on the Partnership Agreement / OPs design

► Open discussion with managing authorities of OPs with identified direct and

indirect health investment possibilities on possible involvement of MoH in

implementation of the OPs (IB / expert support etc.; shall be formalized in e.g.

delegation agreement, memorandum)

Phase Possible roles & responsibilities of MoH as a subject matter expert

Programming

phase

► Ensure health institutions are not excluded from relevant calls

► Help with absorption capacity building via mobilizing relevant health care institutions

► Possibly support applicants in preparation of project applications

► Possibly provide expertise during project applications assessment

► Provide an expertise during monitoring of projects performed by health care

institutions (administrative control, on the spot control)

► Provide an independent expertize in evaluations

Implementation

phase

► Evaluate development in health care system as a whole

► Lessons learned Winding up

I. Coordination of health care system development Coordinator of strategic health investments in regions

► This role reflects implementation structure with many independent regional entities

► Initiate and set up coordination platform and involve regional authorities

► Familiarize regional representatives with health care priorities and their impact on

regional level

► Discuss regional development needs/priorities and find mutual agreement on

future development in each region

► Identify regional priorities to be funded under PAs managed by MoH [support

health care system reform] and priorities to be funded by ROPs [mitigating

regional disparities]

Phase Possible roles & responsibilities of MoH as a coordinator

Programming

phase

► Keep active involvement of regions in coordination structures

► Moderate sharing of experience and support cooperation of regions

► Gather information about projects realized in the regions and monitor developments

in each region/in the system as a whole

Implementation

phase

► Evaluate development in health care system as a whole

► Lessons learned Winding up

Case study #1 Coordination of health care system development

Mental care specialized

centers

Mental care community

centers

Mother / child care ► Two levels of coordination:

► Thematic

► Regional Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Specialized neurological

centers

Region 8

► Two welcome opposing tendencies:

► Specialized care distribution across the country requires proper coordination to avoid concentration of similarly focused centers in one region while omitting the other areas. Coordinator should take into account geography and probability of particular disease emergence, while

► Community-based care or primary care should be developed in all regions. Coordinators should monitor that all the regions are covered by primary care centers.

Illustrative scheme

Case study #2 Development of specialized neurological centers

► Three illustrative regions are developing specialized neurological care centers without coordination

► Each of the regions builds its own specialized neurological center, buys expensive equipment, attracts specialized medical staff

SITUATION::

RESULT::

► Three specialized centers in relatively small area compete with each other

► Small area cannot fulfill the number of patients required so as the specialized centers are sustainable

► High risk of ineligibility of expenses if funded from ESIF

Legend:

Location of specialized neurological center

Illustrative scheme

Case study #2 Development of specialized neurological centers

► Three illustrative regions are developing specialized neurological care centers without coordination

► Each of the regions builds its own specialized neurological center, buys expensive equipment, attracts specialized medical staff

SITUATION::

RESULT::

► Three specialized centers in relatively small area compete with each other

► Small area cannot fulfill the number of patients required so as the specialized centers are sustainable

► High risk of ineligibility of expenses if funded from ESIF

Legend:

Optimal location for specialized neurological center

SOLUTION::

► One highly specialized center for three neighboring regions in the area easily accessible for inhabitants of other two regions

► Complex approach counting on geographic location, existence of similar specialized centers in nearby location and probability of particular disease emergence

Illustrative scheme

II. Implementation structure of respective OPs MoH as an Intermediate body

► Identification of which priorities from the national public health strategy are in line

with the thematic objectives and investment priorities supported under set

Operational Programmes

► Active negotiations with the relevant Managing Authorities on investing in health

and competencies of MoH as an IB (shall be formalized in delegation agreement)

Phase Possible roles & responsibilities of MoH as an intermediate body

Programming

phase

► Preparation of calls for proposals and indicators

► Assessment of project applications and selection of projects

► Preparing and signing Grant Agreements with beneficiaries

► Project implementation monitoring

► Verification of application for payments

► Procurement control

► Conducting/participating on the on-spot controls of projects

► Other activities based on delegation of duties set by the respective MA

Implementation

phase

► Closing of Operational Programmes Winding up

II. Implementation structure of respective OPs MoH as a beneficiary

► Mapping of health investment possibilities under thematic objectives and within

national OPs

► Preliminary negotiations with Managing Authorities of OPs from which MoH

expects to apply for money

Phase Roles & responsibilities of MoH as a beneficiary

Programming

phase

► Development of evidence-based project, proper financial planning and consideration

of project sustainability

► Preparation of project applications that comply with all requirements

► Proper project team set up

► Main responsibility lays in proper project implementation (public procurement,

change management, fulfillment of indicators etc.)

► Securing of continuity of project implementation and continuity of human resources

► Ensuring the coherence of individual project with national strategic frameworks

► Possible coordination with other departments in MoH (other institutions)

Implementation

phase

► Sustainability of projects Winding up

VIII. Principles of effective coordination (ii) Effective involvement of MoH in various stages of

OP lifecycle [EY’s professional opinion]

Organizational set up Good practices identified

1. Coordinator of health care system development

i. Specialized department at MoH dealing with horizontal and vertical coordination of

investments in health = hereinafter indicated as a department for coordination of

health strategy implementation

ii. External coordination platform bringing together the above mentioned department

with representatives of regions to ensure horizontal cooperation = hereinafter

indicated as a coordination committee

2. Implementation structure of respective OPs

i. Function of Intermediate Body in responsibility of department solely focused on EU

Funds implementation and management = hereinafter indicated as a department for

EU Funds

ii. Implementation of projects financed from ESIF (beneficiary) in responsibility of

relevant departments or eventually Project management office (PMO)

The above mentioned roles should be institutionally detached and shall not overlap

Coordinator of health care system development i. Department for coordination of health strategy implementation

► Coordination body in the structures of the MoH

► Should be a part of strategic department or be closely linked to this

department

► Main competencies & responsibilities:

► Development of health care strategy/individual action plans

► Mapping of health issues covered by other OPs

► Coordination with other MAs in the areas resulting from initial mapping

► Negotiation about involvement of MoH in implementation of OPs in

2014 - 2020 programming period

► Ongoing coordination of activities among other MAs and especially

with regions

[formally in the Coordination committee, informally on an ongoing basis]

Political support and mandate given to this department is very important factor to be able to

effectively fulfil the role of a coordinator of the whole health care system development.

Coordinator of health care system development ii. Coordination committee

► Composition of the Coordination committee:

► Chaired by representatives of MoH [Department for coordination of health strategy

implementation]

► Representatives of regions [Bodies responsible for HC in the regions, ROP MAs]

► Main competencies & responsibilities:

► Agrees on health priorities and specific form of implementation of health priorities

on regional level

► Reviews investments to be supported in each region regarding the priorities

agreed and categorize investments:

► Strategic investments of national importance [to be further reviewed and approved by the

Committee; sources of funding needs to be further coordinated]

► Investments of regional importance [remains in competency of regions; funding solely from

ROPs]

► Coordinates implementation of projects of national importance

► Evaluates and monitors progress towards agreed strategic objectives

Body coordinating overall quality and efficiency of implementation of health care development

needs and improvement of health care system across all the regions.

Implementation structure of respective OPs i. Department for EU Funds (Intermediate Body)

► Intermediate body responsible for implementation of activities delegated

on it by a respective MA (based on Delegation Agreement)

► This department should be independent on other departments

► Competencies & responsibilities*:

► Consultations to applicants

► Managing of calls for proposal

► Assessment of project applications and selection of projects

► Absorption capacity building

► Cooperation with beneficiaries

► Monitoring of projects (incl. administrative and on the spot controls)

► Coordination with MA on other related activities (evaluations, reporting etc.)

Department responsible for performance of activities delegated by MA (related to health care

direct investments). Specific competencies always depend on negotiations with Managing

Authority.

* Specific competencies of the IB always depend on negotiations with Managing Authority in each country.

Implementation structure of respective OPs ii. Beneficiary

► Two possible approaches based on complexity and number of

projects managed

i. Single projects could efficiently been managed by relevant departments

ii. In case of complex projects/higher number of projects PMO could

support effective implementation

Project Management Office ► Supports implementation and application of centralized management standards

► If involved also in projects implementation, it could bring cost and time savings

thanks to concentration of management and administrative capacities in one

department

► Simplifies coordination and monitoring of investments and projects in health

Relevant project management capacities are critical factor

regardless the form of organizational set up

Example of possible organizational platform

Develops healthcare strategy and coordinates

strategy implementation on a day-to-day basis

Strategic coordination department at MoH

EU funds

departme

nt (IB)

Ministry of Health

Specialized

departments

/ PMO

(Beneficiarie

s)

Legend:

Key departments in the structure

Participants of Coordination Committee

Ongoing coordination & cooperation

Illustrative scheme

Vertical cooperation

Stakeholders

Coordination Committee

MAs of national

OPs Regional

HC

institutions

National HC

institutions

ROP manag.

authorities

IX. New concepts in health


Health in the EU strategic context

► Health sector as one of the most important in public spending… ► 15 % of all government expenditure in the EU

► 8 % of the total European workforce

► 10 % of the EU’s GDP*

► …is a part of the Europe 2020 policy framework and has three main

branches:

INVESTING IN

SUSTAINABLE HEALTH

SYSTEM

► Health expenditure

is recognized as

growth-friendly

expenditure

► Potential for

efficiency gains in

the health care

sector

INVESTING IN

PEOPLE’S HEALTH

► Precondition for

economic prosperity

► Influences

economic

outcomes:

► Productivity

► Labour supply

► Human capital

► Public spending

INVESTING IN

REDUCING HEALTH

INEQUALITIES

► Contributes to

social cohesion

► Allows improvement

of average levels of

health

* Source: Commission Staff Working Document - Social Investment Package: Investing in health, February 2013

Use of information technologies in health care 1/3

► Cost- and time-effective means of health care

provision through integration of all relevant

patient information and medical processes

► Stands for electronic storage, exchange of

patient data and the provision of health care by

electronic means

► Allows interaction between:

► Patient and health care provider

► Medical facilities (including pharmacies)

► Patients

► Health care professionals

► Supported measures based on the degree of

development:

► IT infrastructure development

► Development of systems, moduls and

applications

► Implementation of eHealth into praxis

► Information about individuals’ lifetime health

status that can be found in one place and can

be shared across different medical facilities

► Creates a more efficient, convenient and more

cost-effective delivery of care:

► Saves time of physicians, other medical

personnel as well as patients

► Improves management, coordination and

administrative efficiency

► Enhances the quality of the provided care

through evidence-based tools which help to make

decisions about treatment

► Enables faster sharing of patient information with

other health care providers across institutions

Areas for improvement eHealth concepts 1/3

(i) Electronic health records


► Consists of two tightly connected processes:

► ePrescribing – prescribing using electronic

software

► eDispensing – act of electronic reception of the

prescription by the pharmacy and dispensing it to

the patient

► Has a high impact on effectiveness, quality and

sustainability of medical care through:

► Patient safety as it allows easier access to

medication history reduces the risk of negative

drug interactions

► Efficient prescription reducing the number of

duplicate prescriptions

► Management efficiency allowing overview and

easier monitoring

Areas for improvement (ii) ePrescription

► Reduces hospitalization and general

practitioner or specialist visits

► Reduces travel time

► Improves access to health care particularly for

elderly or disabled people

► Telemedicine:

► Refers to health care services at a distance,

where interaction between the health care

provider and the patient is needed

► Video consultations with specialist

► Remote medical evaluation and diagnosis

► Digital transmission of medical images

► Telecare:

► Based on patient monitoring using telephones,

computers, videophones, alarms and other

portable or wearable systems

► Remote physiological monitoring of a patient

► Pill dispensers and reminders

► Environment monitoring (floods, fire)

(iii) Telehealth


► Medical and public health practice supported by

mobile devices such as:

► Mobile phones

► Patient monitoring devices

► Personal digital assistants (PDA)

► Allows collection of medical, physiological,

lifestyle, daily activity and environmental data

► Potential to serve as a basis for evidence-

driven care practice

► Enables more accurate diagnosis and treatment

► Saves time of health care professionals spent

on accessing and analyzing information

► Allows patients to do more medical and care

interventions remotely by themselves, guided

by monitoring and reporting systems, reducing

hospitalization

Areas for improvement (iv) mHealth

► Allows effective and sustainable knowledge and

information sharing

► Includes:

► Health information system for citizens in order to

increase health literacy

► Health knowledge management systems for

professionals and students

► Virtual health care teams which consist of health

care professionals who cooperate and share

information on illnesses and patients through

digital equipment

(v) Networking and knowledge sharing

Cost-effectiveness of care

► Worldwide problem of ineffective use of

medicines:

► Prescription of overpriced medicines

► Use of an excessive number of sometimes

unnecessary medications (polypharmacy)

► Inappropriate self-medication

► Use of less expensive equivalent (generic)

drugs

► Set of prescription guidelines to prevent misuse

and unnecessary use of medicines (e.g.

antibiotics)

► Awareness about medicines and better literacy

will allow patients to better manage their

medication

► Transfer of information between the health care

units participating in the care of the patient will

help to lower the number of unnecessarily

prescribed medicines

Areas for improvement Cost-effective use of medicines

► Patient classification system which assumes

that the treatment of patients with the same

diagnosis will require a similar or identical

diagnostic and therapeutic algorithm

► Financial benefits:

► Using DRG funding as a fixed payment per case

in a specific DRG

► Budget set up based on the measurement of

production by DRG

► Management benefits:

► Access to provided care through clinically and

economically comparable units

► Tool for measuring the outputs

► Tool for measuring the quality of the provided

health care

► DRG allows professionals with a different focus

to better communicate (e.g. communication

between economists and doctors)

► DRG allows comparison of different HC

providers on their performance activity

DRG: Diagnosis-related group

Transformation of care delivery 1/2

► Process of gradual reduction in specialized

institutional care for patients

► Potential contribution to elimination of the

increasing costs caused by the ageing

population

► Patient-centered care solutions and

personalized care for chronic and long-term

care needs

► Deinstitutionalization consists of two main

areas:

► Cost-effective path of care which

strengthens the primary care

► Community based care

Areas for improvement Deinstitutionalization

► Cost-effective path of care should always lead

from primary care (advanced practice nurses,

general practitioners, family doctors) to

secondary care (specialists, hospitals and

emergency care) and then, where appropriate,

to tertiary care (highly specialized consultative

health care)

► Benefits:

► Increases the accessibility to primary health care

and reduces inequalities

► Reduces the unnecessary use of specialist care

► Reduces inpatient hospital care

► Takes care of patient’s disease prevention

► Ensures patient follow-up care after secondary

care

► Links patients to social care

► Requires to make primary care more attractive

to both patients and practitioners

Strengthening of primary care

Transformation of care delivery 2/2

► Community-based care is especially

contributive to:

► Seniors dependent on long-term care

► People with disabilities

► People with mental health problems

► Lower costs of ambulatory care and care

provided to patients home compared to costly

hospital / medical institution care

► Provides better outcomes in terms of quality of

life in contrast to institutional care causing long-

term social exclusion and segregation of the

patients

► Community-based services include:

► Personal assistance

► Respite care

► Family-based care

► Hospital at home

► Independent living

Areas for improvement Community-based care

Investing in people’s health 1/2

► Stands for the process of optimizing

opportunities for health, participation and

security in order to enhance quality of life as

people age

► Elderly people will account for 29,5 % of the EU

28’s population by 2060 (17,5 % in 2011)

► The health status of individuals strongly

influences their labour market participation

► Health sustaining activities prevent costly

health care and lower dependency burdens

► Activities improving the employability of older

people also enable people to work longer and

retire more gradually

► Stands for the process of enabling people to

increase control over, and to improve their

health

► Potential for cost savings for subsequent

(secondary or tertiary) care and cure and the

improvement of the individuals’ health allowing

them to live a more active and independent life

► Primary prevention aims to avoid occurrence

of disease through:

► Eliminating disease agents

► Increasing resistance to disease

► Secondary prevention aims to detect and treat

a disease early on and attempts to prevent

asymptomatic disease from progressing to

symptomatic disease

► Tertiary prevention attempts to reduce the

damage caused by symptomatic disease by

focusing on mental, physical, and social

rehabilitation

Areas for improvement Active and healthy ageing Health prevention

► Stands for the process of enabling people to

increase control over, and to improve their

health

► Raises awareness of health risks and how to

prevent them

Health promotion

Investing in people’s health 2/2

► The concept aims to enable and encourage

patients to take control of their health needs

through their own health decisions and self-

selected changes to their lifestyle

► An empowered patient:

► Understands his health conditions

► Feels able to participate in decision making with

his health care professional and to make

informed choices about treatment

► Understands the need to make necessary

changes to his lifestyle

► Takes responsibility for his health and actively

seeks care only when necessary

► The concept requires patients to take

responsibility for their own health through e.g.:

► Attending regular preventive checks

► Leading a healthy lifestyle

Areas for improvement Patient empowerment

Investing in reducing health inequalities

Areas for improvement ► Investing in reducing health inequalities breaks

the vicious spiral of poor health contributing to,

and resulting from, poverty and exclusion

► Health inequalities represent:

► Waste of human potential

► Huge potential economic loss

► Reasons:

► Barriers in access to health care

► Social status / mental state

► Barriers in access to health care can be

removed through e.g.:

► Use of ICT in health such as telehealth or

mhealth

► Improved health care territorial cover

► Cross border care

► Inequalities caused by social status / mental

care can be removed through contribution

towards reaching Europe 2020 poverty and

social exclusion target

► Specific activities addressing health

inequalities:

► Ensure physical activity possibilities in

poorer regions / areas

► Address risk factors that are particularly

prevalent in disadvantaged population

groups (e.g. tobacco consumption)

► Set up, improve or expand local health

care basic services (including

infrastructure) for the rural population

► Support to better living and housing

conditions for vulnerable groups:

► Access to acceptable standards of housing

and indoor temperature

► Access to sanitation and water which meets

EU standards

► Bring innovations to the care system to

improve patients’ health literacy

X. Discussion about specific EC regulation (i) Performance reserve and monitoring

[Analysis of EU regulation]

Performance framework One of the pillars towards the result orientation of ESIF

1. Clear articulation of the objectives of OPs with a

strong intervention logic

2. Definition of ex-ante conditionalities to ensure that

the necessary prerequisites are in place for the

effective implementation of ESIF

3. Establishment of clear and measurable milestones

and targets to ensure progress is made as planned

(performance framework)

► Regular monitoring by the EC and the monitoring

committee for each programme:

► MA provides information on progress in the

Annual Implementation Report (AIR), beginning

for the reports submitted in 2017

► Annual review meeting for all OPs convened

every year from 2016 until 2023

► Monitoring committee reviews implementation of

the OP and progress towards achieving its

objectives

► Two formal reviews scheduled for 2019 and the

closure of the programming period

Areas for improvement Three pillars of the result orientation of ESIF Time framework

Milestones and targets in form of:

► Financial indicators

► One indicator per priority in form of the total amount

of eligible expenditure


► Selected by Member States from among the

indicators already chosen for the programme


► Key implementation steps

► Used to set a milestone when no measurable

output is expected by the end of 2018

Building blocks of performance framework

2014 2018 2019 2023 2025

► Milestones (intermediate targets) to be achieved by 31

December 2018

► Performance review in 2019

► Targets set to be achieved by 31 December 2023

► Final assessment and the closure of the programming

period in 2025

Monitoring performance

Performance reserve 6% of the allocation for successful priorities

Areas for improvement Performance reserve

► Total amount of the performance reserve allocated by ESI

Fund and category of region shall be 6%

► Constitutes between 5 and 7% of the allocation to each

priority within a programme

► Corresponding amounts shall be set out in the OPs broken

down by priority and, where appropriate, by ESI Fund and

by category of region

► Will be allocated to OPs and priorities which have

achieved their milestones

Performance review

► Carried out in 2019 on the basis of the information and the

assessment presented in the annual implementation report

(AIR)

► EC adopts a decision to determine for each MS and ESI

Fund, the OPs and priorities which have attained their

milestones and will get the performance reserve

► Where priorities have not achieved their milestones,

the MS shall propose the reallocation of the

corresponding amount to “successful” priorities

► The number of output indicators selected for a priority

should be as low as possible – increases in their number

raises the risk of failing the milestone set

► Appropriate ex-ante assessment of each programme

should address the suitability of milestones and targets

selected. The assessment should analyze:

► Relevance of the milestones

► Whether the milestones are realistically achievable

► Ensure that are not unrealistically low or high

► The key question is: “What should be achieved by the end

of 2018?”

► Monitoring committee may also make observations to

the MAs regarding implementation and should then

monitor actions taken as a result of its observations to

ensure achievement of the milestones

► MS should not fail to submit information on progress

against the milestones in the AIR as the reserve will not be

allocated for the priorities or programmes not supported by

progress report

Steps towards successful achievement of performance reserve

Useful sources:

Guidance fiche: Performance Framework Review and Reserve in 2014-2020; Version 3 – 19 July 2013 available at http://ec.europa.eu/fisheries/reform/emff/guidance-performance-framework-review_en.pdf

http://ec.europa.eu/fisheries/reform/emff/guidance-performance-framework-review_en.pdf








Reporting system Annual implementation report

► The Annual Implementation Report (AIR) consists of the

AIR itself and the corresponding set of Indicators

► The AIR contains details of both the physical and

financial progress that has occurred in the year

► Including the contribution of the ESIFs to changes in

the value of result indicators

► The AIR should include the following information:

► Key information on implementation of the programme and

its priorities by reference to the financial data

► Common and programme-specific indicators and

quantified target values*

► The data transmitted shall relate to values for

indicators for fully implemented operations and also

where possible for selected operations

► A synthesis of the findings of all evaluations of the

programme that have become available during the

previous financial year

► Actions taken to fulfil the ex ante conditionalities (only in

the report to be submitted in 2016)

► Any issues affecting the performance of the

programme, and the corrective measures taken

► A citizen's summary of the content of the AIRs that

shall be made public

► In addition, the AIR submitted in 2017 shall:

► Set out and assess the previous information and the

progress towards achieving the objectives of the

programme

► Set out the actions taken to fulfil the ex-ante

conditionalities not fulfilled at the time of adoption of

programmes

► Assess the implementation of actions to take into account

the principles of promotion of men and women equality

and non-discrimination, sustainable development,

and the role of the partners**

► Report on support used for climate change targets

► The AIR for the financial years of 2014-2022 has to be

submitted to the European Commission by 31 May

from 2016 until and including 2023***

► Following this, the Commission may make observations

to the MA concerning issues affecting implementation of

the programme

► Each programme’s performance is also the subject of

the annual review meeting attended by the

representatives of the Commission and the Member State

* And beginning from the report submitted in 2017 the milestones defined in the performance framework

** Referred to in Article 5 in the implementation of the programme

*** The last AIR covering the financial year of 2023 is to be submitted by 15 February 2025

Useful sources:

Guidance fiche No 5: Annual Implementation Report, Version 3 – 7 March 2014 available at http://ec.europa.eu/fisheries/reform/emff/doc/04-annual-implementation-report_en.pdf

SFC2007: System for Fund management in the European Community 2007-2013 - The Annual Implementation Report FAQ available at http://ec.europa.eu/employment_social/sfc2007/quick-guides/sfc2007_ms_air_faq.pdf

http://ec.europa.eu/fisheries/reform/emff/doc/04-annual-implementation-report_en.pdf









http://ec.europa.eu/employment_social/sfc2007/quick-guides/sfc2007_ms_air_faq.pdf




X. Discussion about specific EC regulation (ii) State aid

[Analysis of EU regulation]

State Aid EU State Aid policy framework 1/3

► Article 107(1) of the EC Treaty on the Functioning of the European Union

(hereinafter “the Treaty”) prohibits Member States from distorting competition on

the Common Market by giving state aid to undertakings*

“Save as otherwise provided in the Treaties, any aid granted by a Member State or through State

resources in any form whatsoever which distorts or threatens to distort competition by favouring certain

undertakings or the production of certain goods shall, in so far as it affects trade between Member

States, be incompatible with the internal market.”

► To determine whether an intervention/investment represents state aid or not,

Article 107 (1) of the Treaty refers to four test criteria:

► Is the measure (i.e. form of support) being provided by the State or state resources?

► Does the measure favor particular undertakings or the production of certain goods?

► Does the measure affect tradable activity between Member States?

► Will the measure distort competition, or does it have potential to distort competition?

! The fair chance exits that interventions of Member States in health care markets

may meet all criteria and fall under the Community regime of State Aid

* every entity engaged in economic activities is an undertaking within the meaning of EC competition law


EXCEPTIONS

► Categories acknowledged by the Commission as compatible with the

common market*, e.g. ► regional aid, allocated according to the map for regional aid in the period 2007-2013

► aid for the creation of small enterprises by women; aid in favor of SMEs, to allow them to benefit from

consultancy services and participation in fairs;

► aid for research, development and innovation, in particular concerning cooperation between research

organizations and enterprises, intellectual property rights costs for SMEs etc.

! Health care is not addressed among the exempted categories

► The Commission has also the power to approve national state aid measures

on the basis of:

► Article 107 (3) of the Treaty

► e.g. according to sub para (c) of this Treaty “aid to facilitate the development of certain economic

activities or of certain economic areas, where such aid does not adversely affect trading conditions to an

extent contrary to the common interest” may be allowed

► Article 106 (2) of the Treaty

► deals with Services of General Economic Interest (SGEI) and provides an exemption from the prohibition

laid down in Article 107 (1) EC

* Commission Regulation (EU) N°651/2014 of 17 June 2014 declaring certain categories of aid compatible with the internal market in application of Articles 107 and 108 of the Treaty


EXCEPTIONS

► State Aid under conditions of De minimis rules* are exempted from the

notification requirement

Main conditions set by the regulation:

► De minimis aid can not exceed EUR 200 000 (EUR 100 000 in case of road freight transport)

granted over a period of three years. In case of the SGEI, the interventions can not exceed EUR

500 000 over any period of three fiscal years to meet the SGEI de minimis Regulation rules.

► De minimis aid may be granted to an undertaking that has received other State aid as long as the

de minimis aid is not used to top up that other aid beyond the allowable ceiling for the same

attributable costs [= the treshold of EUR 200 000 is per Member State].

► Member State must check before providing it that a new grant will not breach the limit of EUR

200,000 per undertaking.

► Only transparent de minimis aid, i.e. aid where the amount can be calculated precisely in advance

without needing to carry out a risk assessment, could be applied.

* Regulation (EU) No 1407/2013 on the application of Articles 107 and 108 of the Treaty on the Functioning of the European Union to de minimis aid

State Aid The concept of undertaking in health care (analysis of case law)

“Every entity engaged in economic activities is an undertaking within the meaning of EC competition law”

► In application of the definition of undertakings to health care cases the European Court of

Justice (ECJ) and the Court of First Instance (CFI) distinct between bodies managing

health care schemes and health care providers*

► Managing bodies

► It depends on the national design of health

care schemes whether managing bodies

fall within the ambit of EC competition law

► The main argument is related to the

principle of solidarity and universal

coverage.

In state oriented HC systems in which the

principle of solidarity is predominant,

benefits granted by public authorities to

managing bodies of these schemes do not

fall within ambit of Article 107 (1) of the

Treaty

► Health care providers

► In cases where health care providers, like

doctors and hospitals are concerned, ECJ

simply departs from the assumption that

health care is (usually) provided for

economic consideration

► Concerns of universal coverage do not

play a role in the ECJ’s case law on the

concept of undertaking and to health care

providers

Doctors and other health care providers

are in general concerned to be engaged in

economic activities and thus fall within

ambit of Article 107 (1) of the Treaty

* Analysis of EU law approach towards health care with respect to EC competition law; THE COMPETITION LAW REVIEW, Volume 6 Issue 1 pp 5-29; Financing Health Care in EU Law: Do the European State Aid Rules Write Out an Effective Prescription for Integrating Competition Law with Health Care?

State Aid Concept of SGEI and it application in health care

► SGEIs represent economic activities that public authorities identify as being of particular

importance to citizens and that would not be supplied if there were no public intervention.

► The state aid for SGEI is regulated by Commission Decision of 20 December 2011 on the

application of Article 106.2 of the Treaty in the form of public service compensation

granted to certain undertakings entrusted with the operation of services of general

economic interest.

► Issues of general interest built upon the concept of SGEI do not constitute state aid,

provided that the following conditions are met [Altmark case]:

(1) the beneficiary must have public service obligations to discharge, and the obligations must be clearly

assigned;

(2) the parameters for calculating the compensation must be established in advance in an objective and

transparent manner;

(3) the compensation cannot exceed the relevant costs and a reasonable profit (no overcompensation);

(4) the provider is either chosen through a public procurement procedure or the level of compensation is

determined based on an analysis of the costs of an average "well-run“ undertaking in the sector concerned -

EFFICIENCY criterion.

! Concept of the SGEI and its exemption from the state aid rules might be applicable in many

situations in health care.

State Aid Concept of SGEI and its application in health care (analysis of case law)

► Some useful conclusions from the jurisdiction in relation to SGEI*:

► Bodies managing a health care scheme based on both competition and solidarity

elements may benefit from the jurisdictional approach of Altmark

► The jurisdictional decisions reflect opinion that SGEI missions may be derived from

general obligations. A consequence an open group of operators may be entrusted with

a SGEI mission.

This is an important conclusion for the health care sector, as in this sector an open group of operators is

supposed to realize objectives of general interest.

► On the other hand, it has still not been enlightened, whether SGEI mission still need to

be derived from explicit official acts or whether general obligations related to public

interest issues suffice.

However, based on CFI‘s judgment in a case concerning state aid granted in Italy, it can be concluded that

merely claiming that the public interest is involved without putting forward any substantiated evidence will not

help Member States to escape from the European state aid rules.

Some countries have therefore clearly defined which tasks and services are considered of general economic

interest [e.g. in Slovakia, providing healthcare in the outpatient care and inpatient care is legally defined as a

service of general economic interest].

* THE COMPETITION LAW REVIEW, Volume 6 Issue 1 pp 5-29; Financing Health Care in EU Law: Do the European State Aid Rules Write Out an Effective Prescription for Integrating Competition Law with Health Care?

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