Health policy responses to the financial crisis in Europe · financial crisis in the European...

POLICY SUMMARY 5

Health policyresponses to thef inancial crisis in Europe

Philipa Mladovsky, Divya Srivastava,Jonathan Cylus, Marina Karanikolos,Tamás Evetovits, Sarah Thomson,Martin McKee

© World Health Organization 2012 and World HealthOrganization, on behalf of the European Observatoryon Health Systems and Policies 2012

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This policy summary is one of a new series to meet the needs of policy-makers andhealth system managers.

The aim is to develop key messages to supportevidence-informedpolicy-making, and theeditors will continue to strengthen the series by working withauthors to improve theconsideration given to policy options andimplementation.

Keywords:

FINANCING, HEALTH

DELIVERY OF HEALTH CARE –economics

HEALTH POLICY

PUBLIC HEALTHADMINISTRATION

HEALTH SYSTEM PLANS –organization andadministration

Health policy responses to the financial crisis in Europe

Philipa Mladovsky, Divya Srivastava, Jonathan Cylus,Marina Karanikolos, Tamás Evetovits, Sarah Thomson,Martin McKee

Health policy responses to thefinancial crisis in Europe

Contents Page

Acknowledgements iv

Executive summary v

Key messages ix

1 Introduction 1

2 Understanding health policy responses to the financial crisis 3

3 Methods 9

4 Results 10

5 Conclusions 27

References 29

Annexes 38

Authors

Philipa Mladovsky, Research Fellow, EuropeanObservatory on Health Systems and Policies andLSE Health.Divya Srivastava, Research Officer, LSE Health,London School of Economics and Political Science.Jonathan Cylus, Technical Officer/ResearchFellow, European Observatory on Health Systemsand Policies and LSE Health.Marina Karanikolos, Technical Officer/ResearchFellow, European Observatory on Health Systemsand Policies and the London School of Hygieneand Tropical Medicine.Tamás Evetovits, Health Economist, WHO BarcelonaOffice for Health Systems Strengthening.Sarah Thomson, Senior Research Fellow, EuropeanObservatory on Health Systems and Policies,Deputy Director of the Observatory’s LSE hub andResearch Fellow and Deputy Director of LSE Health.Martin McKee, Professor of European PublicHealth at LSHTM, London School of Hygiene &Tropical Medicine.

Editors

WHO Regional Office forEurope and EuropeanObservatory on HealthSystems and Policies

EditorGovin Permanand

Editorial BoardJosep FiguerasClaudia SteinJohn LavisDavid McDaidElias Mossialos

Managing EditorsKate Willows FrantzenJonathan NorthCaroline White

The authors and editors aregrateful to the reviewerswho commented on thispublication and contributedtheir expertise.

No: 5

ISSN 2077-1584

Acknowledgements

This policy summary is the result of a collaboration between the EuropeanObservatory on Health Systems and Policies, the WHO Regional Office forEurope, and the European Commission (Directorate-General (DG) forEmployment, Social Affairs and Inclusion). The study benefited from researchundertaken for a project funded by the European Commission (DG forEmployment, Social Affairs and Inclusion) on Health Status, Health Care and Long-term care in the European Union (EU), Contract No. VC/2008/932(Srivastava & Mladovsky, 2011).

We are grateful to Josep Figueras, Matthew Jowett, Nora Markova, EricaRichardson, Tiziana Leone, David Stuckler, experts at DG for Health andConsumers (DG SANCO) and DG for Employment, Social Affairs and Inclusion,participants of the European Health Policy Group meeting in Copenhagen inApril 2012 and an anonymous referee for their comments on previous drafts of this policy summary; and to Katharina Hecht for her assistance in managingpart of the data collection. We are particularly grateful to the following countryexperts who contributed by completing the questionnaires and without whomthis study would not have been possible: Albania: Genc Burazeri; Armenia:Lyudmila Niazyan; Austria: Maria M. Hofmarcher and Leslie Tarver; Azerbaijan:Fuad Ibrahimov; Belarus: Aleksander Grakovich; Belgium: Sophie Gerkens andMaria Isabel Farfan-Portet; Bosnia and Herzegovina: Drazenka Malicbegovic;Bulgaria: Evgenia Delcheva; Croatia: Martina Bogut; Cyprus: Mamas Theodorou;Czech Republic: Tomas Roubal; Denmark: Karsten Vrangbæk; England: VanessaSaliba; Estonia: Triin Habicht; Finland: Jan Klavus; France: Sandra Mounier-Jack;Georgia: George Gotsadze; Germany: Marcial Velasco-Garrido; Greece: DaphneKaitelidou; Hungary: Barbara Koncz; Iceland: Sigrun Gunnarsdottir; Ireland:Steven Thomas; Israel: Amir Shmueli; Italy: Margherita Giannoni; Kyrgyzstan:Baktygul Akkazieva; Latvia: Anita Villerusa; Lithuania: Skirmante Starkuviene;Malta: Natasha Azzopardi Muscat; Netherlands: Ronald Batenburg; Norway:Anne-Karin Lindahl; Poland: Adam Kozierkiewicz; Portugal: Leonor BacelarNicolau; Republic of Moldova: Valeriu Sava; Romania: Victor Olsavszky; RussianFederation: Kirill Danishevskiy; Serbia: Vukasin Radulovic; Slovakia: LuciaKossarova; Slovenia: Rade Pribakovic; Spain: Alexandrina Stoyanova; Sweden:Anna Melke; Switzerland: Raphaël Bize; the former Yugoslav Republic ofMacedonia: Fimka Tozija; Turkey: Salih Mollahaliloğlu; Ukraine: Valery Lekhan;Uzbekistan: Mohir Ahmedov. The responsibility for any mistakes is ours.

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Executive summary

Introduction

The global financial crisis that began in 2007 can be classified as a healthsystem shock – that is, an unexpected occurrence originating outside the health system that has a large negative effect on the availability of healthsystem resources or a large positive effect on the demand for health services.Economic shocks present policy-makers with three main challenges:

• Health systems require predictable sources of revenue with which to planinvestment, determine budgets and purchase goods and services. Suddeninterruptions to public revenue streams can make it difficult to maintainnecessary levels of health care.

• Cuts to public spending on health made in response to an economic shock typically come at a time when health systems may require more, not fewer, resources – for example, to address the adverse health effectsof unemployment.

• Arbitrary cuts to essential services may further destabilize the healthsystem if they erode financial protection, equitable access to care and thequality of care provided, increasing health and other costs in the longerterm. In addition to introducing new inefficiencies, cuts across the boardare unlikely to address existing inefficiencies, potentially exacerbating thefiscal constraint.

In 2009, WHO’s Regional Committee for Europe adopted a resolution(EUR/RC59/R3) urging Member States to ensure that their health systems wouldcontinue to protect and promote universal access to effective health servicesduring a time of economic crisis. To date, there has been no systematic cross-country analysis of health policy responses to the financial crisis in Europe,although some overviews of health system responses to the crisis have beenpublished. This policy summary aims to address a gap in the literature bypresenting a framework for analysing health policy responses to economicshocks; summarizing the results of a survey of health policy responses to thefinancial crisis in the European Region’s 53 Member States; and discussing the potential effects of these responses on health system performance.

Understanding health policy responses to the financial crisis

When confronted by an economic shock affecting the health sector, policy-makers may decide to maintain, decrease or increase current levels of publicexpenditure on health. With each option they could also reallocate funds withinthe health system to enhance efficiency. A range of tools can be used to alter


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expenditure levels, categorized under the following policy domains: the level of contributions for publicly financed care; the volume and quality of publiclyfinanced care; the cost of publicly financed care.

In making decisions about which tools to use, policy-makers need to considerthe impact of proposed reforms on the attainment of health system goals.Achieving fiscal balance is likely to be important in the context of a financialcrisis but generally it is not regarded as a primary goal of the health system – on a par with or overriding health policy goals such as health gain or financialprotection – since, if it were, it could be achieved by cutting public spending onhealth without regard for the consequences. This stands in contrast to the goalof efficiency. The purpose of trying to increase efficiency in the health sector is tomaximize outcomes for a given level of public resources devoted to health care.

Governments’ responses exist in a context of broader constraints andopportunities within and external to the health system. Public policy responsesto economic shocks should vary according to the nature of the shock. The crisishas had devastating consequences for some countries in Europe, particularlythose with high levels of pre-existing debt and deficit, which have found itdifficult to borrow to sustain public spending. Inability to obtain affordablecredit or to generate revenue through taxation severely constrains a highlyindebted country’s fiscal space, leaving it with little option but to cut publicspending. Political preferences may also influence public policy responses.

Survey results

The results of the survey suggest that the response to the crisis across theEuropean Region varied considerably across health systems and, in part,depended on the extent to which countries experienced a significant downturnin their economies. Some countries introduced no new policies, while othersintroduced many. Some health systems were better prepared than others due tofiscal measures they had taken before the crisis, such as accumulating financialreserves. There were many instances in which policies planned before 2008were implemented with greater intensity or speed as they became more urgentor politically feasible in face of the crisis, particularly the restructuring ofsecondary care. There were also cases where planned reforms were sloweddown or abandoned in response to the crisis.

Policies intended to change the level of contributions for publiclyfinanced health care

Several countries reported cuts in the national health budget in response to thefinancial crisis. In some countries, cuts were partly caused by rising unemploymentwhich reduced revenue from social insurance contributions. In a few cases,

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social insurance revenues and expenditures continued to increase, in part dueto the counter-cyclical contribution rate paid by the state for economicallyinactive people. Several countries increased or instituted user charges inresponse to the crisis. In contrast, others reported expanding benefits.

Policies intended to affect the volume and quality of publicly financedhealth care

In general the statutory benefits package and the breadth of populationcoverage were not radically changed following the financial crisis but somereductions were made, usually at the margin. In terms of policies to reducedemand for health services, several countries increased taxes on alcohol andcigarettes, but very few pursued health promotion policies such as healthyeating, exercise and screening in response to the crisis. Only one countryincreased waiting times as an explicit response to the crisis, although waitingtimes may also be increasing elsewhere as an indirect result of other healthpolicy reforms.

Policies intended to affect the costs of publicly financed health care

Many countries introduced or strengthened policies to reduce the price ofmedical goods or improve the rational use of medicines. In most cases thesepolicies were part of ongoing reforms. The crisis increased efforts to negotiatepharmaceutical prices in some national markets.

Some countries reduced the salaries of health professionals, froze them,reduced their rate of increase or used other approaches to lower salaries.Several countries reduced the health service prices paid to providers or linkedpayment to improved performance to realize efficiency gains and contain costs.Several governments are restructuring their Ministry of Health, statutory healthinsurance funds or other purchasing agencies in an attempt to increaseefficiency and reduce overhead costs.

In many countries, the economic crisis created an impetus to speed up theexisting process of restructuring the hospital sector through closures, mergersand centralization, a shift towards outpatient care and improved coordinationwith or investment in primary care.

Conclusions

The survey results indicate that European Region countries have employed a mix of policy tools in response to the financial crisis. Some countries seem to have used the crisis to increase efficiency, although little has been done to enhance value through policies to improve public health, which is a missed opportunity.


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Policies to secure financial sustainability in the face of the financial crisis, and to improve the health sector’s fiscal preparedness for financial crises, should be consistent with the fundamental goals of the health system.

To risk over-simplifying, policy tools likely to promote health system goalsinclude: increased risk pooling; strategic purchasing, where contracts arecombined with accountability mechanisms including quality indicators, patient-reported outcome measures and other forms of feedback; health technologyassessment to assist in setting priorities, combined with accountability,monitoring and transparency measures; controlled investment in the healthsector, particularly for health infrastructure and expensive equipment; publichealth measures to reduce the burden of disease; price reductions forpharmaceuticals combined with cost–effectiveness evidence and othermeasures to promote rational prescribing and dispensing; shifting frominpatient to day-case or ambulatory care, where appropriate; integration andcoordination of primary care and secondary care, and of health and social care;reducing administrative costs while maintaining capacity to manage the healthsystem; fiscal policies to expand the public revenue base; counter-cyclicalmeasures, including subsidies, to protect access and financial protection,especially among poorer people and regular users of health care; and, outsidethe health sector, active labour market programmes and social support servicesto mitigate some of the adverse effects of economic downturns.

Policy tools that risk undermining health system goals include: reducing thescope of essential services covered; reducing population coverage; increases in waiting times for essential services; user charges for essential services; andattrition of health workers caused by reductions in salaries.

The discussion highlights the trade-offs involved in any policy decision. Thesetrade-offs should be understood and made explicit so that decision-makers can openly weigh evidence against ideology in line with societal values. Policydecisions should be guided by a focus on enhancing value in the health systemrather than on identifying areas in which cuts might most easily be made.Viewing fiscal balance as a constraint to be respected, rather than as anobjective in its own right allows decision-makers to shift the terms of debateaway from balancing the budget at any cost towards an emphasis onmaximizing the health system’s performance.

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Key messages

• Economic shocks present policy-makers with three main challenges:

– Health systems require predictable sources of revenue. Suddeninterruptions to public revenue streams can make it difficult tomaintain necessary levels of health care.

– Cuts to public spending on health made in response to an economicshock typically come at a time when health systems may requiremore, not fewer, resources – for example, to address the adversehealth effects of unemployment.

– Arbitrary cuts to essential services may further destabilize the healthsystem if they erode financial protection, equitable access to care andthe quality of care provided, increasing costs in the longer term. Inaddition to introducing new inefficiencies, cuts across the board areunlikely to address existing inefficiencies, potentially exacerbating the fiscal constraint.

• The response to the crisis across the European Region varied across health systems. Some countries introduced no new policies, while others introduced many. Some health systems were better prepared thanothers due to fiscal measures they had taken before the crisis, such asaccumulating financial reserves. There were many instances in whichpolicies planned before 2008 were implemented with greater intensity or speed as they became more urgent or politically feasible in face of thecrisis. There were also cases where planned reforms were slowed down or abandoned in response to the crisis.

• European Region countries employed a mix of policy tools in response tothe financial crisis. Some of the policy responses were positive, suggestingthat some countries have used the crisis to increase efficiency. The breadthand scope of statutory coverage was largely unaffected and in some casesbenefits were expanded for low-income groups. However, some countriesreduced the depth of coverage by increasing user charges for essentialservices, which is a cause for concern. Little was done to increaseefficiency through policies to improve public health.

• Policies to secure financial sustainability in the face of the financial crisis,and to improve the health sector’s fiscal preparedness for financial crises,should be consistent with the fundamental goals of the health system.

• To risk over-simplifying, policy tools likely to promote health system goalsinclude: risk pooling; strategic purchasing; health technology assessment;controlled investment; public health measures; price reductions for


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pharmaceuticals combined with rational prescribing and dispensing;shifting from inpatient to day-case or ambulatory care; integration andcoordination of primary care and secondary care, and of health and socialcare; reducing administrative costs while maintaining capacity to managethe health system; fiscal policies to expand the public revenue base; andcounter-cyclical measures, including subsidies, to protect access andfinancial protection, especially among poorer people and regular users of health care.

• Policy tools that risk undermining health system goals include: reducingthe scope of essential services covered; reducing population coverage;increases in waiting times for essential services; user charges for essentialservices; and attrition of health workers caused by reductions in salaries.

• Where the short-term situation compels governments to cut publicspending on health, the policy emphasis should be on cutting wisely tominimize adverse effects on health system performance, enhancing valueand facilitating efficiency-enhancing reforms in the longer run.

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1 Introduction

The global financial crisis that began in 2007 can be classified as a healthsystem shock – that is, an unexpected occurrence originating outside the healthsystem that has a large negative effect on the availability of health systemresources or a large positive effect on the demand for health services. Economicshocks present three risks which health policy-makers need to contend with.First, health systems require predictable sources of revenue with which to planinvestment, determine budgets and purchase goods and services. Suddeninterruptions to public revenue streams can make it difficult to maintain necessarylevels of health care. Second, cuts to public spending on health made in responseto an economic shock typically come at a time when health systems may requiremore, not fewer, resources – for example, to address the adverse health effectsof unemployment (see Box 1). Third, the nature of the health policy response to an economic shock may further destabilize the health system, particularly ifarbitrary cuts to essential services erode financial protection, equitable access to care and the quality of care provided, increasing health and other costs andexacerbating the fiscal constraint.

In 2009, WHO’s Regional Committee for Europe adopted a resolution(EUR/RC59/R3) urging Member States to ensure that their health systems would continue to protect and promote universal access to effective healthservices during a time of economic crisis (WHO Regional Office for Europe,2009). The resolution built on momentum created by the 2008 Tallinn Charter,which noted that health systems promoted both health and wealth; thatinvestment in health was an investment in future human development; andthat well-functioning health systems were essential for any society to improvehealth and attain health equity (WHO Regional Office for Europe, 2008). Morerecently, WHO has addressed the challenge of sustaining equity, solidarity andhealth gain in the context of the financial crisis, highlighting the diversity ofhealth policies pursued by Member States in response to budgetary pressures(WHO Regional Office for Europe, 2011b).

To date, there has been no systematic cross-country analysis of health policyresponses to the financial crisis in Europe, although some overviews of healthsystem responses to the crisis have been published (Schneider, 2009; EuropeanCommission & Economic Policy Committee (AWG), 2010; Doetter and Gotze,2011; European Hospital and Healthcare Federation, 2011; WHO RegionalOffice for Europe, 2011b; European Federation of Nurses Associations, 2012).1

This policy summary aims to address a gap in the literature by presenting aframework for analysing health policy responses to economic shocks;

1 In addition, an article based on an earlier draft of this policy summary has beenpublished (Mladovsky et al., 2012).


1

Policy summary

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summarizing the results of a survey of health policy responses to the financialcrisis in the European Region’s 53 Member States; and discussing the potential effects of these responses on health system performance.

Box 1. Effects of economic downturns on health

Research on health during the Great Depression in the United States in 1929–1937 showed that while suicides rose, overall mortality fell due to a decrease in infectious diseases and road-traffic accidents (Fishback, Haines & Kantor, 2007). A recent study using city- and state-level mortalities by cause shows that, apartfrom rises in suicides and falls in road-traffic deaths, overall mortality changeswere unrelated to the depression itself (Stuckler et al., 2011a).

The recession following the collapse of the Soviet Union in the early 1990s haddevastating consequences for population health across the region, with mortalityincreases of up to 20% in some countries. The pace of transition, including massprivatization and the absence of a social safety net in some of the countries,extensively affected life expectancy rates (Stuckler, King & McKee, 2009). Manyex-communist countries regained their pre-transition life expectancy levels onlytwo decades later. The adverse consequences of rapid economic reforms werefound to be lower in countries in which many people were members of socialorganizations such as trade unions, religious groups or sports clubs (Stuckler, King & McKee, 2009).

Countries affected by the South East Asian economic crisis of the 1990s adopteddifferent recovery strategies. Thailand and Indonesia, which reduced spending onsocial protection, experienced short-term increases in mortality, while Malaysiamanaged to sustain social protection programmes and showed no obvious changein death rates (Waters, Saadah & Pradhan, 2003; Hopkins, 2006; Chang et al., 2009).

These examples show how health outcomes following recession may differ, inpart depending on the context and causes of the crisis, but also depending on a country’s response.

A series of studies using aggregate-level data have suggested that health mightnot be affected by economic downturns in high-income countries, as mortalitytends to fall when the economy slows down and rise when the economy speedsup (Ruhm, 2000, 2003, 2008; Gerdtham & Ruhm, 2006). This effect has beenobserved at least in the short run, with the extent of the effect varyingsubstantially for different age groups (Joyce & Mocan, 1993), sexes (Chang et al., 2009) and diseases (Waters, Saadah & Pradhan, 2003), and the results are somewhat sensitive to the indicators used to measure economic change(Gerdtham & Johannesson, 2005; Svensson, 2007; Economou, Nikolau &Theodossiou, 2008; Stuckler, Meissner & King, 2008). Noting the counterintuitivenature of these findings (Catalano & Bellows, 2005), researchers have suggestedthat recessions may have a positive impact on health because increased leisuretime allows people to engage in health-enhancing activities such as exercise, or to cut down on over-consumption of food and alcohol.

2 Understanding health policy responses to the financial crisis

Fig. 1 depicts a framework for describing possible health policy responses to health system shocks. The framework has three main dimensions: healthexpenditure options, policy domains and outcomes. First, when confronted byan economic shock affecting the health sector, policy-makers may decide tomaintain, decrease or increase current levels of public expenditure on health.With each option they could also reallocate funds within the health system toenhance efficiency.


However, other research shows that economic downturns pose clear risks tohealth due to suicides and alcohol-related mortality (Stuckler et al., 2009; Stuckler,Basu & McKee, 2010; Suhrcke et al., 2011). These studies also find that adverseeffects can be partly mitigated by providing job reintegration programmes andsupport to families during periods of economic instability, as well as maintainingregulation of the alcohol industry to avoid hazardous drinking as a copingmechanism. Where such measures have been in place, the health benefits ofeconomic crises, such as declining road-traffic accidents as people drive less, tendto outweigh the risks, improving population health, at least in the short-term.

In summary, while additional research is needed to understand the longer-termand indirect effects of economic crises on health and health systems, someevidence from previous economic downturns suggests that recession, especiallyaccompanied by increases in unemployment, is damaging to public health(Kaplan, 2012; McKee, Basu & Stuckler, 2012). Maintaining spending on socialprotection, particularly on active labour market programmes, is likely to reducenegative effects on health.

Given the long delays in publishing mortality data in many countries, onlypreliminary conclusions can be drawn about the effects of the current crisis inEurope. However, research to date confirms a sharp rise in suicides in the countriesworst affected and a fall in deaths from road-traffic accidents, most notable incountries where initial accident levels were highest (Stuckler et al., 2011b).

More detailed evidence emerging from Greece, the European country that hasbeen hardest hit by the financial crisis, points to a worsening of mental healthstatus in the past two years (Economou et al., 2011; Madianos et al., 2011); self-reported general health has also deteriorated since the start of the crisis and there has been a significant increase in the number of people who felt theyneeded health care, but did not access it (Kentikelenis et al., 2011); the numberof new HIV cases among injecting drug users (IDU) has risen dramatically, thoughtto be caused by reduced service provision (EMCDDA & ECDC, 2011).

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Fig. 1. Health policy responses to the financial crisis and other economic shocks

Second, a range of policy tools within three main policy domains can be usedto alter expenditure levels. These can be categorized as:

• the level of contributions for publicly financed care (the size of the nationalhealth budget, social insurance contributions and transfers from the healthbudget, aspects of fiscal policy such as earmarking taxes for health, shiftingto private expenditure on health in the form of user charges or privatehealth insurance);

• the volume and quality of publicly financed care (the statutory benefitspackage, population coverage, non-price rationing in the form of waiting times);

• the cost of publicly financed care (the price of medical goods, health workersalaries, payments to providers, overhead costs, service reconfiguration).

In many cases, policies will affect more than one of these factors. For example,altering the price of medical goods will not only change the unit cost of care; it may also change the volume of medical goods provided and the level ofcontributions, if user charges are involved.

Third, when making decisions policy-makers need to consider the impact of anyproposed reforms on the attainment of health system goals. Health system

Policy summary

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Healthexpenditure Policy domains Outcomes

Cut

Increase

Maintain

Reallocate

Financing/contributions

Volume and qualityof services

Costs

Effect on healthsystem goals

Financial crisis and other constraints/opportunities

goals can be articulated in many ways; different policy documents put forwarda range of goals (see WHO, 2000, 2010; Figueras, Lessof & Srivastava, 2006;Kutzin, 2008):

• health status: improving health outcomes and health service outcomes

• financial protection: ensuring people do not suffer financial hardship when using needed health care

• efficiency: maximizing health gain from given resources and avoidingwaste, enhancing value by ensuring benefits outweigh costs

• equity: ensuring health services are distributed in relation to need andcontributions are set according to capacity to pay

• quality: combines clinical effectiveness with patient experience andtherefore captures safety, effectiveness, accessibility, acceptability

• responsiveness: meeting people's legitimate non-health expectationsabout how the health system treats them

• transparency: providing reliable information about features of the healthsystem such as benefits, costs and quality

• accountability: monitoring and evaluation of performance which isassociated with tangible consequences (penalties or rewards).

Fig. 2 makes explicit the links between health care expenditure, policy tools andgoals or outcomes. Changes to expenditure should be considered in the light oftheir potential impact on the attainment of health system goals. Achieving fiscalbalance is likely to be important in the context of a financial crisis but generallyit is not regarded as a primary goal of the health system – on a par with oroverriding health policy goals such as health gain or financial protection – since,if it were, it could be achieved by cutting public spending on health withoutregard for the consequences (Thomson et al., 2009). This stands in contrast tothe goal of efficiency. The purpose of trying to increase efficiency2 in the healthsector is to maximize outcomes for a given level of public resources devoted tohealth care (Weinstein & Stason, 1977). Efficiency gains imply achieving similaroutcomes at lower cost, better outcomes at similar cost or better outcomes at

2 Technical efficiency refers to the physical relation between resources (capital and labour)and health outcomes: obtaining the maximum level of output for a given level of inputor a minimum level of input for a given level of output. Productive efficiency refers tominimizing total cost for given output, or the maximization of health outcome for agiven level of cost. Allocative efficiency refers to maximizing the value of the output orthe appropriate combination of health programmes to maximize the health of society(Palmer & Torgerson, 1999).


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greater cost, where the benefits exceed the extra cost involved (Chernew et al.,1998; Palmer & Torgerson, 1999; Docteur & Oxley, 2003; Goetghebeur, Forrest& Hay, 2003; Dormont, Grignon & Huber, 2005; OECD, 2006; Pammolli et al.,2008). As we have noted, arbitrary cuts to public spending on health inresponse to an economic shock may undermine health system performance byreducing financial protection, equitable access to care and the quality of careprovided. This in turn might reduce efficiency by lowering health outcomes andincreasing health and other costs in the longer term. In addition to introducingnew inefficiencies, cuts across the board are unlikely to address existinginefficiencies, potentially exacerbating the fiscal constraint (Kutzin, 2008;Thomson, Foubister & Mossialos, 2009).

All three sets of responses exist in a context of broader constraints andopportunities within and external to the health system. Public policy responsesto economic shocks should vary according to the nature of the shock. Thecurrent economic crisis, considered by many to be the worst since the GreatDepression, was triggered by a combination of easy access to credit,irresponsible lending and high-risk investment involving complex financialinstruments. When investment-related loans could not be repaid, the financialinstruments lost considerable value (Wade, 2009) and financial institutions andothers holding or exposed to these securities suffered massive losses. Lenderreluctance to take on further liabilities led to liquidity shortages and concernsabout the solvency of financial institutions, deepening the crisis and causing itto extend well beyond the financial sector. Although the crisis to some extentoriginated in the United States (US), it quickly spread to other countries,resulting in bank failures, stock market crashes, drops in asset prices, negativegross domestic product (GDP) growth, rising unemployment and, ultimately,bailouts of entire countries.

The crisis has had devastating consequences for some countries in Europe,particularly those with high levels of pre-existing debt and deficit, which havefound it difficult to borrow to sustain public spending. Inability to obtainaffordable credit or to generate revenue through taxation severely constrains a highly indebted country’s fiscal space, leaving it with little option but to cutpublic spending. Within the Eurozone, national inability to form independentmonetary policy also limits policy options for combating the crisis. For Greece,Ireland and Portugal, bailout packages from the European Commission, theInternational Monetary Fund (IMF) and the European Central Bank (the “troika”)have actually mandated public sector reforms (including reforms to the healthsector) as conditionality for the receipt of funds, removing national autonomyin some areas of public policy (Fahy, 2012).

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Fiscal space may be further constrained by a rapid increase in unemployment. In the European Region, unemployment rates rose from 7.4% in 2008 to 8.6%in 2009 (WHO Regional Office for Europe, 2012). Rising unemployment notonly reduces household consumption and tax revenues; it also adds to pressureon the government’s welfare budget, as the need for unemployment and othersocial security benefits, including health benefits, increases. Countries that relyon the labour market to finance health care may find that paying social insurancecontributions for a growing number of unemployed people is another source offiscal pressure. Finally, political preferences may influence public policy responsesas much as the magnitude of the fiscal constraint created or exacerbated by theeconomic shock.

In the context of pressure for cuts in public spending, the health sector is likelyto be affected. Research suggests that public spending on health in Europe hastended to fall after previous economic crises, often at a faster rate than othertypes of government expenditure (Cylus, Mladovsky & McKee, in press). Recenthealth expenditure data suggest that a similar pattern is emerging in manycountries (see section 4). The health sector may be vulnerable to budget cutsfor a range of reasons. Public spending on health accounts for a substantialproportion of total government expenditure: nearly 13% on average in theEuropean Region (see Table 1). Health system inefficiencies may make itpolitically difficult to argue for maintaining current levels of public expenditureon health during a period of fiscal austerity. It may also be easier to cut publicspending on health than to make cuts in other areas of social protection, such as pensions, either because there is more scope for efficiency gains in the health system or because health benefits are less clearly defined than other benefits (Fahy, 2012). Conversely, counter-cyclical health policies such as holding financial reserves earmarked for health or linking governmentcontributions for economically inactive groups of people to average earnings in previous years may ease pressure to cut public spending on health (WHORegional Office for Europe, 2011b).

Other factors that may influence the nature, scale and intensity of the healthpolicy response to the crisis include the capacity of key stakeholders forimplementation (e.g. availability of human resources and expertise); theavailability and use of evidence to inform reforms (e.g. effective healthtechnology assessment (HTA) systems in place); political feasibility (e.g. policiesmay be resisted or overturned by politicians, professionals or the public, or,conversely, planned “unpopular” policies may become more politically feasiblein the context of the crisis); and the presence of other public sector reforms(e.g. cuts or stimulus packages affecting pensions, jobs, welfare benefits andthe unemployment rate).


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Table 1. Public expenditure on health as a percentage of total governmentexpenditure, WHO European Region

Policy summary

8

Country 2008 2009 Difference2008–2009

Kazakhstan 8.3 11.3 3.0Monaco 15.8 18.5 2.7Tajikistan 5.0 6.4 1.4Azerbaijan 2.5 3.7 1.2Bosnia and Herzegovina 14.0 15.1 1.1Republic of Moldova 13.0 14.1 1.1Uzbekistan 8.6 9.6 1.0Belarus 8.2 8.8 0.6Italy 13.6 14.2 0.6Malta 12.4 13.0 0.6Albania 8.2 8.4 0.2Georgia 7.3 7.5 0.2Kyrgyzstan 11.5 11.7 0.2Switzerland 19.9 20.0 0.1Andorra 21.3 21.3 0.0Austria 15.8 15.8 0.0Belgium 14.8 14.8 0.0Bulgaria 9.1 9.1 0.0Croatia 17.6 17.6 0.0Cyprus 5.8 5.8 0.0Czech Republic 13.3 13.3 0.0Denmark 15.3 15.3 0.0Finland 12.6 12.6 0.0France 16.0 16.0 0.0Germany 18.0 18.0 0.0Greece 13.0 13.0 0.0Hungary 10.2 10.2 0.0Iceland 13.1 13.1 0.0Ireland 16.0 16.0 0.0Israel 10.0 10.0 0.0Latvia 10.2 10.2 0.0

Source: WHO, 2012.

3 Methods

To map health policy responses to the financial crisis, we analysed healthexpenditure data from the Health for All and WHOSIS databases and sent aquestionnaire to a network of health policy experts in the European Region’s53 Member States. Most of the experts were based in universities, WHOcountry offices and other non-governmental organizations. Completedquestionnaires were received in March and April 2011.


Country 2008 2009 Difference2008–2009

Lithuania 12.8 12.8 0.0Luxembourg 13.7 13.7 0.0Montenegro 13.6 13.6 0.0Netherlands 16.2 16.2 0.0Norway 16.7 16.7 0.0Poland 10.9 10.9 0.0Portugal 15.4 15.4 0.0Romania 11.8 11.8 0.0San Marino 13.6 13.6 0.0Slovenia 12.9 12.9 0.0Spain 15.2 15.2 0.0Sweden 13.8 13.8 0.0Turkey 12.8 12.8 0.0Turkmenistan 7.0 7.0 0.0Ukraine 8.6 8.6 0.0United Kingdom 15.1 15.1 0.0Serbia 14.1 13.9 -0.2Estonia 11.9 11.7 -0.2Armenia 7.2 6.6 -0.6Russian Federation 9.2 8.5 -0.7Slovakia 15.4 14.0 -1.4The former Yugoslav Republic of Macedonia 13.6 12.1 -1.5

9

Because it was not always clear to what extent a policy was, in fact, a responseto the crisis, as opposed to being part of an ongoing reform process, we askedrespondents to divide policies into two groups based on whether they were(a) defined by the relevant authorities in the country as a response to the crisisor (b) either partially a response to the crisis (i.e. planned before the crisis butimplemented with greater or less speed or intensity than planned) or possibly a response to the crisis (i.e. planned and implemented since the start of thecrisis, but not defined by the relevant authorities as a response to the crisis).Both types of policies are reported here. We also asked respondents to provideevidence of the impact of policy responses on health system performance, butin almost every case they reported that evidence was not yet available.

Survey responses were categorized using the framework (Fig. 1). All of the data were analysed separately by two researchers (i.e. two people extracted the same data to ensure accuracy) and summarized in tables. The tables wereverified by the respondents and by experts from WHO. The completed policysummary was reviewed by experts from WHO, the World Bank and theOrganisation for Economic Co-operation and Development (OECD). Annex 1contains the full results of the survey.

The study has several limitations. First, as we anticipated, it is difficult to definewhether or not policies are in fact a response to the financial crisis. Second, we asked respondents to provide information distinguishing between types ofhealth care (curative, preventative, long-term care, medical goods, etc.) wherepossible, but comparing types of health care across countries is challenging,particularly due to the lack of a common definition of the term “public health”(McKee & Jacobson, 2000; Kaiser & Mackenbach, 2008). Where necessary, we clarified terminology with respondents. Third, the information provided byexperts may be of varying completeness and quality. Fourth, we have not beenable to systematically include information on each health system’s degree offiscal preparedness. Some countries may have introduced measures to improveefficiency or cut costs just before the crisis began, so that there was not muchroom for further reform. It is possible to capture this in case studies, butdetailed analysis covering 53 countries was beyond the scope of this exercise.Finally, evaluating policy responses to the financial crisis in a general way maybe misleading because different policies need to be considered in context toestablish actual impact on health system performance and health expenditure.

4 Results

Forty-five countries responded to the questionnaire. Their responses are summarized below (for more detailed results, see Annex 1), with a brief commentary on the potential impact of each policy tool on health system performance.

Policy summary

10

4.1 Overview

WHO data indicate that, between 1998 and 2008, government spending onhealth as a share of GDP increased in most European countries (35 out of 53).From 2007 to 2008 real GDP per person contracted in just one country (Ireland)but grew in all others, ranging from 2.8% in France to 21.1% in the RussianFederation (Fig. 2). From 2008 to 2009 public expenditure on health per capitagrew in all but nine countries (Fig. 2).3 This suggests there was no immediatebudgetary response in the health sector to the financial crisis. However, GDPgrowth from 2008 to 2009 indicates a bleaker outlook: the size of the realeconomy contracted in 38 countries to varying degrees (from -0.1% in Portugalto -13.9% in Ukraine). Overall, real GDP per capita contracted by -3.4% in the European Region. The decline in GDP could take time to affect politicaldecisions that influence public spending on health, so data for 2010 and 2011should give a better picture of the trends when they become available.

Between 1998 and 2008, total government spending as a share of GDPdecreased in the European Region (from 42.4% to 40.9% in aggregate); thatis, the public sector’s share of the economy (the size of government) becamesmaller. During this period, public spending on health grew to consume agreater share of total government spending (rising from 11.6% in 1998 to12.8% in 2008), because governments maintained or increased the healthshare of the government budget (WHO Regional Office for Europe, 2011b).However, from 2008 to 2009 only 14 countries had an increase in publicspending on health as a share of total government expenditure, ranging from0.1% to 3% (Table 1). Most of these were Member States that have beenlargely unaffected by the financial crisis and where public expenditure on healthis increasing from a very low base. This suggests that in affected countries, thefinancial crisis may already be having a negative effect on the prioritygovernments accord to health budgets.

The effect of the financial crisis on health policy varied across health systems inEurope and in part depended on the extent to which countries experienced asignificant downturn in their economies. Within the European Region, Albania,Azerbaijan, Israel and Norway were mostly insulated from the crisis andtherefore reported no direct health policy responses at all. Of the countries thatwere affected by the crisis, some introduced several new policies in response(Czech Republic, Greece, Ireland, Portugal, Republic of Moldova); in Greece,Ireland and Portugal the reforms were part of a broader debt restructuringprocess which required intervention from the EU, the European Central Bank

3 Cyprus (-0.1%), the former Yugoslav Republic of Macedonia (-1.0%), Serbia (-2.4%),Hungary (-3.4%), Romania (-8.0%), Ukraine (-12.9%), Iceland (-13.1%), Lithuania (-16.8%)and Latvia (-16.9%) all experienced a drop in real public health expenditure per capita.


11

Fig. 2. GDP growth and change in public spending on health per capita, WHO European Region

Source: GDP data from WHO Regional Office for Europe, 2011a; health spending data fromWHO, 2011.Note: Data purchasing power parity (PPP) adjusted.

Policy summary

12

-20% -10% 0% 10% 20% 30% 40% 50% 60% 70% 80%

Azerbaijan

Tajikistan

Kyrgyzstan

Kazakhstan

Turkey

Montenegro

Republic of Moldova

Spain

Ireland

Portugal

Italy

Poland

Luxembourg

Denmark

United Kingdom

Germany

Georgia

Netherlands

Albania

Switzerland

Belgium

Uzbekistan

Russian Federation

Greece

Czech Republic

Armenia

Slovenia

Bosnia and Herzegovina

Turkmenistan

Finland

Belarus

Norway

Bulgaria

Austria

France

Slovakia

Sweden

Malta

Estonia

Israel

Croatia

Cyprus

The former Yugoslav Republic of Macedonia

Serbia

Hungary

Romania

Ukraine

Iceland

Lithuania

Latvia

-0.1

5.7

-2.4

6.3

6.35.8

14.3

4.9-13.1

8.6

15.6

6.7

15.6

15.4 15.4

1.9

6.7

6.4

6.9

4.6

-3.4

9.9

-12.9

6.7

6.7 8.2

16.3 16.3

6.7 6.7

-16.9 -16.9

-16.8 -16.8

-8.0-8.0

0.0

3.60.2

5.4 0.5

3.0

5.35.4

5.0

2.6 2.9

11.5

13.5

2.8

4.6

5.7

6.9

3.1

3.3

3.4

3.6

3.7

4.2

3.6

11.4

11.4

10.5

14.0

5.9

5.9

3.4

3.1

6.1

21.1

4.6

4.6

9.6

-4.9

34.6

4.3

11.9

8.6

-1.0

6.7

3.6

9.9

73.7

6.4

5.4

9.09.0

7.87.8

10.910.3

13.013.1

14.8

5.5

4.7

7.97.9

8.08.0

4.7

7.58.28.2

8.28.2

8.88.8

5.3

9.1

17.5

9.1

4.3

6.76.74.4

6.86.83.7

7.5

7.6

8.5

17.5

26.626.6

28.328.3

Per capita government expenditure on health (PPP int. $) 2008–2009Real GDP US PPP per capita growth 2007–2008

ugoslav Republic of MacedoniaThe former Y

-13.1

-2.4

Latvia

Lithuania

Iceland

Ukraine

Romania

yHungar

Serbia

ugoslav Republic of Macedonia

Cyprus

Croatia

-12.9

-3.4

--1166.9

--116.6..8

----88.0

-1.0

4.9

-2.4

5.7

-0.1 88.6

115.5..6

4115.5.4

6.6..7

9.9

-3.4

88..2

116.6..3

76.6..7

-1.0

0.0

Israel

Estonia

Malta

Sweden

Slovakia

France

Austria

Bulgaria

wayNor

Belarus

Finland

urkmenistanT

1.9

4.6

5.4

14.0

10.5

11.4

11.4

3.6

4.2

3.7

3.6

3.4

3.3

3.1

4.6

2.8

13.5

11.5

2.9 2.6

3.0

0.55.4

0.23.6

0.0

zegovinaBosnia and Her

Slovenia

Armenia

Czech Republic

Greece

Russian Federation

Uzbekistan

Belgium

Switzerland

Albania

Netherlands

Georgia

Germany

14.3

5.86.3

6.3

67 6..7

6.66.4

66.9

6 11

3.6 5.9

7

9.6

4.66

4.6

21.1

6.1

56 5.9

10.5

5.7

5.0

5.45.3

99.0

57..8

4.7 6.

4

5.57.

46 7

4.46Germany

United Kingdom

Denmark

Luxembourg

Poland

Italy

Portugal

Ireland

Spain

Republic of Moldova

Montenegro

urkeyT

Kazakhstan

-4.9

4.3

7.6

4.3

9.9

4.3

3.1

3.4

14.813.113.0

10.310.9

7.7.9

8.8..0

4.7

3

7.5.558.8.2

7.55

8.8.2

8.8..8

5.3

9.9..1

117.7.5

4.3

66..7

6.6.8

7

3.7

7.67.6

226.6.6

-10%-20%

Kyrgyzstan

ajikistanT

Azerbaijan

40%30%20%10%0%

9.99.9

11.9 34.6

8.5228.8.3

Real GDP US PPP per capita growth 2007–2008Per capita government expenditure on health (PPP int. $) 2008–2009

80%70%60%50%40%73.7

Real GDP US PPP per capita growth 2007–2008Per capita government expenditure on health (PPP int. $) 2008–2009

and the IMF. In other affected countries, however, very few or no policychanges were made (Denmark, Iceland, Finland, Germany, Kyrgyzstan, Malta,Poland, Russian Federation, Slovakia, Switzerland, the former Yugoslav Republicof Macedonia, Uzbekistan). In either case, there were many instances in whichpolicies planned before 2008 were implemented with greater intensity or speedas they became more urgent or (more often) politically feasible in face of thecrisis, particularly the restructuring of secondary care. In general, a wide rangeof measures was used, covering all three policy domains presented in Fig. 1.

There were also cases where planned reforms were slowed down or abandonedin response to the crisis. For example, Romania abandoned a plan to build eightnew hospitals and Ireland did not build one in four of proposed new healthfacilities. In Bulgaria the government decided to postpone full prohibition ofsmoking in public places. Also in Bulgaria, a policy to introduce a system ofcompulsory private health insurance, which was anyway unpopular with thepublic and doctors’ unions, was rejected by a new government that wished toretain control of public resources and institutions through the National HealthInsurance Fund. Bosnia and Herzegovina had difficulty implementing its recentlypassed health insurance laws due to a lack of reliable sources of funding, andtherefore decided to wait until after the crisis. In Georgia the transfer of hospitalinfrastructure ownership from the state to the private sector stalled due to the withdrawal of investors as a result both of the financial crisis and war with Russian Federation in 2008; the process was resumed in 2010. Ukraineattempted to introduce programmes seeking to increase efficiency, but mostwere not implemented due to a lack of political will. On the other hand, somegovernments were able to employ the financial crisis as a lever to strengthentheir position in ongoing negotiations with other health system stakeholders, in particular with the pharmaceutical sector (e.g. Austria, Latvia, Poland,Portugal, Russian Federation, Serbia, Slovenia and Turkey).

A few of the policy measures planned or implemented in response to the crisis were quickly reversed due to their unpopularity with key stakeholders,particularly efforts to reform provider payment. In Bulgaria the Ministry ofFinance attempted to take control of setting health service prices but thereform was strongly resisted by the medical union and eventually reversed. For a short period Hungary introduced tighter volume controls in the paymentof inpatient care providers but this was also reversed due to pressure fromhospitals. In the former Yugoslav Republic of Macedonia the value of acapitation point for primary care physicians was briefly decreased by 10%before doctors’ protests led to its reversal. In Romania a new system of payinggeneral practitioners (GPs), including a cap on the number of hours worked perweek, was proposed as part of a revised framework contract but rejected byGPs. In Ukraine the government attempted to stabilize rising pharmaceutical


13

prices by placing a cap on retail prices, which resulted in the closure ofpharmacies. The approach was fiercely resisted by the pharmaceutical industry and the government responded by implementing softer price controlmechanisms, which accounted for fluctuations in national currency rates.

A handful of countries were in the process of undergoing significant healthsector reforms funded by loans from international organizations such as theIMF, the World Bank and the EU when the crisis struck, so cost-cutting orefficiency-increasing measures were a continuation (Romania and Serbia). Many of the Commonwealth of Independent States (CIS) countries have verylow levels of health expenditure and a high proportion of spending throughout-of-pocket payments, leaving very little room for cutting public spending on health (Table 1). Some of them also have ongoing obligations to externalfunders to increase their public health spending annually (e.g. Kyrgyzstan) and programmes aimed at increasing health system efficiency planned beforethe crisis are currently being implemented. One or two countries had beenworking to slow health expenditure growth in recent years, making it difficultto determine whether or not new policies were explicit responses to the crisis(e.g. Croatia, Switzerland).

Some countries were better prepared than others due to fiscal measures they had taken before the crisis (the Czech Republic, Estonia, Italy, Lithuania,Republic of Moldova and Slovakia). These countries were able to draw onreserves or employ other counter-cyclical mechanisms that can compensate for the reduction of payroll tax revenues. For example, at the start of the crisis,the Estonian government cut back on public expenditure, including on health (a political decision made to comply with Maastricht criteria so that Estoniacould join the Eurozone; Estonia had low external debt and a low currentaccount deficit, meaning that deficit financing was a viable alternative). TheEstonian health system was better prepared for fiscal constraint than those of many of its neighbours. Better preparedness originated mainly from twosources. First, a pre-commitment to prioritize health spending in a downturn by allowing the health sector to accumulate reserves in the health insurancefund put the health insurance fund in a relatively strong position when it cameto budget negotiations with the Ministry of Finance. As a result, a transparentpolitical debate took place over the question of where to cut and how much to cut. Second, the Estonian health system invested appropriately in the healthsector before the crisis; when the crisis struck, the system could cope withdelays in investment without sacrificing health system goals such as quality of care in the short run. This stands in contrast to other countries, such asHungary, where the health system had already exhausted its (non-structural)efficiency reserves by the time the financial crisis began, meaning that healthsystem goals were likely to be eroded much faster.

Policy summary

14

Some countries prioritized paying off health sector debts at the expense ofhealth expenditure growth. In others, health budgets were ring-fenced whileother sectors experienced cuts (Belgium, Denmark and England). The Finnishgovernment implemented an economic stimulus package to mitigate some ofthe negative effects of the economic downturn.

4.2 Policies intended to change the level of contributions for publiclyfinanced health care

4.2.1 National health budget

Several countries reported cuts in the national health budget in response to thefinancial crisis (Bulgaria, Croatia, Estonia, Hungary, Iceland, Ireland, Italy, Greece,Latvia, Romania, Portugal, Spain). In some of these the health budget was reducedby over 20% (for example in Bulgaria and Latvia). Cuts were partly caused byrising unemployment which reduced revenue from social insurance contributions(Bulgaria, Estonia, Hungary, Romania). In other countries, social insurancerevenues and expenditures continued to increase (Austria, the Czech Republic,Poland, Slovakia; in the latter due to the high and counter-cyclical contributionrate paid by the state for economically inactive people), and the national health budget also rose in France, Denmark, the former Yugoslav Republic ofMacedonia and Turkey. In Denmark the education budget was used to cross-subsidize the health budget. It was maintained at previous levels in Albania,Belgium, England and Norway. Latvia received a World Bank loan in response to the crisis, to cover access to health services by poorer population groups.

As noted, decisions about whether to increase or decrease public spending on health in response to a health system shock may be driven by a mixture of political preferences and technical considerations. In the current crisis, large fiscal imbalances have left some countries with little or no choice in theirresponse; Greece and Portugal have been were particularly affected and wererequired to implement public sector cuts as part of bailout conditionalities.Where the short-term situation is such that governments are compelled to cutpublic spending on health, the policy emphasis should be on cutting wisely tominimize adverse effects on health system performance, enhancing value asmuch as possible and facilitating efficiency-enhancing reforms in the longerrun. The rest of this document is concerned with how this might be achieved.

4.2.2 Fiscal policy

Notwithstanding increases in taxes on alcohol and cigarettes (see below), fewcountries have reformed fiscal policy to increase revenue for health systemfinancing. In Italy, regions with large health care deficits have raised local taxesto recover deficits. In France, a new tax of 2% on certain sources of income


15

was set up in 2009 to finance social security (including health) expenditure and was subsequently increased to 4% in 2010 and 6% in 2011. Hungaryintroduced a public health tax on food and drinks with a high sugar content.

Although increases in taxation may reduce the need to increase governmentborrowing, very few countries have used fiscal policy to raise revenue for healthservices in response to the current crisis. Reluctance to introduce higher taxes forhealth care may be underpinned by valid technical and political considerations(such as a negative effect on the labour market, productivity and competitiveness),but the perception that tax-based financing of health care is as a general ruleunsustainable is unfounded (Thomson, Foubister & Mossialos, 2009).

4.2.3 Statutory health insurance revenue

Some countries increased employer/employee contribution rates either acrossthe board or for specific population subgroups (Bulgaria, Greece, Portugal,Romania, Slovenia). Slovakia reduced the state’s contribution for economicallyinactive people. Hungary lowered the contribution rate and the governmentincreased its budget transfers on behalf of non-contributing but eligiblepopulation groups to compensate the statutory health insurance fund for the loss of revenue (this was its most explicit and progressive response to thefinancial crisis; see WHO Regional Office for Europe, 2011b). In the Republic of Moldova, the rate of discount for statutory health insurance increased from50% to 75% for low-income populations. Turkey transferred responsibility forhealth care payments for government employees and their dependants fromthe Ministry of Finance to the Social Security Institute. Switzerland debatedincreasing premium subsidies for low-income families, but no measures werepassed. Slovakia and Lithuania already had in place counter-cyclical measuresfor government subsidies for those insured by the state in order to sustainstatutory health insurance revenue during a downturn. In Austria and Romaniathe government introduced subsidies to bail out social health insurance funds in order to help them pay off debts or prevent further indebtedness.

In countries that rely predominantly on employment-based social insurancecontributions, revenue can be maintained by lifting income or earnings ceilings, broadening the contribution base to encompass non-wage income or increasing transfers from the government budget (Thomson, Foubister &Mossialos, 2009). All of these are likely to be relevant options for governmentswanting to stimulate employment while maintaining or increasing publicspending on health (Thomson, Foubister & Mossialos, 2009). Another strategythat may be useful for smoothing some revenue over economic cycles is tomake government contributions for economically inactive groups of peoplecounter-cyclical by linking them to average earnings in previous years, as is thecase in Lithuania and Slovakia.

Policy summary

16

4.2.4 User charges (coverage depth)

Several countries increased or introduced user charges for health services inresponse to the crisis (Armenia, Czech Republic, Denmark, Estonia, France,Greece, Ireland, Italy, Latvia, Netherlands, Portugal, Romania, RussianFederation, Slovenia, Switzerland, Turkey). In some countries, user charges wereintroduced or increased in the hospital sector (Armenia, Czech Republic, Estonia(for inpatient nursing care), France, Ireland, Romania, Russia). Pharmaceuticals were subject to increased user charges in several countries (Czech Republic,France, Ireland, Latvia, Portugal, Slovenia). In England, a programme to expandthe range of long-term conditions that benefit from free prescriptions wasannounced by the previous government but not implemented; this will now no longer be taken forward. User charges were increased for ambulatory carein Greece, Italy, Romania and Turkey. User charges for emergency departmentsincreased in Ireland and for services not considered urgent in Italy. InSwitzerland the co-insurance rate will increase from 10% to 15% for peoplewho opt for traditional insurance plans (to encourage people to subscribe to a managed-care model of insurance).

Some countries introduced or increased charges for specific services such as in vitro fertilization (IVF) (Denmark and the Netherlands), ambulance transport(France and Slovenia), physiotherapy (the Netherlands), some mental healthservices (the Netherlands), some vaccines such as yellow fever, Japaneseencephalitis, typhoid, meningitis and rabies tetravalent (Portugal), GP homevisits (Romania), non-acute spa treatment, dental prostheses and someophthalmologic appliances (Slovenia), and doctor declarations attesting to the incapacity of a patient (Portugal) (see section 4.3.1 below on reductions in the benefit package).

In contrast, other countries reported expanding benefits, targeting low-incomegroups in the area of pharmaceuticals (Austria, France, Ireland, Italy, Republic of Moldova), reducing user charges (Croatia for primary care and outpatientprescription drugs) or abolishing user charges for some services (Italy, Hungary –although in Hungary’s case it was not a response to the crisis but it helped topromote financial protection).

Evidence from this study and a study on previous crises (Cylus, Mladovsky &McKee, in press) suggests that policy-makers may rely on user charges andother policies that shift costs to patients in an effort to slow aggregateexpenditure growth. However, user charges increase the financial burden onhouseholds (Wagstaff et al., 1992) and have been shown to be equally likely to reduce the use of high-value (cost-effective) and low-value care and areparticularly likely to reduce use among lower-income individuals and olderpeople, even when the level of user charges is low (Lohr et al., 1986; Manning


17

et al., 1987; Newhouse & Rand Corporation Insurance Experiment Group,1993; Gemmill, Thomson & Mossialos, 2008). Applying or increasing usercharges in primary or ambulatory specialist care may worsen health outcomesand lead to increased spending in other areas (e.g. emergency care). As a result,the potential for cost savings or enhanced efficiency is limited. Targeted usercharges selectively applied to low-value services or with exemptions or caps forpoorer households or regular users of care are more likely to enhance efficiency.However, it may not always be possible to identify low-value care and thetransaction costs involved may be significant (Braithwaite & Rosen, 2007; Bach, 2008; Thomson, Foubister & Mossialos, 2009).

4.3 Policies intended to affect the volume and quality of publiclyfinanced health care

4.3.1. Health benefits (coverage scope)

In general the statutory benefits package was not radically changed followingthe financial crisis, but some reductions were made, usually at the margin. Mostcountries did not report how coverage decisions were made. Only the CzechRepublic and Estonia reported plans to make greater use of HTA in evaluatingthe benefits package (although in the case of Estonia this was part of an ongoingprocess which was viewed more favourably by policy-makers in light of thecrisis). Reported mandatory coverage reductions included lower reimbursementof: dental care for certain population groups (Estonia, Ireland); IVF, physiotherapy,mental health services and coverage of care outside the EU (the Netherlands);cosmetic surgery (Portugal); non-acute spa treatment, certain medicines, non-urgent ambulance services, dental prostheses and some ophthalmologicappliances (Slovenia); eyeglasses (Switzerland); and temporary sickness benefitspaid by the statutory health insurance fund (Estonia, Hungary and Lithuania).The Russian Federation postponed adding outpatient prescription drugs to thebenefits package to 2013. On the other hand, Armenia included primary care in the basic primary care package, although this was part of ongoing reforms.Other countries expanded the scope of benefits in a targeted way, and theseare discussed under coverage breadth and contributions (section 4.3.2).

A fundamental objective of health policy at any time, but particularly during an economic crisis, is to maintain access to essential services for the population,especially for poorer people and regular users of health care (World Bank,2009). Changing the range of services included in the statutory benefitspackage (coverage scope) can be a valuable tool for setting priorities in thehealth system, particularly if changes are based on evidence and aim topromote the use of high-value care and discourage the use of low-value care. It can also be used to explicitly ration the quantity of care available. Evidence on clinical practice variation and inappropriate use of services may provide

Policy summary

18

justification for limiting volume of care and enforcing clinical practiceguidelines, but targeted implementation of these policies remains a challenge.Hungary introduced volume limits to inpatient services, but left it to thehospitals and doctors themselves to ration care implicitly or explicitly. In times of resource constraint countries may apply budget cuts across the whole sector,reducing funding for the majority of services available. However, cuts across theboard run the risk of undermining access to needed services, adversely affectingfinancial protection, health and efficiency. In contrast, selective, evidence-basedand transparent reductions in the scope of coverage represent an opportunityfor enhancing efficiency without undermining health system performance(Thomson, Foubister & Mossialos, 2009).

To this end, many countries have adopted HTA in the last two decades to assistin setting priorities (Velasco-Garrido & Busse, 2005), mainly in the area ofpharmaceuticals, and to devise clinical guidelines (Draborg et al., 2005; Lavis et al., 2007; Sorenson, Drummond & Kanavos, 2008). However, its use indetermining the contents of the benefits package has been limited due totechnical and political challenges and resource constraints (Ettelt S et al., 2007;Sorenson, Drummond & Kanavos, 2008). HTA is therefore more likely to beuseful as part of a longer-term strategy for enhancing efficiency than as a tool for quick decision-making. Nevertheless, countries with established HTAprogrammes will be better placed to make informed decisions in times ofeconomic crisis.

4.3.2. Population coverage (coverage breadth)

Ireland was the only country to remove eligibility for some aspects of statutorycoverage from some residents; in 2008 the Irish government excluded wealthyindividuals over the age of 70 from statutory coverage of primary care, althoughsince the general election in February 2011 the government has announcedplans to extend coverage to the whole population (universal coverage). TheCzech Republic reported reducing entitlement at the margin by reducingstatutory coverage for foreigners. Cyprus attributed its further postponement of implementation of universal coverage to the financial crisis, while Hungaryintroduced incentives for improved checks for eligibility for statutory coverageto identify and penalize those who avoid paying contributions. Several countriesreported expanding statutory coverage for previously uninsured groups ofpeople (Belarus, Bosnia and Herzegovina, Georgia, Republic of Moldova) orintroducing universal coverage (the former Yugoslav Republic of Macedonia).Thus, particularly in the former Union of Soviet Socialist Republics (USSR), somecountries without universal coverage are expanding eligibility for benefits totargeted population groups, but as part of ongoing reforms rather than inresponse to the economic crisis.


19

The share of the population entitled to statutory benefits is a crucialdeterminant of financial protection in the health system. Restricting eligibilityfor statutory coverage (e.g. on the basis of household income) may lead to an absolute reduction in public spending on health. However, evidence fromGermany and the Netherlands demonstrates that it adds to rather thanalleviates fiscal pressure in the health system (Thomson & Mossialos, 2006;Albrecht, Schiffhorst & Kitzler, 2007). This is partly due to the loss of contributionsfrom wealthier households. It is also due to segmentation of the national riskpool, which leaves the statutory risk pool with a concentration of older, poorerand sicker people and people with non-contributing dependants (Thomson &Mossialos, 2006). The Netherlands abandoned this policy in 2006 and Germanyhas taken numerous measures to mitigate its adverse effects.

Lowering the breadth, scope and depth of coverage creates a role for voluntaryhealth insurance (VHI). However, the market failures that characterize VHI, inparticular information problems relating to adverse selection and risk selection,mean that those reliant on voluntary cover may be placed at risk (Barr, 2004),particularly older people and people in poor health (Mossialos & Thomson, 2004;Thomson & Mossialos, 2006, 2009). In addition, the European experience of VHI indicates that in most countries it fails to address gaps in statutorycoverage: VHI market development is frequently very limited, particularlyoutside EU15 countries; VHI policies often do not develop to cover the mostimportant gaps; and where they are available, they may not be accessible tothose who need them most, even where the market is extensively regulated(Thomson & Mossialos, 2009).

4.3.3. Non-price rationing (waiting times, service dilution and delay)

The Estonian Health Insurance Fund supervisory board attempted to ration thevolume of care provided by deciding to increase maximum waiting times foroutpatient specialists’ visits from four to six weeks in March 2009. No othercountries reported increasing waiting as an explicit policy response to thefinancial crisis. Rather, in some countries health sector reforms may haveinadvertently led to increases in waiting times, such as in Ireland, wherechanges in health policy have led to a 9% increase in the number of patientson a waiting list between 2009 and 2010.

Changing waiting times may alter demand for publicly financed care withoutundermining health outcomes if patients on longer waiting lists choose privatealternatives (Hoel & Sæther, 2003) or choose to withdraw from treatment. Areview of the literature on waiting times (Garber, 2000) suggests that resourcesshould be allocated to different treatments according to their cost–effectiveness.However, reducing timely access to care may have an adverse impact on clinicalquality, which would undermine the goal of improving health. Its use as a policy

Policy summary

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tool may also be limited by legitimate user expectations regarding acceptablestandards of health care.

There is an unexplored area of non-price based rationing mechanisms that areless tangible to both patients and policy-makers, and also difficult to research.These may take different forms of delaying, denying and diluting clinicalservices (“quality skimping”), with significant implications for health gain andefficiency of the use of limited resources. There is anecdotal evidence of such a response by providers to budget cuts. Delaying care in a non-transparentmanner and deviating from clinical practice guidelines on the grounds of costconsiderations are just two of the many implicit rationing mechanisms on thesupply side. Where monitoring of provider compliance with clinical standards isweak and professional organizations are less rigorous in enforcing good clinicalpractice, implicit rationing mechanisms may hide some of the adverse effects of the financial crisis. While waiting lists may not be a desired alternative formof rationing, they certainly make the process explicit and more transparent.Targeted research programmes are needed to explore the magnitude of implicitrationing and provide evidence to inform policy-makers (WHO, 2011).

4.3.4 Changing individuals’ behaviour (health prevention and promotion)

As previously mentioned, comparing international data on public healthfinancing and policy is challenging due to the lack of a pan-European definitionof the term “public health”. The following evidence on the effect of thefinancial crisis on public health in Europe is therefore illustrative and cannotserve as a comprehensive overview.

Several countries increased taxes on alcohol and cigarettes (Bulgaria, Estoniaand Ukraine, while the Czech Republic plans to do so in 2012) or pursuedhealth promotion policies, such as encouragement for healthy eating, exerciseand screening (Belgium, Bosnia and Herzegovina, Greece, Hungary, Republic ofMoldova). These policies seek to reduce the need for health care and aregenerally intended to lower the volume of publicly financed care provided. Fourcountries reported cuts to public health budgets. In Estonia, the Ministry’shealth expenditure fell by 24% in 2009 compared to 2008. This was partiallyachieved through cutting administrative costs and cutting the public healthbudget from 2009. Cuts focused on non-communicable diseases (NCDs) andprogrammes on communicable diseases were protected. EU social funds wereused to compensate for the reduction in NCD budget, but these funds will nolonger be available from 2012. In Italy, there were plans to cut the fund fordisease prevention and health promotion from EUR 29.6 to EUR 5.9 million in2011. In Latvia the public health budget was cut by 88.6% from 2008 to 2010.In Ukraine, expenditure on preventative services reduced by 9%. Threecountries reported the closure or merger of public health bodies. In Iceland,


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there were plans to merge the Directorate of Health and the Public HealthInstitute in 2011. In Latvia, the Public Health Agency was closed in 2009. Manypublic health functions were distributed to other institutions and some werelost. In Lithuania, there was a reorganization of public health, resulting in themerger of seven public health institutions in 2009–2010.

Evidence on the economic benefits of prevention has grown in recent years,supporting broad public health promotion and preventative measures (e.g. systematic screening for hypertension, cholesterol, some cancers, healthadvice on diet, alcohol and smoking), although gaps remain (Schwappach,Boluarte & Suhrcke, 2007). Most published work is from the United States and Australia, however (Atun, 2004; Atun, Bennett & Duran, 2008). There isevidence to suggest that taxation can be a useful policy tool to address publichealth concerns and generate government revenue (Chaloupka & Warner,2000). Along with fiscal measures, an OECD study indicates that healtheducation and promotion, regulation and counselling on diet, smoking andalcohol by family doctors are cost–effective measures (Sassi, 2010). Thesepolicies could increase the efficiency of health service delivery in the medium to long term, but they may not address short-term fiscal constraints.

4.4 Policies intended to affect the costs of publicly financed health care

4.4.1 Prices of medical goods

Many countries introduced or strengthened policies to reduce the price ofmedical goods (pharmaceuticals, medical devices and equipment) or improve therational use of drugs (Austria, Belgium, Belarus, Bosnia and Herzegovina, Croatia,the Czech Republic, France, Estonia, Greece, Iceland, Ireland, Hungary, Latvia,Lithuania, Malta, Republic of Moldova, Poland, Portugal, Romania, RussianFederation, Serbia, Slovakia, Slovenia, Spain, the former Yugoslav Republic ofMacedonia, Turkey). A wide variety of measures were used, including genericsubstitution, INN prescribing, claw-back mechanisms, price negotiations andlengthening prescription validity. In most cases these policies were part ofongoing reforms, but the crisis often prompted, speeded up or intensifiedimplementation. Bulgaria and the Czech Republic are also in the process ofincreasing government regulation of the purchasing of medical devices. At thesame time, in many countries VAT increases affecting pharmaceuticals and otherproducts have to some degree attenuated the benefits to patients gained frommeasures designed to reduce prices.

The crisis increased efforts to negotiate pharmaceutical prices in some nationalmarkets, highlighting the importance of the public authority as a monopsonybuyer. Improved government procurement practices and positive lists contributeto lower medicine prices when balanced with regulated wholesale and retail

Policy summary

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mark-ups (WHO, 2004). The range of approaches used by countries to controlprices can include free pricing, ex ante pricing relative to a substitute, internationalreference pricing, price volume agreements, price cuts, profit controls and ex post pricing relative to a substitute (Office of Fair Trading, 2007).

However, the positive effects of price controls may be offset by increases in thequantity of drugs prescribed or a change in the product mix to include moreexpensive medicines. For example, the downward effect on prices attributed to reference pricing is often short-lived (Lopez-Casasnovas & Puig-Junoy, 2000;Donatini et al., 2001; Nink, Schroder & Selke, 2001). As a result, pricing policiesshould be combined with policies targeting health professionals to encouragerational prescribing and dispensing in primary and secondary care. Again,however, savings might be offset by increases in volume and therefore short-lived (Harris & Scrivener, 1996; Buzzelli et al., 2006; Andersson et al., 2007;Mossialos & Srivastava, 2008). Nevertheless, even if such policy measures donot lower pharmaceutical expenditure, they may enhance efficiency withoutany negative effect on health outcomes. Policies to promote greater use ofgeneric medicines are likely to lower pharmaceutical expenditure and enhanceefficiency (Mrazek & Frank, 2004). In contrast, policies that aim to cut publicspending on prescription drugs by shifting costs to households are generallyfound to be of limited effectiveness and are discussed in the section on usercharges above.

4.4.2 Salaries and motivation of health sector workers

Some countries reduced the salaries of health professionals (Cyprus, France,Greece, Ireland, Lithuania, Romania), froze them (England, Portugal, Slovenia) orreduced their rate of increase (Denmark). Other approaches to lowering salariesincluded increasing public sector pension contributions substantially and reducingthe benefits, leading to a de facto pay cut (England), cutting overtime and night shifts, and lengthening shifts that require fewer staff and costs (Iceland),and making workers accept lower wages in order to maintain their contracts(privately contracted housekeeping and IT support staff in Serbia). In the CzechRepublic physicians managed to resist cuts to their salaries through negotiationor protests. Albania, which was largely insulated from the crisis, and Belarusand Ukraine continued to increase health worker salaries. In 2011 the formerYugoslav Republic of Macedonia approved the employment of additional healthworkers to improve quality and access to public health institutions, as well as to prevent qualified medical staff from leaving the public sector.

Employee wages, salaries and allowances account for 42.3% of public spendingon health in the 18 countries of the European Region for which data areavailable (WHO, 2006). This helps to explain the policy focus on cutting salariesin many countries. However, these policies may exacerbate wage imbalances


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across countries (depending on the relative change in wages in net immigrationcountries compared to net emigration countries), possibly increasing healthworker migration in Europe and other regions, and adding to problems ofhuman resource shortages, which risks undermining quality and efficiency in the health system (Wismar et al., 2011). Wage imbalances could also becreated within countries if health sector wages fall at a different rate to wagesin other sectors. Policy-makers can apply a range of non-financial tools to retainworkers and improve performance, including clear job descriptions, professionalnorms and codes of conduct, the proper matching of skills to the tasks in hand, supervision, information and communication, infrastructure includingequipment and supplies, life-long learning, team management and teamworking, and responsibility with accountability (WHO, 2006). Improvements inthese areas may provide some limited help in retaining health workers facingsalary reductions and freezes.

A longer-term view of increasing efficiency in the supply of human resources for health would consider a broader range of strategies, in particular changingthe skill mix and substitution of health workers’ roles (typically nurses and GPstaking on some of the work of specialists or nurses taking on some of the workof GPs) to reduce the unit cost of labour or improve productivity. Reviews havefound that nurse substitution typically has either no or some improved effect on the quality of care, suggesting that this policy has the potential to increaseefficiency (McKee, Dubois & Sibbald, 2006). However, cost savings depend onthe magnitude of the salary differential between doctors and nurses, and maybe offset by the lower productivity of nurses compared to doctors (Laurant et al., 2005).

4.4.3 Payments to providers

In response to the crisis several countries have reduced the tariffs (i.e. prices)paid to providers (Estonia, Ireland, Romania, Slovenia) or linked payment toimproved performance to realize efficiency gains and contain costs (newcontractual measures to manage provider costs in Bosnia and Herzegovina;reported plans to introduce diagnosis-related group (DRG) payments forinpatient care in Bulgaria and the Czech Republic; pay for performance (P4P) inItaly; per capita payment in primary care in Portugal; performance assessmentand result-based financing in the Republic of Moldova). The crisis speeded upreforms in this area in some countries (Austria), but in others reforms wereresisted (Bulgaria, Hungary, the former Yugoslav Republic of Macedonia). InUkraine, a system of health services quality control has been developed, but hadno practical effect due to the lack of measures to deal with non-compliance.Planned changes to the legal status of health service providers in the RussianFederation affecting their payment mechanisms have been postponed until 2013.

Policy summary

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Measures that target the supply side offer considerable scope for improvinghealth system functioning in comparison to those focused on curtailingutilization by patients. Changes in how health care is purchased and providersare reimbursed offer significant potential to enhance efficiency, quality andequity. Many EU countries have moved away from passive reimbursement ofproviders towards strategic purchasing, explicitly linking resource allocation to information on population health needs, cost–effectiveness and providerperformance (Figueras, Robinson & Jakubowski, 2005). Measures include theuse of health needs assessment, HTA, contracting, quality monitoring andperformance-based payment. In addition, most countries set case-based tariffscentrally, which may promote provider competition based on quality, wherequality information is available (Busse et al., 2011).

Volume and outcome contracts combined with prospective activity-basedpayments employing some case-mix measures, such as DRGs, have been linked to increased hospital efficiency. However, these types of contracts require sophisticated design in order to prevent gaming by providers, while the necessary information systems are in place in only a very few countries in Europe (Figueras, Robinson & Jakubowski, 2005). In physician payment,typically at the primary care level, fee-for-service and capitation have beenfound to be flawed methods for motivating physicians to achieve specific goals.Payment innovations that blend elements of fee-for-service, capitation and caserates can promote health system goals. These innovations include capitationwith fee-for-service carve-outs, department budgets with individual fee-for-service or “contact” capitation, and case rates for defined episodes of illness(Robinson, 2001). P4P is also growing in popularity, although evidence from the United States and the United Kingdom suggests policy-makers should pay careful attention to how any P4P scheme is designed and implemented(Maynard, 2008). In any provider payment reform, various other factors arelikely to influence successful implementation, including the way provision isorganized and regulation.

4.4.4 Overhead costs: restructuring the Ministry of Health andpurchasing agencies

Several governments are restructuring the Ministry of Health, statutory healthinsurance funds or other purchasing agencies in an attempt to reduce overheadcosts and increase efficiency (Bulgaria, Croatia, the Czech Republic, England,Iceland, Latvia, Lithuania, Portugal, Romania).

Reducing the number of civil servants or removing their employment conditions(tenure, pay, pensions) is one way of cutting public spending on health but risksloss of skilled staff and strike action by public sector workers, as demonstratedby recent trends across Europe (Parry, 2011). Depending on the context, it also


25

risks losing experienced personnel at a time of rapid reform, which requiresincreased, not decreased, capacity for planning and oversight.

Reforming health insurance market structure (e.g. by consolidating risk pools)can also reduce overhead costs (Kutzin, 2008; Thomson, Foubister & Mossialos,2009). In addition, addressing fragmented pooling may contribute significantlyto financial sustainability because a lower number of pools means less need for complex and resource-intensive risk adjustment and, by strengthening the power of purchasers in relation to providers, may lead to better (morestrategic) purchasing.

4.4.5 Provider infrastructure and capital investment

In many countries, the economic crisis created an impetus to: speed up theexisting process of restructuring the hospital sector through closures, mergersand centralization (Denmark, Greece, Latvia, Portugal, Slovenia); shift towardsoutpatient care (Belarus, Ireland, Greece, Lithuania); improve coordination with or investment in primary care (Armenia, Lithuania, Republic of Moldova,Netherlands); merge health centres (Iceland); and reorganize emergencymedical services (the former Yugoslav Republic of Macedonia). Some countriesabandoned (Romania) or stalled (Georgia) investment plans to build newhospitals, slowed modernization programmes involving upgrading of hospitaland ambulance services (Armenia) and purchasing of expensive equipment(Belarus), or reduced the share of capital expenditure (Ukraine). In contrast,some countries increased funding for modernization of public health providersusing resources from the mandatory health insurance fund (Republic ofMoldova) or developed e-health systems, with the implementation of anintegrated health management information system and electronic health card(Latvia, the former Yugoslav Republic of Macedonia) and a new electronicprescription system (Croatia).

The hospital sector absorbs a large part (35–70%) of national healthexpenditure in the European Region (Rechel et al., 2009). Most countries are in the process of reducing hospital capacity in order to increase efficiency byclosing unnecessary facilities and replacing expensive inpatient care with morecost–effective alternatives such as day surgery (McKee & Healy, 2002). Thesechanges have generally been shown to have no negative impact on quality ofcare. However, while they may enhance efficiency they do not necessarily lowerpublic spending, since savings are used elsewhere in the health system. Also,unidentified costs may be borne by patients and their carers and need to beadequately monitored (Clarke, 1996). To preserve quality of care, it is clear that reducing acute care capacity must be accompanied by investment inalternative services, such as community-based care (sometimes termed

Policy summary

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“hospital reconfiguration”). In western Europe planning strategies have beenmore successful in this respect than market forces (Healy & McKee, 2002).

Some governments have sought to finance capital investment through greateruse of market competition, while others are opting for a publicly led approachto capital investment. The former approach, characterized by public–privatepartnerships (PPPs), has been highly problematic. It may act as a barrier tocollaboration between facilities offering complementary services to a definedpopulation, leading to fragmentation and duplication. Furthermore, PPPs donot generate new financial resources for the health sector but are simply a way of raising debt finance, often transferring risk to future generations. Thismay benefit governments that need to meet short-term fiscal targets but doesnot necessarily reduce costs or increase efficiency in the longer term (Rechel et al., 2009).

Reductions in hospital capacity reflect a growing emphasis on coordinatingprimary, secondary and tertiary care with a view to delivering care in lower-costsettings where possible and appropriate; expanding the scope of what can beprovided in lower-cost settings; and strengthening intra-system coordination toimprove quality and address the inefficiency effects of fragmentation in delivery(Saltman, Rico & Boerma, 2006; Figueras et al., 2008). GP gatekeeping is anestablished way of coordinating care, although caution is required to ensure itdoes not lead to unnecessary delays in obtaining specialist care when needed.Recent developments include primary care-based networks, nurse-led strategies(France, the Netherlands, Sweden, the United Kingdom), disease managementprogrammes, the use of multidisciplinary teams to support audit and qualitymonitoring, financing reforms to better integrate care involving risk-basedfunding or reallocation (Netherlands and Germany), bonuses for recruitingpatients (France) and paying providers for performance (France, the UnitedKingdom) (Nolte, Knai & McKee, 2008). Evidence of the effectiveness of suchreforms is inconclusive. In the key area of integration of care for people withchronic conditions, there is a lack of data on quality of care and patientoutcomes across different approaches and on transferability across differentsystems. The evidence does suggest that reforms cannot be relied on to yieldcost savings (Nolte & McKee, 2008).

5 Conclusions

The survey results indicate that European Region countries have employed amix of policy tools in response to the financial crisis. Some countries seem tohave used the crisis to try to increase efficiency, particularly in the hospital andpharmaceutical sectors, although little has been done to enhance value throughpolicies to improve public health, which is a missed opportunity.


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To date, the breadth and scope of statutory coverage have largely beenunaffected. Some countries have actually expanded benefits for low-incomegroups, to strengthen access to health care. However, several countries havelowered coverage depth by increasing user charges for essential services, whichis a cause for concern. The international evidence suggests that user chargesdisproportionately affect low-income groups and regular users of care, and areunlikely to reduce public or total spending on health in the longer term due toreduced use of necessary care and, in some cases, increased use of free butmore resource-intensive services such as emergency care.

While research provides insight into the potential impact of many of the policiesadopted, each policy needs to be carefully evaluated in the context in which itis introduced, since both a given health system’s starting point and a specificpolicy’s design will play an important role in determining outcomes. To risksimplifying, policy options can be divided into two categories: those that arelikely to enhance efficiency and will not have an adverse impact on, or mayeven promote, other health system goals; and those that are likely to have more harmful effects.

Policy tools likely to promote health system goals:

• Increased risk pooling

• Strategic purchasing, where contracts are combined with accountabilitymechanisms including quality indicators, patient-reported outcomemeasures and other forms of feedback

• HTA to assist in setting priorities, combined with accountability, monitoring and transparency measures

• Controlled investment in the health sector, particularly for healthinfrastructure and expensive equipment

• Public health measures to reduce the burden of disease

• Price reductions for pharmaceuticals combined with cost–effectivenessevidence and other measures to promote rational prescribing anddispensing

• Shifting from inpatient to day-case or ambulatory care, where appropriate

• Integration and coordination of primary care and secondary care, and of health and social care

• Reducing administrative costs while maintaining capacity to manage the health system

• Fiscal policies to expand the public revenue base

Policy summary

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• Counter-cyclical measures introduced before the onset of a health system shock

• Targeting financial protection measures towards poorer people and regularusers of health care.

Policy tools that risk undermining health system goals:

• Reducing the scope of essential services covered

• Reducing population coverage

• Increases in waiting times for needed services

• User charges for essential services

• Attrition of health workers caused by imbalances in salaries relative to therest of the economy and, where relevant, foreign labour markets.

This policy summary has highlighted the wide range of health policy responsesto the financial crisis across Europe and noted some of the trade-offs involved.The crisis has left a few countries with little or no choice but to introduce cuts.Where the short-term situation compels governments to cut public spending on health, the policy emphasis should be on cutting wisely to minimize adverse effects on health system performance, enhancing value and facilitatingefficiency-enhancing reforms in the longer run.

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37

Policy summary

38

An

nex

1

Tab

le A

.1. P

olic

ies

targ

etin

g f

inan

cial

co

ntr

ibu

tio

ns

to t

he

hea

lth

sys

tem

in t

he

con

text

of

the

eco

no

mic

cri

sis,

W

HO

Eu

rop

ean

Reg

ion

No

tes:

No

info

rmat

ion

was

ava

ilabl

e fo

r A

ndor

ra, K

azak

hsta

n, L

uxem

bour

g, M

onac

o, M

onte

negr

o, S

an M

arin

o, T

ajik

ista

n an

d Tu

rkm

enis

tan.

Text

not

in it

alic

s in

dica

tes

a po

licy

whi

ch w

as d

efin

ed b

y th

e re

leva

nt a

utho

ritie

s in

the

cou

ntry

as

a re

spon

se t

o th

e cr

isis

. Tex

t in

ital

ics

indi

cate

s a

polic

y w

hich

was

eith

er p

artia

lly a

res

pons

e to

the

cris

is, t

hat

is, i

t w

as p

lann

ed b

efor

e th

e cr

isis

but

impl

emen

ted

afte

r w

ithgr

eate

r/le

ss s

peed

/inte

nsity

tha

n pl

anne

d; o

r po

ssib

ly a

res

pons

e to

the

cris

is, t

hat

is, i

t w

as p

lann

ed a

nd im

plem

ente

d si

nce

the

star

t of

th

e cr

isis

, but

not

def

ined

by

the

rele

vant

aut

horit

ies

as a

res

pons

e to

the

cris

is. A

bla

nk c

ell i

ndic

ates

no

polic

y re

spon

se t

o th

e cr

isis

(n

ot n

o re

spon

se t

o th

e su

rvey

).

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Alb

ania

Ther

e h

ave

bee

n s

om

e sm

all

red

uct

ion

s in

th

e ex

tern

alfi

nan

cial

ass

ista

nce

pro

vid

edto

Alb

ania

sin

ce t

he

star

t o

f th

e cr

isis

. Ho

wev

er,

acco

rdin

g t

o t

he

Min

istr

y o

fH

ealt

h t

her

e h

ave

bee

n n

om

ajo

r co

nse

qu

ence

s in

th

eh

ealt

h s

ecto

r as

a r

esu

lt

and

pu

blic

hea

lth

car

eex

pen

dit

ure

as

a p

erce

nta

ge

of

the

ove

rall

bu

dg

et (

i.e.

7.6%

in 2

008,

8.1

% in

200

9)an

d a

s a

per

cen

tag

e o

fg

ross

do

mes

tic

pro

du

ct(G

DP)

(i.e

. 2.5

% in

200

8 an

d 2

.7%

in 2

009)

hav

eb

een

rea

son

ably

sta

ble

si

nce

at

leas

t 20

06.

Health policy responses to the financial crisis in Europe – Annexes

Arm

enia

Dat

a fr

om

th

e N

atio

nal

Hea

lth

Acc

ou

nts

(N

HA

)sh

ow

th

at a

lth

ou

gh

GD

Pan

d t

ota

l go

vern

men

tsp

end

ing

bo

th in

crea

sed

in

ab

solu

te t

erm

s in

200

8co

mp

ared

to

200

7, p

ub

licex

pen

dit

ure

s o

n h

ealt

h f

ell

sig

nif

ican

tly

fro

m A

MD

66

bill

ion

to

AM

D 5

3 b

illio

n.

This

red

uct

ion

was

du

e to

the

eco

no

mic

cri

sis

and

was

con

trar

y to

th

e g

oal

s o

f th

eg

ove

rnm

ent’

s h

ealt

h p

olic

yto

incr

ease

pu

blic

fu

nd

sal

loca

ted

to

th

e h

ealt

hse

cto

r an

d t

he

Pove

rty

Red

uct

ion

Str

ateg

y ad

op

ted

by

the

go

vern

men

t fo

r th

ep

erio

d 2

004–

2015

.

In 2

011,

th

eg

ove

rnm

ent

intr

od

uce

d p

atie

nt

co-p

aym

ents

fo

r a

ran

ge

of

serv

ices

no

min

ally

co

vere

du

nd

er t

he

stat

uto

ryb

enef

its

pac

kag

e. A

maj

or

mo

tiva

tio

n is

to

incr

ease

go

vern

men

tre

ven

ues

, as

ho

spit

als

wer

e se

en b

y th

eM

inis

try

of

Fin

ance

as

a m

ajo

r ar

ea o

f th

e “b

lack

eco

no

my”

.H

ence

fo

rmal

izin

gu

no

ffic

ial p

aym

ents

is

th

e g

oal

.

Au

stri

aTh

e A

ust

rian

Min

istr

y o

fH

ealt

h in

tro

du

ced

th

eA

ust

rian

Hea

lth

Fu

nd

La

w in

Sep

tem

ber

200

9 to

safe

gu

ard

th

e re

ven

ues

of

sick

nes

s fu

nd

s an

d p

reve

nt

them

fro

m p

lun

gin

g

furt

her

into

deb

t d

ue

to

the

eco

no

mic

do

wn

turn

.Th

e H

ealt

h F

un

d m

easu

res

incl

ud

e an

an

nu

alg

ove

rnm

ent

cash

su

bsi

dy

for

the

sick

nes

s fu

nd

s to

hel

p b

alan

ce t

he

bu

dg

etan

d a

lso

req

uir

e si

ckn

ess

fun

ds

to c

ut

cost

s. T

he

go

vern

men

t co

ntr

ibu

tio

n t

oth

e H

ealt

h F

un

d w

as s

et a

t

In a

mea

sure

aim

ing

to o

ffer

fin

anci

alre

lief

to s

oci

ally

vuln

erab

le p

olic

yh

old

ers,

as

of

1Ja

nu

ary

2008

ace

ilin

g w

as s

et o

np

resc

rip

tio

n f

ees,

targ

eted

esp

ecia

lly

at p

eop

le w

ith

hig

hd

rug

nee

ds

and

low

inco

mes

. Un

der

th

en

ew la

w, a

cap

is s

etat

2%

of

an in

sure

dp

erso

n’s

an

nu

al n

etin

com

e sp

ent

on

pre

scri

pti

on

dru

gco

sts,

aft

er w

hic

h t

he

39

Policy summary

40

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Au

stri

a (c

on

t.)

EUR

100

mill

ion

in 2

009

bu

tin

201

1 it

was

cu

t to

EU

R 4

0m

illio

n d

ue

to b

ud

get

con

solid

atio

n a

s a

resu

lt o

fth

e cr

isis

. Th

e g

ove

rnm

ent

has

ple

dg

ed t

o c

on

trib

ute

EUR

40

mill

ion

an

nu

ally

thro

ug

h t

o f

isca

l yea

r 20

14b

ut

it r

emai

ns

to b

e se

enw

het

her

th

e p

olic

y w

illco

nti

nu

e af

ter

that

.

A D

ebt

Forg

iven

ess

Law

w

as a

lso

intr

od

uce

d t

o

wri

te o

ff d

ebts

acc

um

ula

ted

by

the

fun

ds

wit

h y

earl

yin

stal

men

ts o

f EU

R 1

50m

illio

n b

etw

een

201

0 an

d 2

012.

As

par

t o

f th

e H

ealt

h F

un

dla

w, t

he

Fed

erat

ion

of

Soci

alH

ealt

h In

sura

nce

Fu

nd

s w

asre

qu

ired

to

su

bm

it a

ro

adm

ap f

or

cost

-co

nta

inm

ent

effo

rts

in n

ego

tiat

ion

wit

hp

rovi

der

s, e

spec

ially

th

ed

oct

ors

ass

oci

atio

n.

insu

red

per

son

isex

emp

t fr

om

all

pre

scri

pti

on

dru

gch

arg

es f

or

the

rem

ain

der

of

the

cale

nd

ar y

ear.

Init

ial c

alcu

lati

on

s b

y th

e Fe

der

atio

n

of

Soci

al H

ealt

hIn

sura

nce

Fu

nd

sp

red

icte

d t

hat

th

en

ew e

xem

pti

on

wo

uld

ben

efit

app

roxi

mat

ely

300

000

peo

ple

. Giv

enth

e re

ven

ue

loss

es

for

stat

uto

ry h

ealt

hin

sura

nce

th

ere

isu

nce

rtai

nty

ove

r th

esu

stai

nab

ility

of

the

po

licy

in li

gh

t o

f th

eec

on

om

ic d

ow

ntu

rn.

It a

lso

rem

ain

s to

be

seen

wh

eth

er t

he

go

vern

men

t w

illco

mp

ensa

te s

oci

alin

sura

nce

fo

r th

ere

ven

ue

loss

es a

nd

wh

o w

ill u

ltim

atel

yp

ay f

or

the

cap

.


Aze

rbai

jan

Del

ay in

imp

lem

enta

tio

n

of

maj

or

hea

lth

fin

anci

ng

refo

rm, i

ncl

ud

ing

intr

od

uct

ion

of

man

dat

ory

hea

lth

insu

ran

ce. I

n J

anu

ary

2008

, bef

ore

th

e cr

isis

beg

an, t

he

Pres

iden

t o

fA

zerb

aija

n s

ign

ed t

he

dec

ree

app

rovi

ng

“T

he

Co

nce

pt

for

Hea

lth

Fin

anci

ng

Ref

orm

an

dIn

tro

du

ctio

n o

f M

and

ato

ryH

ealt

h In

sura

nce

fo

r 20

08–2

012”

. Th

e C

on

cep

td

escr

ibed

ove

rall

app

roac

hes

to

hea

lth

fin

anci

ng

ref

orm

inA

zerb

aija

n, i

ncl

ud

ing

th

e es

tab

lish

men

t o

f an

ind

epen

den

t si

ng

le-p

ayer

agen

cy u

nd

er t

he

Cab

inet

o

f M

inis

ters

, in

tro

du

cin

gn

ew p

rovi

der

pay

men

tm

ech

anis

ms

and

per

cap

ita

allo

cati

on

of

hea

lth

car

efu

nd

s. In

Au

gu

st 2

008,

th

e C

abin

et o

f M

inis

ters

app

rove

d t

he

Act

ion

Pla

nfo

r im

ple

men

tati

on

of

the

Co

nce

pt.

Ho

wev

er,

to d

ate

it h

as n

ot

bee

nim

ple

men

ted

. Th

e cr

isis

mig

ht

hav

e af

fect

ed t

oso

me

exte

nt

the

will

ing

nes

so

f th

e g

ove

rnm

ent

tola

un

ch t

he

refo

rms,

bu

t th

is is

no

t th

e m

ain

sta

ted

reas

on

fo

r th

e st

alem

ate.

41

Policy summary

42

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Bel

aru

sA

list

of

med

ical

serv

ices

exe

mp

t fr

om

val

ue

add

ed

tax

(VA

T) h

as b

een

app

rove

d.

In 2

009

the

tax

syst

em in

Bel

arus

chan

ged

fro

m o

ne

wit

h m

arg

inal

rat

esto

on

e w

ith

a f

lat

rate

of

12.0

% o

fsa

lary

.

Fro

m 2

009,

th

eg

ove

rnm

ent

has

b

een

inve

stig

atin

gu

ser

char

ges

po

licie

sas

a w

ay o

f ra

isin

gre

ven

ue.

Incr

ease

in e

xpo

rt

of

hig

h-t

ech

med

ical

serv

ices

to

rai

seg

ove

rnm

ent

reve

nu

es (

in 2

010

reac

hin

g U

SD 1

8.6

mill

ion

, exc

eed

ing

the

exp

ecte

d a

mo

un

tb

y U

SD 3

.1 m

illio

n).

Bel

giu

mG

iven

th

e cu

rren

t ec

on

om

icsi

tuat

ion

, th

ere

was

ad

ebat

e o

n w

het

her

to

resp

ect

the

ann

ual

gro

wth

no

rm o

f 4.

5% t

hat

was

esta

blis

hed

in 2

004,

th

efi

nal

dec

isio

n t

aken

was

in

fav

ou

r o

f “p

rote

ctin

g”

the

hea

lth

car

e b

ud

get

.

Enla

rgem

ent

of

the

gro

up

en

titl

ed

to in

crea

sed

reim

bu

rsem

ent

of

hea

lth

car

e ex

pen

ses:

fro

m 2

007,

low

-in

com

e fa

mili

es

(or

ind

ivid

ual

s) a

reel

igib

le. I

n 2

011

the

inco

me

ceili

ng

was

fixe

d a

t EU

R 1

5 16

3.96

and

incr

ease

d b

y EU

R 2

807.

26 f

or

each

add

itio

nal

fam

ilym

emb

er. N

ewre

imb

urs

emen

ts f

or

pat

ien

ts w

ith

cer

tain

chro

nic

co

nd

itio

ns

wer

e al

so in

tro

du

ced

.

Bo

snia

an

dH

erze

go

vin

a


43

Bu

lgar

iaTh

e M

inis

try

of

Hea

lth

bu

dg

et r

edu

ced

fro

mB

GN

713

mill

ion

in 2

008

toB

GN

537

mill

ion

in 2

009

and

BG

N 5

70 m

illio

n in

201

0.

Plan

ned

NH

IF (

Nat

ion

alH

ealt

h In

sura

nce

Fu

nd

)re

ven

ues

in 2

009

wer

e B

GN

2.4

7 m

illio

n b

ut

on

ly B

GN

2.2

1 m

illio

n

was

co

llect

ed. P

lan

ned

exp

end

itu

res

wer

e B

GN

2.0

7 m

illio

n b

ut

real

exp

end

itu

res

wer

e B

GN

1.7

5 m

illio

n.

The

go

vern

men

t in

crea

sed

the

soci

al h

ealt

h in

sura

nce

(SH

I) c

on

trib

uti

on

rat

e fr

om

6% t

o 8

% o

f in

com

e in

2009

. Th

e ad

dit

ion

al in

com

ew

as t

ran

sfer

red

into

are

serv

e fu

nd

to

pay

fo

rh

ealt

h in

sura

nce

ref

orm

–th

e g

ove

rnm

ent

pro

po

sed

com

pu

lso

ry in

sura

nce

pro

vid

ed b

y p

riva

te f

un

ds.

Ho

wev

er t

his

po

licy

was

un

po

pu

lar

wit

h t

he

pu

blic

and

do

cto

rs u

nio

ns

and

was

reje

cted

by

the

new

go

vern

men

t, w

hic

h w

ish

edto

ret

ain

co

ntr

ol o

f p

ub

licre

sou

rces

an

d in

stit

uti

on

sth

rou

gh

th

e N

HIF

. In

201

1th

e g

ove

rnm

ent

agre

ed

to u

se t

he

extr

a fu

nd

ing

dir

ectl

y o

n h

ealt

h s

ervi

ces

and

acc

epte

d a

bal

ance

db

ud

get

fo

r th

e N

HIF

(i.e

. to

spen

d a

ll th

e fu

nd

s ra

ised

).

Policy summary

44

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Cro

atia

Go

vern

men

t d

ebt

for

hea

lth

exp

end

itu

res

amo

un

ted

to

HR

K 4

.8 b

illio

n in

200

8; t

he

go

al t

hu

s b

ecam

e to

red

uce

the

def

icit

an

d e

nsu

re t

hat

spen

din

g is

fin

ance

d o

nly

fro

m r

even

ues

, wit

h n

ewb

orr

ow

ing

on

ly t

o c

ove

rp

revi

ou

s lia

bili

ties

. By

the

end

of

2010

, th

e g

ove

rnm

ent

had

red

uce

d t

he

bu

dg

et f

or

hea

lth

by

HR

K 1

.5 b

illio

n(w

ith

un

pai

d d

ebt

red

uce

db

y al

mo

st 2

0%).

In 2

011,

to

red

uce

th

ed

efic

it, t

he

go

vern

men

tp

asse

d n

ew le

gis

lati

on

o

n f

isca

l res

po

nsi

bili

ty(i

ncl

ud

ing

in t

he

hea

lth

sect

or)

in o

rder

to

en

sure

that

sp

end

ing

is f

inan

ced

on

ly b

y re

ven

ues

an

d n

ewb

orr

ow

ing

is o

nly

to

co

ver

pre

vio

us

liab

iliti

es o

r fo

rd

evel

op

men

t. O

ffic

e-h

old

ers

fro

m s

tate

leve

l to

loca

lle

vel i

n C

roat

ia w

ill h

ave

to o

ffer

th

eir

resi

gn

atio

n

if it

is e

stab

lish

ed t

hat

th

ey

hav

e b

reac

hed

th

e fi

scal

acco

un

tab

ility

leg

isla

tio

n.

Acc

ord

ing

to

th

e le

gis

lati

on

,th

e to

tal e

xpen

dit

ure

of

the

gen

eral

bu

dg

et (

the

go

vern

men

t’s

bu

dg

et

plu

s b

ud

get

s o

f lo

cal s

elf-

Intr

od

uce

d in

201

1:

– h

ealt

h c

are

con

trib

uti

on

so

n p

ensi

on

s (w

ith

dif

fere

nti

atio

n r

elat

ive

to t

he

pen

sio

n a

mo

un

t)

– sp

ecia

l co

ntr

ibu

tio

ns

rela

ted

to

hig

h-r

isk

beh

avio

urs

(“h

ealt

h t

ax

on

to

bac

co”)

– re

imb

urs

emen

t o

f co

sts

of

med

ical

tre

atm

ent

for

traf

fic

acci

den

ts f

rom

insu

ran

ce c

om

pan

ies

– co

-pay

men

t in

pri

mar

yh

ealt

h c

are;

co

-pay

men

tp

er p

resc

rip

tio

n

– in

com

e fr

om

sup

ple

men

tary

hea

lth

insu

ran

ce.

Co

-pay

men

ts h

ave

bee

n r

edu

ced

fro

mH

RK

15

in 2

009

toH

RK

10

for

pri

mar

yca

re v

isit

s an

dp

resc

rip

tio

ns.

Sup

ple

men

tary

hea

lth

insu

ran

cep

rem

ium

s in

crea

sed

in 2

010,

dep

end

ing

on

inco

me:

an

insu

red

per

son

(em

plo

yee)

wit

h a

mo

nth

ly s

alar

y o

rin

com

e o

f m

ore

th

an H

RK

510

8 p

ays

HR

K13

0 p

er m

on

thin

stea

d o

f H

RK

80;

an

insu

red

per

son

(pen

sio

ner

) w

ith

a

mo

nth

ly p

ensi

on

o

r in

com

e o

f m

ore

than

HR

K 5

108

pay

sH

RK

80

per

mo

nth

inst

ead

of

HR

K 5

0.C

erta

in c

ateg

ori

es o

fin

sura

nce

are

exe

mp

tfr

om

pay

men

t(d

epen

ds

on

: hea

lth

stat

us,

eco

no

mic

stat

us,

ag

e, e

tc.)

.


go

vern

men

t u

nit

s an

dfi

nan

cial

pla

ns

for

extr

a-b

ud

get

ary

use

rs)

is t

o b

ere

du

ced

an

nu

ally

by

on

ep

erce

nta

ge

po

int

of

the

pro

ject

ed G

DP.

Cyp

rus

Cze

ch R

epu

blic

Dec

reas

e in

Min

istr

y o

f H

ealt

h b

ud

get

by

CZK

200

0 m

illio

n (

abo

ut

30%

dec

reas

e) in

201

0co

mp

ared

to

200

8.

Ther

e w

as a

slig

ht

incr

ease

in S

HI r

even

ues

fro

m 2

008

to 2

011

du

e to

use

of

fin

anci

al r

eser

ves.

Incr

ease

of

pre

miu

ms

for

self

-em

plo

yed

(eq

ual

izat

ion

of

curr

ent

dis

par

itie

s w

ith

emp

loye

es)

and

cei

ling

fo

r p

rem

ium

pay

men

tssl

igh

tly

rais

ed t

o in

crea

seco

ntr

ibu

tio

n o

f h

igh

ear

ner

sp

lan

ned

fo

r 20

12/2

013.

Incr

ease

of

use

rch

arg

es f

or

inp

atie

nt

stay

fro

m C

ZK 6

0 to

CZK

100

per

day

inh

osp

ital

pla

nn

ed f

or

2012

. A la

w is

pla

nn

edfo

r 20

12 w

hic

h w

illin

tro

du

ce t

he

po

ssib

ility

of

char

gin

gco

-pay

men

ts f

or

mo

re“l

uxu

rio

us”

car

e,w

hic

h w

ill b

e o

f th

esa

me

qu

alit

y as

th

est

and

ard

car

e p

rovi

ded

un

der

SH

I bu

t w

ith

bet

ter

(ho

tel-

typ

e)am

enit

ies.

The

Min

istr

y o

f H

ealt

hcu

t re

imb

urs

emen

tra

te o

f d

rug

s b

yin

sura

nce

fu

nd

s b

y7%

bet

wee

n 2

009

and

201

1. T

his

can

resu

lt in

an

incr

ease

of

co-p

aym

ents

by

pat

ien

ts if

th

eim

po

rter

/pro

du

cer

do

es n

ot

red

uce

th

ew

ho

lesa

le p

rice

.

45

Policy summary

46

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Den

mar

kC

on

tin

ued

gro

wth

in h

ealt

hca

re b

ud

get

s b

y D

KK

5b

illio

n t

hro

ug

h 2

011–

2013

fin

ance

d in

par

t th

rou

gh

cro

ss-s

ub

sid

izat

ion

of

the

hea

lth

bu

dg

et f

rom

th

eed

uca

tio

n b

ud

get

.

Fro

m 2

011,

intr

od

uct

ion

of

use

rch

arg

es f

or

in v

itro

fert

iliza

tio

n.

Esto

nia

The

hea

lth

insu

ran

ce b

ud

get

on

hea

lth

car

e (t

emp

ora

rysi

ck le

ave

ben

efit

s ex

clu

ded

)d

ecre

ased

by

1% in

200

9co

mp

ared

to

200

8, w

hic

hw

as a

chie

ved

by

usi

ng

colle

cted

res

erve

s to

fill

th

eg

ap b

etw

een

rev

enu

es a

nd

exp

end

itu

res.

Th

e M

inis

try’

sh

ealt

h e

xpen

dit

ure

red

uce

db

y 24

% in

200

9 co

mp

ared

to 2

008.

Th

is w

as p

arti

ally

ach

ieve

d t

hro

ug

h c

utt

ing

adm

inis

trat

ive

cost

s an

dcu

ttin

g t

he

pu

blic

hea

lth

bu

dg

et f

rom

200

9.

Cu

ts f

ocu

sed

on

no

nco

mm

un

icab

le d

isea

ses

(NC

Ds)

an

d p

rog

ram

mes

o

n c

om

mu

nic

able

dis

ease

sw

ere

pro

tect

ed. E

uro

pea

nU

nio

n (

EU)

soci

al f

un

ds

wer

e u

sed

to

co

mp

ensa

tefo

r th

e re

du

ctio

n in

NC

Db

ud

get

bu

t th

ese

fun

ds

will

no

lon

ger

be

avai

lab

lefr

om

201

2.

In 2

009

the

dec

reas

e in

SH

Ire

ven

ues

was

11%

an

d in

2010

5%

, du

e to

incr

ease

du

nem

plo

ymen

t an

dd

ecre

ased

sal

arie

s.

Esto

nia

n H

ealt

h In

sura

nce

Fun

d (

EHIF

) ac

cum

ula

ted

sub

stan

tial

res

erve

s b

efo

reth

e cr

isis

. Th

e g

ove

rnm

ent

did

no

t al

low

th

ese

rese

rves

to b

e d

eple

ted

du

rin

g t

he

init

ial p

erio

d o

f th

e cr

isis

,b

ut

late

r th

ese

rese

rves

wer

e g

rad

ual

ly u

sed

to

com

pen

sate

fo

r th

ed

ecre

asin

g r

even

ues

o

f th

e EH

IF.

15%

co

-in

sura

nce

rat

efo

r n

urs

ing

inp

atie

nt

care

was

intr

od

uce

dfr

om

201

0.


47

Fin

lan

dU

ser

char

ges

fo

rp

ub

lic h

ealt

h s

ervi

ces

rais

ed b

y 10

% in

201

0(u

ser

char

ges

are

revi

sed

eve

ry s

eco

nd

year

bas

ed o

n t

he

pu

blic

pen

sio

ns

ind

ex).

An

incr

easi

ng

nu

mb

ero

f m

un

icip

alit

ies

are

intr

od

uci

ng

ser

vice

vou

cher

s. T

he

incr

ease

d u

se o

fse

rvic

e vo

uch

ers

isex

pec

ted

to

mit

igat

ep

ub

lic s

ecto

r co

stp

ress

ure

s an

din

crea

se t

he

free

do

mo

f ch

oic

e o

f th

e u

sers

of

serv

ices

. Acc

ord

ing

to a

su

rvey

co

nd

uct

edb

y Si

tra

and

th

eA

sso

ciat

ion

of

Fin

nis

hLo

cal a

nd

Reg

ion

alA

uth

ori

ties

, ser

vice

vou

cher

s ar

ep

arti

cula

rly

use

d f

or

soci

al s

ervi

ces.

Th

eir

intr

od

uct

ion

fo

r u

sein

hea

lth

car

e se

rvic

esw

as p

lan

ned

fo

r 20

11.

Fran

ceSi

nce

th

e ec

on

om

ic c

risi

s,th

e h

ealt

h b

ud

get

has

incr

ease

d s

har

ply

an

d

the

def

icit

has

ris

en f

rom

EUR

4.4

bill

ion

in 2

008

toEU

R 1

0.6

bill

ion

in 2

009.

Th

eh

ealt

h b

ud

get

am

ou

nte

d t

oEU

R 1

1.9

bill

ion

in 2

010

and

was

pla

nn

ed t

o b

e re

du

ced

to E

UR

11.

3 b

illio

n in

201

1.In

201

0 th

e to

tal i

ncr

ease

inh

ealt

h s

pen

din

g w

as 3

.2%

com

par

ed t

o 2

009.

Th

ein

crea

se in

th

e d

efic

it is

Follo

win

g t

he

chan

ge

in t

he

law

in20

07, t

he

allo

cati

on

of

reve

nu

es f

rom

tob

acco

tax

in 2

009

was

incr

ease

d a

nd

is

no

w p

aid

to

th

eh

ealt

h in

sura

nce

bu

dg

et a

t a

rate

o

f 98

.75%

.

Incr

ease

in a

new

con

trib

uti

on

th

at

is a

pp

lied

on

so

me

reve

nu

es (

“fo

rfai

t

Sin

ce 2

008

new

co

-pay

men

ts f

or

pre

scri

pti

on

dru

gs,

do

cto

r vi

sits

an

dam

bu

lan

ce t

ran

spo

rtar

e n

ot

reim

bu

rsab

leb

y p

riva

te v

olu

nta

ryh

ealt

h in

sura

nce

.

The

soci

al s

ecu

rity

bu

dg

et o

f N

ove

mb

er20

10 in

clu

ded

th

efo

llow

ing

mea

sure

s to

incr

ease

rev

enu

es:

a d

ecre

ase

fro

m 3

5%

Policy summary

48

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Fran

ce (

con

t.)

linke

d b

oth

wit

h h

igh

erex

pen

ses

and

low

erre

ven

ues

fro

m t

ax (

e.g

.G

ener

al S

oci

al C

on

trib

uti

on

,th

e in

com

e ta

x ea

rmar

ked

for

soci

al s

ecu

rity

sp

end

ing

).In

201

1 th

e p

lan

nin

gb

ud

get

ary

assu

mp

tio

n

was

th

at e

xpen

ses

for

hea

lth

wo

uld

incr

ease

ove

rall

by

2.9%

inco

mp

aris

on

wit

h 2

010.

The

soci

al s

ecu

rity

bu

dg

et

of

No

vem

ber

201

0 in

clu

ded

a n

um

ber

of

mea

sure

s to

red

uce

co

sts

and

incr

ease

reve

nu

es. I

t w

as a

nti

cip

ated

that

sav

ing

s in

201

1 in

hea

lth

exp

ense

s w

ou

ldre

ach

EU

R 2

bill

ion

.

soci

al s

ur

l’ép

arg

ne

sala

rial

e”),

wh

ich

was

set

up

in 2

009

and

wh

ose

rat

e h

asin

crea

sed

fro

m 2

% in

2009

to

4%

in 2

010

and

6%

in 2

011.

Tax

and

so

cial

con

trib

uti

on

re

liefs

hav

e b

een

intr

od

uce

d s

ince

2007

to

pro

mo

teem

plo

ymen

t.

to 3

0% o

f th

e ra

te

of

reim

bu

rsem

ent

of

ph

arm

aceu

tica

ls; a

dec

reas

e fr

om

65%

to

60%

fo

r th

e ra

te

of

reim

bu

rsem

ent

of

med

ical

pro

ced

ure

s.Th

is c

om

es in

ad

dit

ion

to t

he

incr

ease

fro

mEU

R 1

6 to

EU

R 1

8 p

erd

ay f

or

the

pat

ien

t’s

con

trib

uti

on

to

a s

tay

in h

osp

ital

th

at w

asin

tro

du

ced

in 2

010.

In a

dd

itio

n, F

ren

chst

atu

tory

hea

lth

insu

ran

ce h

as a

pp

lied

a n

ew r

ule

sin

ce 2

009

that

pen

aliz

es p

atie

nts

wh

o d

o n

ot

follo

wth

e ag

reed

med

ical

pat

hw

ay b

y in

crea

sin

gth

eir

co-p

aym

ent

con

trib

uti

on

by

40%

.

Geo

rgia

Wh

ile t

he

stat

e b

ud

get

fo

r th

e h

ealt

h s

ecto

r g

rew

ever

y ye

ar s

ince

200

6,

the

bu

dg

et f

or

2011

was

red

uce

d b

y 7.

9% c

om

par

edto

201

0.

Exp

ansi

on

of

hea

lth

insu

ran

ce f

or

the

po

or

(co

ntr

ibu

tio

ns

by

the

go

vern

men

t); f

or

som

ep

ub

lic s

ecto

r em

plo

yees

(fu

nd

ed b

y g

ove

rnm

ent)

and

vo

lun

tary

hea

lth

insu

ran

ce (

stat

e-su

bsi

diz

edfo

r lo

w-i

nco

me

fam

ilies

).Pr

emiu

ms

for

the

Med

ical

Insu

ran

ce P

rog

ram

me

(MIP

)

Exp

ansi

on

of

size

of

self

-in

sure

d e

nro

lled

in p

rep

aid

ris

k p

oo

lsth

rou

gh

intr

od

uct

ion

of

Vo

lun

tary

Hea

lth

Insu

ran

ce (

VH

I) –

in20

09 t

he

shar

e o

fp

op

ula

tio

n e

nro

lled

in t

hes

e sc

hem

esre

ach

ed 9

.7%

.


49

are

fully

pai

d b

y th

eg

ove

rnm

ent

and

pu

rch

ased

fro

m p

riva

te in

sura

nce

com

pan

ies.

In 2

011

the

go

vern

men

t re

du

ced

bu

dg

et a

lloca

tio

ns

for

MIP

as a

res

ult

of

insu

ran

cep

rem

ium

op

tim

izat

ion

.

In 2

010,

a n

atio

nal

su

rvey

esti

mat

ed h

ealt

h in

sura

nce

cove

rag

e to

be

30%

of

the

po

pu

lati

on

(20

% u

nd

er t

he

sub

sid

ized

, po

vert

y-fo

cuse

dM

IP a

nd

10%

th

rou

gh

volu

nta

ry e

nro

lmen

t).

Ger

man

y

Gre

ece

In M

ay 2

010,

Gre

ece

was

pu

t u

nd

er t

he

sup

ervi

sio

n

of

Euro

pea

n C

om

mis

sio

n,

the

Euro

pea

n C

entr

al B

ank

(EC

B)

and

th

e In

tern

atio

nal

Mo

net

ary

Fun

d (

IMF)

du

e to

the

pu

blic

def

icit

an

d d

ebts

as w

ell a

s th

e cr

edit

cri

sis.

The

Mem

ora

nd

um

th

atG

reec

e si

gn

ed d

icta

tes

a se

ries

of

mea

sure

sre

ferr

ing

to

th

e h

ealt

hse

cto

r, fo

cusi

ng

esp

ecia

llyo

n r

edu

ctio

n o

f p

ub

licex

pen

dit

ure

. In

th

e co

nte

xto

f th

e M

emo

ran

du

m, p

ub

lich

ealt

h e

xpen

dit

ure

had

to

be

red

uce

d b

y 0.

5% o

f G

DP

du

rin

g 2

011.

Fro

m 2

011,

th

e ci

vil

serv

ants

’ SH

I fu

nd

em

plo

yer

(i.e

. sta

te)

con

trib

uti

on

ra

te is

set

at

5.1%

of

civi

lse

rvan

ts’ s

alar

ies,

wh

ile t

he

con

trib

uti

on

of

the

fun

d’s

pen

sio

ner

s is

gra

du

ally

bei

ng

incr

ease

d f

rom

2.5

5%to

4%

in 2

013.

Pre

vio

usl

y,th

e p

ub

lic s

ecto

r d

id n

ot

con

trib

ute

a s

pec

ific

per

cen

tag

e; d

epen

din

g

on

th

e n

eed

s o

f th

e so

cial

sec

uri

ty f

un

d, t

he

con

trib

uti

on

of

the

pu

blic

sect

or

(go

vern

men

t) w

asth

rou

gh

th

e st

ate

bu

dg

et.

Wit

h t

he

init

iati

on

of

the

new

so

cial

sec

uri

ty f

un

d f

or

Fro

m 2

011,

an

incr

ease

in u

ser

char

ges

fro

m E

UR

3

to E

UR

5 in

ou

tpat

ien

td

epar

tmen

ts o

f p

ub

licfa

cilit

ies;

use

r ch

arg

esin

hea

lth

cen

tres

rem

ove

d f

or

cert

ain

vuln

erab

le g

rou

ps.

Policy summary

50

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Gre

ece

(co

nt.

)Th

e h

ealt

h b

ud

get

fo

r 20

11d

ecre

ased

by

EUR

1.4

bill

ion

,w

ith

EU

R 5

68 m

illio

n s

aved

thro

ug

h m

easu

res

dic

tate

db

y th

e M

emo

ran

du

m r

elat

edto

sal

arie

s an

d b

enef

its

cuts

and

EU

R 8

40 m

illio

n s

aved

thro

ug

h c

uts

in o

per

atin

gco

sts

of

ho

spit

als.

the

Gre

ek p

op

ula

tio

n(E

OPY

Y –

Nat

ion

al H

ealt

hSe

rvic

e O

rgan

izat

ion

) th

e5.

1% w

as s

pec

ifie

d in

th

eM

emo

ran

du

m.

Hu

ng

ary

The

cen

tral

ly s

et b

ud

get

fo

rth

e h

ealt

h in

sura

nce

fu

nd

(HIF

) d

id n

ot

chan

ge

mu

chn

om

inal

ly b

etw

een

200

8an

d 2

011,

wh

ich

imp

lies

that

rea

l exp

end

itu

re o

nh

ealt

h d

ecre

ased

wh

enad

just

ing

fo

r in

flat

ion

.O

vera

ll, a

slig

ht

red

uct

ion

ing

ove

rnm

ent

exp

end

itu

re o

nh

ealt

h a

s a

shar

e o

f G

DP.

The

tota

l exp

end

itu

re f

rom

the

HIF

, in

clu

din

g a

lso

th

eca

sh b

enef

its,

was

HU

F 14

45m

illio

n in

200

8 an

d w

asex

pec

ted

to

be

HU

F 14

59m

illio

n in

201

1.

Sin

ce 2

009

the

hea

lth

con

trib

uti

on

pai

d b

y th

eem

plo

yer

dec

lined

fro

m 5

%to

2%

fo

r ea

rnin

gs

bel

ow

twic

e th

e m

inim

um

wag

e,w

hile

it r

emai

ned

5%

fo

rth

ose

ab

ove

th

is t

hre

sho

ld.

To c

om

pen

sate

th

e H

IF f

or

the

loss

in r

even

ues

, th

ece

ntr

al b

ud

get

co

ntr

ibu

tio

no

n b

ehal

f o

f el

igib

le b

ut

no

n-c

on

trib

uti

ng

per

son

s(p

ensi

on

ers,

yo

un

gst

ers,

ho

mel

ess,

etc

.) w

as r

aise

dfr

om

HU

F 45

00/p

erso

n t

oH

UF

9300

/per

son

.

This

en

taile

d a

maj

or

shif

t in

the

reve

nu

e m

ix f

or

hea

lth

:g

ener

al t

ax r

even

ue

tran

sfer

sto

HIF

alm

ost

do

ub

led

ino

rder

to

co

mp

ensa

te f

or

the

red

uct

ion

of

the

SHI

reve

nu

es d

ue

to r

edu

ctio

no

f th

e SH

I co

ntr

ibu

tio

nra

tes,

wh

ich

was

mea

nt

to s

tim

ula

te la

bo

ur

mar

ket.

Ch

ang

es in

use

rch

arg

es N

OT

as a

resp

on

se t

o t

he

cris

is,

bu

t re

leva

nt

in t

he

con

text

of

the

cris

isre

spo

nse

mea

sure

s.

In 2

008

the

follo

win

gfe

es w

ere

abo

lish

ed:

HU

F 30

0 p

er v

isit

fo

rse

rvic

es o

f G

Ps,

den

tist

s, o

utp

atie

nt

care

an

d o

utp

atie

nt

reh

abili

tati

on

; HU

F60

0 p

er v

isit

in c

ase

of

mis

sin

g p

aper

s in

ou

tpat

ien

t ca

re,

wh

ere

adm

itta

nce

pap

ers

are

nee

ded

;H

UF

1000

per

vis

it

in c

ase

of

cau

sele

ssu

se o

f n

igh

t d

uty

.In

pat

ien

t d

aily

fee

:H

UF

300

per

day

.

Fro

m 2

008

ph

arm

aceu

tica

l an

dm

edic

al a

pp

lian

ceco

mp

anie

s w

ere

ob

liged

to

pay

a f

eeto

th

e g

ove

rnm

ent

exch

equ

er f

or

the

pro

mo

tio

nal

act

ivit

yo

f th

eir

med

ical

sal

esre

pre

sen

tati

ves.

Th

isam

ou

nts

to

aro

un

dH

UF

5 m

illio

n p

erye

ar (

app

rox.

EUR

2000

0) f

or

asa

les

rep

rese

nta

tive

of

ph

arm

aceu

tica

lsan

d H

UF

1 m

illio

n

for

on

e in

th

e ar

ea

of

med

ical

pro

du

cts.


51

In 2

010,

th

e it

emiz

ed h

ealt

hco

ntr

ibu

tio

n (

a ta

x o

fH

UF

1950

per

mo

nth

per

emp

loye

e p

aid

by

emp

loye

rs)

was

ab

olis

hed

.

Sin

ce 2

008,

GPs

(g

ener

alp

ract

itio

ner

) an

d o

ut-

an

din

pat

ien

t p

rovi

der

s g

et H

UF

50 c

om

pen

sati

on

fo

r ea

cho

nlin

e el

igib

ility

ch

eck

(ch

ecki

ng

th

e va

lidat

ion

of

insu

ran

ce b

y so

cial

sec

uri

tyn

um

ber

). T

his

do

es n

ot

mea

n t

hat

pat

ien

ts w

ith

ou

tva

lid in

sura

nce

sta

tus

will

no

t b

e tr

eate

d, b

ut

the

HIF

will

rep

ort

to

th

e ta

x ag

ency

wh

ich

, in

tu

rn, c

olle

cts

un

pai

d c

on

trib

uti

on

sre

tro

spec

tive

ly. T

his

mea

sure

targ

eted

imp

rove

d c

olle

ctio

n.

Icel

and

The

nat

ion

al b

ud

get

has

bee

n c

ut

con

sid

erab

ly

po

st-c

risi

s, in

clu

din

gap

pro

xim

atel

y 5%

an

nu

alcu

ts t

o t

he

hea

lth

car

e an

d s

oci

al s

ecu

rity

sec

tors

.A

cco

rdin

g t

o n

atio

nal

stat

isti

cs, p

er c

apit

a to

tal

hea

lth

exp

end

itu

re g

row

thw

as -

3.1%

in 2

009

and

-4.

0% in

201

0. A

s o

f M

arch

2009

, th

e M

inis

try

of

Hea

lth

has

red

uce

d e

xpen

dit

ure

s,in

clu

din

g f

or

equ

ipm

ent,

dru

gs,

op

erat

ing

exp

ense

san

d p

atie

nt

tran

spo

rt.

Policy summary

52

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Icel

and

(co

nt.

)Th

e b

ud

get

of

the

Nat

ion

alU

niv

ersi

ty H

osp

ital

has

bee

nre

du

ced

by

app

roxi

mat

ely

18%

fro

m 2

007

to 2

010.

Irel

and

The

2009

hea

lth

bu

dg

etin

crea

sed

by

1%.

Savi

ng

s in

th

e h

ealt

hb

ud

get

of

ove

r EU

R 1

bill

ion

ann

ou

nce

d in

201

0 b

ud

get

.

In 2

011,

th

e o

vera

ll b

ud

get

for

hea

lth

was

do

wn

by

a fu

rth

er E

UR

746

mill

ion

(a

yea

r-o

n-y

ear

6.6%

cu

t fo

rth

e H

ealt

h S

ervi

ce E

xecu

tive

(HSE

)).

Incr

ease

d f

un

ds

to c

ove

rin

crea

sin

g n

um

ber

s o

fp

eop

le o

n lo

w in

com

esel

igib

le f

or

med

ical

car

ds

(by

Sep

tem

ber

200

9,1.

4m

illio

n p

eop

le w

ere

cove

red

by

med

ical

car

ds,

up

by

4% y

ear

on

yea

r):

incr

ease

in t

he

2009

med

ical

card

bu

dg

et e

qu

ival

ent

to a

1% r

eal i

ncr

ease

in f

un

din

gp

er c

apit

a; s

up

ple

men

tary

bu

dg

et a

nn

ou

nce

d in

No

vem

ber

200

9 an

d e

xtra

fun

ds

(EU

R 2

30 m

illio

n)

wer

e m

ade

avai

lab

le f

or

2010

in t

he

Dec

emb

erb

ud

get

.

In 2

009,

th

e h

ealt

hle

vy, a

su

rro

gat

ein

com

e ta

x, w

asd

ou

ble

d t

o 4

% o

n

all e

arn

ing

s u

p t

oEU

R 7

5 03

6 an

dra

ised

to

5%

on

earn

ing

s o

ver

EUR

75

036.

Th

e th

resh

old

o

f p

aym

ent

was

als

ore

du

ced

.

Tax

relie

f fo

r p

riva

ten

urs

ing

ho

mes

an

dh

osp

ital

s w

as t

o s

top

as p

art

of

a b

road

erp

olic

y o

f en

din

gp

rop

erty

-rel

ated

tax

relie

f, h

ow

ever

no

exac

t en

d d

ate

was

nam

ed. P

allia

tive

care

co

nti

nu

es t

o b

eel

igib

le f

or

tax

relie

f.

Fro

m 2

009,

fo

r th

etw

o-t

hir

ds

of

the

po

pu

lati

on

wit

ho

ut

med

ical

car

ds

(med

ical

card

s co

nfe

r fr

eeac

cess

to

GPs

an

dw

aive

ho

spit

alin

pat

ien

t fe

es f

or

tho

se u

nd

er c

erta

inin

com

e th

resh

old

san

d s

om

e p

eop

le

ove

r 70

yea

rs o

f ag

e)u

ser

char

ges

incr

ease

dfo

r p

ub

lic (

17%

) an

dp

riva

te (

20%

) b

eds

inp

ub

lic h

osp

ital

s, u

seo

f th

e em

erg

ency

dep

artm

ent

in p

ub

lich

osp

ital

s, e

mer

gen

cyd

epar

tmen

t ch

arg

es,

and

ded

uct

ible

s fo

rth

e d

rug

s p

aym

ent

sch

eme

(wh

ich

reim

bu

rses

no

n-

med

ical

car

d h

old

ers

for

cost

of

dru

gs

ove

ra

cert

ain

am

ou

nt)

.

In t

he

2010

bu

dg

et:

intr

od

uct

ion

of

a50

cen

t ch

arg

e fo

r


53

The

2011

bu

dg

et: m

ino

rfu

nd

ing

incr

ease

s to

can

cer

care

(EU

R 1

0 m

illio

n),

ho

mec

are

pac

kag

es

(EU

R 8

mill

ion

) ch

ildp

rote

ctio

n (

EUR

9 m

illio

n)

and

th

e Fa

ir D

eal

(EU

R 6

mill

ion

), w

hic

hp

rovi

des

fin

anci

al s

up

po

rtfo

r p

eop

le a

sses

sed

as

nee

din

g lo

ng

-ter

m

nu

rsin

g h

om

e ca

re.

a p

resc

rip

tio

n f

or

all

med

ical

car

d h

old

ers

up

to

a m

axim

um

of

EUR

10

per

fam

ily p

erm

on

th; i

ncr

easi

ng

th

ed

rug

s re

imb

urs

emen

tth

resh

old

to

EU

R 1

20(f

rom

EU

R 1

00 in

2009

) a

mo

nth

fo

r th

e 70

% o

f th

ep

op

ula

tio

n w

ho

pay

for

thei

r o

wn

dru

gs.

Isra

el

Ital

yFo

r th

e h

ealt

h c

are

sect

or,

inre

aliz

atio

n o

f th

e ag

reem

ent

bet

wee

n t

he

stat

e an

d t

he

reg

ion

s in

Dec

emb

er 2

010,

add

itio

nal

res

ou

rces

wer

efo

rese

en a

mo

un

tin

g t

oEU

R1.

1 m

illio

n in

201

0,

as w

ell a

s EU

R 4

00 m

illio

n

and

EU

R30

0 m

illio

n,

resp

ecti

vely

, in

th

e tw

ofo

llow

ing

yea

rs, i

n o

rder

to

incr

ease

Nat

ion

al H

ealt

hSe

rvic

e fu

nd

ing

an

d t

oin

crea

se t

he

fun

d f

or

lon

g-

term

car

e an

d t

he

fun

d f

or

soci

al p

olic

y, a

s w

ell a

s to

fin

ance

inve

stm

ents

in p

ub

licsa

nit

ary

infr

astr

uct

ure

s.

Ho

wev

er, i

n 2

011

a n

ewse

ries

of

cuts

in h

ealt

h c

are

exp

end

itu

res

was

fo

rese

enb

y th

e g

ove

rnm

ent.

Th

eN

atio

nal

Co

mm

issi

on

on

Fro

m 2

010,

reg

ion

sw

ith

larg

e h

ealt

hca

re d

efic

its

hav

eh

ad t

o r

aise

loca

lta

xes

to r

eco

ver

def

icit

s.

For

2010

–201

1,re

mo

ved

fee

of

EUR

10

for

spec

ialis

tan

d d

iag

no

stic

serv

ices

.

The

2011

Fin

anci

alLa

w in

tro

du

ces

incr

ease

s in

co

-pay

men

t fe

es f

or

visi

ts t

o d

oct

ors

an

dan

alys

is (

EUR

10+

) an

d f

or

inte

rven

tio

ns

in e

mer

gen

cy w

ard

sn

ot

just

ifie

d b

yu

rgen

t si

tuat

ion

s (E

UR

25+

).

Policy summary

54

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Ital

y (c

on

t.)

Soci

al A

ffai

rs in

Par

liam

ent

(Co

mm

issi

on

e A

ffar

iso

cial

id

ella

Cam

era)

has

dis

cuss

eda

seri

es o

f cu

ts in

wel

fare

as

par

t o

f th

e 20

11 F

inan

cial

Law

. Th

e cu

ts w

ere

very

exte

nsi

ve. I

n 2

011,

inve

stm

ent

in h

ealt

h c

are

infr

astr

uct

ure

s w

as t

o b

e cu

t fr

om

ove

r EU

R 1

bill

ion

to E

UR

236

mill

ion

. Res

earc

hfu

nd

ing

fo

r th

e p

ub

lich

ealt

h c

are

sect

or

was

to

be

cut

fro

m E

UR

91.

9 m

illio

n t

oEU

R 1

8.4

mill

ion

. Th

e fu

nd

for

dis

ease

pre

ven

tio

n a

nd

hea

lth

pro

mo

tio

n w

as t

o b

ecu

t fr

om

EU

R 2

9.6

mill

ion

to

EUR

5.9

mill

ion

. Pal

liati

veca

re w

as t

o b

e cu

t to

on

lyEU

R 1

mill

ion

. Res

ou

rces

fo

rse

mi-

auto

mat

ic d

efib

rilla

tors

and

rel

ated

eq

uip

men

t in

pu

blic

pla

ces

was

to

be

red

uce

d f

rom

EU

R 4

mill

ion

to E

UR

2 m

illio

n.

Fro

m 2

010

a ti

gh

ter

bu

dg

etca

p w

as f

ixed

fo

r re

gio

ns’

ph

arm

aceu

tica

l exp

end

itu

re.

The

bu

dg

et f

or

dru

gs

has

bee

n r

edu

ced

in a

bso

lute

valu

e b

y EU

R 8

00 m

illio

nst

arti

ng

fro

m 2

010,

bei

ng

fixe

d a

t 13

.3%

of

tota

l pu

blic

hea

lth

car

e ex

pen

dit

ure

.C

on

seq

uen

tly

the

leve

l of


55

fin

anci

ng

by

the

stat

e w

asre

du

ced

by

EUR

800

mill

ion

fro

m t

he

year

201

0.

Kyr

gyz

stan

Latv

iaTh

e h

ealt

h c

are

exp

end

itu

reb

ud

get

incr

ease

d b

etw

een

2005

an

d 2

008

reac

hin

g

LVL

576.

56 m

illio

n. F

rom

2009

it d

ecre

ased

fal

ling

to

LV

L 50

3.73

mill

ion

, an

dLV

L 43

2.78

mill

ion

in 2

010.

The

follo

win

g s

pec

ific

fin

anci

al c

uts

in e

xpen

dit

ure

wer

e m

ade

by

the

Min

istr

yo

f H

ealt

h in

201

0 co

mp

ared

to

200

8: t

reat

men

t -4

0.4%

;p

ub

lic h

ealt

h -

88.6

%;

cen

tral

ad

min

istr

atio

n -

58.6

%; m

edic

al a

nd

hea

lth

edu

cati

on

at

un

iver

sity

-41

.7%

; ad

min

istr

atio

n

of

hea

lth

car

e fi

nan

cin

g -

67.7

%. F

un

din

g in

th

eb

ud

get

fo

r w

ork

of

hea

rth

ealt

h c

abin

ets

and

co

ntr

ol

and

ep

idem

iolo

gic

alsu

rvei

llan

ce d

ecre

ased

by

86.9

% a

nd

fu

nd

ing

fo

rh

ealt

h s

tati

stic

s re

du

ced

b

y 74

% in

201

0 co

mp

ared

to 2

008.

In 2

009

the

ph

arm

aceu

tica

lre

imb

urs

emen

t b

ud

get

w

as d

ecre

ased

by

7.1%

com

par

ed t

o 2

008.

Pri

mar

y

The

Cab

inet

of

Min

iste

rs a

men

ded

Reg

ula

tio

ns

on

th

eR

eim

bu

rsem

ent

of

Phar

mac

euti

cals

.Th

ese

cam

e in

to f

orc

ein

200

9; t

hei

r ef

fect

sw

ere

the

red

uct

ion

o

f th

e p

erce

nta

ge

of

reim

bu

rsem

ent

for

cert

ain

dia

gn

ose

sfr

om

75%

to

50%

an

d f

rom

90%

to

75%

for

oth

er d

iag

no

ses.

Thu

s th

e fi

nan

cial

bu

rden

was

par

tial

lysh

ifte

d t

o p

atie

nts

.C

on

seq

uen

tly,

th

ere

was

an

incr

ease

inp

atie

nt

co-p

aym

ent

by

59%

in 2

009

com

par

ed t

o 2

008.

This

res

ult

ed in

an

aver

age

leve

l of

pat

ien

t co

-pay

men

tsin

th

e re

imb

urs

emen

tsy

stem

of

app

roxi

-m

atel

y 30

% in

200

9.A

t th

e sa

me

tim

e,10

0% r

eim

bu

rsem

ent

was

mai

nta

ined

fo

r

Policy summary

56

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Latv

ia (

con

t.)

care

was

set

as

a p

rio

rity

, so

cuts

in t

he

reim

bu

rsem

ent

of

ph

arm

aceu

tica

ls w

ere

pro

po

rtio

nal

ly s

mal

ler

than

cu

ts in

th

e se

cto

r o

f in

pat

ien

t h

ealt

h c

are.

the

mo

st s

ever

ed

iag

no

ses,

su

ch

as o

nco

log

y an

den

do

crin

olo

gy.

Mo

sto

f th

e co

-pay

men

tin

crea

ses

wer

e fo

rca

rdio

vasc

ula

r sy

stem

dis

ease

s. T

he

red

uct

ion

of t

he r

ate

of r

eim

-bu

rsem

ent

was

a

shor

t-te

rm m

easu

re

to r

edu

ce c

ost

s; it

was

un

der

sto

od

th

at it

cou

ld s

erio

usl

y af

fect

pu

blic

hea

lth

ind

icat

ors

in t

he

lon

ger

ter

m. T

he

rate

of

reim

bu

rsem

ent

for

card

iova

scu

lar

dis

ease

s h

as b

een

incr

ease

d t

o t

he

pre

vio

us

leve

l of

75%

from

1N

ovem

ber

2010

.

The

Soci

al S

afet

y N

etw

as in

tro

du

ced

inLa

tvia

at

the

end

of

2009

an

d is

fin

ance

db

y a

loan

fro

m t

he

Wo

rld

Ban

k. M

ost

of

the

Soci

al S

afet

y N

etsp

end

ing

on

hea

lth

care

is in

ten

ded

to

cove

r th

e co

-pay

men

to

f p

atie

nts

fo

r h

ealt

hca

re s

ervi

ces

and

to

pro

vid

e 10

0%


57

reim

bu

rsem

ent

of

med

icin

al p

rod

uct

sfo

r th

e le

ss w

ell-

off

–th

ose

wh

o r

ecei

ve

less

th

an L

VL

120

per

mo

nth

, eq

uiv

alen

t to

EU

R 1

70. I

t w

asp

lan

ned

th

at t

his

mea

sure

will

en

d o

n31

Dec

emb

er 2

011.

Lith

uan

iaIn

200

8 g

ove

rnm

ent

exp

end

itu

re o

n h

ealt

h w

asLT

L 10

00.7

mill

ion

bu

t it

dec

lined

to

LTL

854

.4 m

illio

nin

200

9. In

200

9 th

e b

ud

get

of

the

Co

mp

uls

ory

Hea

lth

Insu

ran

ce F

un

d (

CH

IF)

rem

ain

ed a

t th

e sa

me

leve

las

in 2

008.

Ho

wev

er, i

n

the

year

201

0 it

s b

ud

get

dec

reas

ed b

y 8%

co

mp

ared

to y

ears

200

9 an

d 2

008

(LTL

4.0

1 b

illio

n c

om

par

edto

LTL

4.3

9 b

illio

n).

Du

e to

incr

easi

ng

un

emp

loy -

men

t, t

he

amo

un

t o

f m

on

eyco

llect

ed b

y th

e C

HIF

sig

nif

ican

tly

dec

lined

du

rin

gre

cen

t ye

ars,

wh

erea

s st

ate

sub

sid

ies

for

peo

ple

insu

red

by

the

stat

e m

ore

th

ando

uble

d (f

rom

LTL

674

mill

ion

in 2

007

to L

TL 7

81 m

illio

n in

2008

, LTL

1.1

bill

ion

in 2

009

and

LTL

1.5

bill

ion

in 2

010)

.Th

e su

bsi

die

s fo

r th

ose

insu

red

by

the

stat

ein

crea

sed

fro

m L

TL 3

53 in

2007

to

LTL

428

in 2

008,

LT

L 60

5 in

200

9, a

nd

LTL

744

in 2

010

per

insu

red

per

son

per

yea

r. Fo

r th

e ye

ar 2

011

it w

as p

lan

ned

th

at t

he

stat

ew

ou

ld p

ay L

TL 7

33 p

erin

sure

d p

erso

n. A

cco

rdin

gto

hea

lth

insu

ran

cele

gis

lati

on

, in

an

y g

iven

year

, th

is a

mo

un

t is

calc

ula

ted

as

app

roxi

mat

ely

on

e-th

ird

of

the

aver

age

gro

ss s

alar

y in

th

e co

un

try

two

yea

rs p

revi

ou

sly.

Policy summary

58

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Mal

ta

Net

her

lan

ds

Co

-pay

men

ts w

ere

tob

e in

crea

sed

fo

rce

rtai

n s

ervi

ces

fro

m20

10, a

s a

resu

lt o

fre

stri

ctio

ns

in t

he

ben

efit

pac

kag

e.

No

rway

The

stat

e b

ud

get

has

bee

nm

ain

tain

ed t

hro

ug

ho

ut

the

cris

is d

ue

to s

ub

stan

tial

oil

reve

nu

es.

Pola

nd

It w

as e

xpec

ted

th

at in

201

1th

ere

wo

uld

be

a 2.

6%in

crea

se in

th

e N

atio

nal

Hea

lth

Fu

nd

’s (N

HF)

rev

enu

esan

d e

xpen

dit

ure

s co

mp

ared

to 2

010,

du

e to

mo

der

ate

incr

ease

s o

f u

nem

plo

ymen

t.B

y co

mp

aris

on

, th

e N

HF'

sre

ven

ues

an

d e

xpen

dit

ure

sin

crea

sed

by

11.5

% in

200

9co

mp

ared

to

200

8 an

d a

bo

ut

8% in

201

0 co

mp

ared

to

2009

. In

200

9, t

he

go

vern

-m

ent

cut

its

inve

stm

ent

exp

end

itu

res

in h

ealt

h c

are

infr

astr

uct

ure

by

hal

f. T

he

low

er e

xpen

dit

ure

s w

ere

con

tin

ued

in s

ub

seq

uen

tst

ate

bu

dg

ets.


59

Port

ug

alTh

e g

ove

rnm

ent

has

init

iate

d a

co

mp

reh

ensi

vere

form

pac

kag

e to

imp

rove

effi

cien

cy a

nd

to

red

uce

sig

nif

ican

tly

the

cost

s o

f th

e h

ealt

h c

are

sect

or.

Au

tho

riti

es e

xpec

ted

th

ep

acka

ge

to y

ield

sav

ing

sw

ort

h E

UR

700

mill

ion

in20

11, o

f w

hic

h E

UR

100

mill

ion

is p

art

of

anad

dit

ion

al c

on

solid

atio

np

acka

ge.

Th

e g

ove

rnm

ent

is c

om

mit

ted

to

ach

ieve

furt

her

co

st s

avin

gs

of

EUR

200

mill

ion

in 2

012

by

cutt

ing

op

erat

ion

al

cost

s b

y 10

%.

Thro

ug

h t

he

Fun

daç

ão p

ara

a C

iên

cia

e a

Tecn

olo

gia

(FC

T), t

he

stat

e su

bsi

diz

esre

sear

ch a

nd

dev

elo

pm

ent

(R&

D),

gra

nts

hig

her

edu

cati

on

res

earc

hsc

ho

lars

hip

s an

d a

war

ds

fun

din

g t

o r

esea

rch

un

its.

In20

11, s

om

e R

&D

un

its

wer

ein

form

ed t

hat

a la

rge

par

to

f th

e p

red

icte

d f

un

din

gw

ou

ld n

ot

be

avai

lab

le a

nd

man

y re

sear

ch s

cho

lars

hip

sar

e al

so b

ein

g e

limin

ated

. It

is n

ot

clea

r h

ow

far

th

e cu

tsw

ill g

o.

AD

SE (

hea

lth

sys

tem

fo

rp

ub

lic s

ecto

r w

ork

ers)

refo

rm in

201

1: t

he

con

trib

uti

on

of

1.5%

o

f th

e sa

lary

of

pu

blic

wo

rker

s w

as n

ot

pla

nn

ed

to b

e in

crea

sed

, bu

t th

eco

ntr

ibu

tio

n o

f 1.

3% o

fp

ensi

on

ers

was

pla

nn

ed

to in

crea

se b

y 0.

1% p

er

year

un

til i

t m

atch

es t

he

con

trib

uti

on

of

acti

vew

ork

ers.

Use

r ch

arg

es o

f th

eN

HS

(Nat

ion

al H

ealt

hSe

rvic

e) w

ere

up

dat

edan

d in

cen

tive

s w

ere

crea

ted

to

pro

mo

teth

e p

aym

ent

of

thes

ech

arg

es (

sin

ce s

om

ep

eop

le ig

no

red

eman

ds

for

pay

men

t,si

nce

th

is is

ask

ed f

or

afte

r th

e se

rvic

e h

asb

een

giv

en).

Fro

m 2

011:

(1)

Incr

ease

in c

har

ges

app

lied

to

so

me

vacc

ines

, su

ch a

sye

llow

feve

r, Ja

pan

ese

ence

ph

alit

is, t

yph

oid

,m

enin

git

is a

nd

rab

ies

tetr

aval

ent.

Th

ese

char

ges

of

less

th

anEU

R 1

per

vac

cin

ein

crea

sed

to

EU

R 5

0–10

0 p

er v

acci

ne.

(2

) In

crea

se in

ch

arg

esas

ked

fo

r d

oct

or

dec

lara

tio

ns

by

ah

ealt

h a

uth

ori

ty o

r a

pu

blic

hea

lth

pro

fess

ion

al f

rom

less

than

EU

R 1

to

EU

R 2

0;d

oct

or

dec

lara

tio

ns

atte

stin

g t

o t

he

inca

pac

ity

of

a p

atie

nt

for

hea

lth

rea

son

s b

ya

med

ical

bo

ard

to

EUR

50;

do

cto

rd

ecla

rati

on

s o

f ap

pea

l

Policy summary

60

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Port

ug

al(c

on

t.)

by

a m

edic

al b

oar

d t

oEU

R 1

00. T

his

mea

ns

that

a d

isab

led

per

son

wh

o w

ants

to

acc

ess

fisc

al b

enef

its

(pay

ing

less

inco

me

tax,

fo

rin

stan

ce, o

r p

ayin

g le

ssta

xes

wh

en b

uyi

ng

a

car

adap

ted

fo

rd

isab

led

peo

ple

), a

nd

for

wh

om

ask

ing

fo

r a

do

cto

r’s

dec

lara

tio

no

f ap

pea

l by

a m

edic

alb

oar

d is

man

dat

ory

to

acce

ss t

hes

e b

enef

its,

no

w h

as t

o p

ay m

uch

mo

re t

han

bef

ore

.

Stat

e su

bsi

dy

for

som

ep

har

mac

euti

cal d

rug

sw

as c

ance

lled

, to

tally

or

par

tial

ly: I

n 2

010,

a

law

wh

ich

gra

nte

d10

0% s

tate

su

bsi

dy

for

som

e an

ti-

dep

ress

ants

, an

ti-

psy

cho

tic

and

oth

erd

rug

s as

soci

ated

wit

hth

e tr

eatm

ent

of

afe

w s

erio

us

men

tal

illn

esse

s (s

uch

as

sch

izo

ph

ren

ia,

dem

enti

a, a

uti

sm,

bip

ola

r d

iso

rder

) w

as r

evo

ked

. Th

ose

pat

ien

ts n

ow

hav

e to

pay

5–1

0% o

f th

e co

st


61

of

trea

tmen

t. T

he

Ord

er o

f M

edic

alD

octo

rs o

ffic

ially

sta

ted

thei

r o

pp

osi

tio

n t

oth

e m

easu

re. F

rom

Jan

uar

y 20

11, 1

6 ty

pes

of

ph

arm

aceu

tica

ld

rug

s (f

or

wh

ich

med

ical

pre

scri

pti

on

was

no

t m

and

ato

ry)

wer

e n

o lo

ng

ersu

bsi

diz

ed, i

ncl

ud

ing

par

acet

amo

l, an

tiac

ids

and

an

tivi

rals

.

Rep

ub

lic o

fM

old

ova

Ther

e w

as a

red

uct

ion

of

6% in

GD

P in

200

9. T

he

hea

lth

bu

dg

et a

lso

fel

l in

this

yea

r. H

ow

ever

, th

e 20

10an

d 2

011

bu

dg

ets

wer

e n

ot

affe

cted

by

the

cris

is a

s th

eco

un

try’

s ec

on

om

yst

abili

zed

.

Ther

e w

as a

7%

incr

ease

in

tra

nsf

ers

fro

m t

he

stat

eb

ud

get

to

man

dat

ory

hea

lth

insu

ran

ce f

un

ds

in20

09 t

o c

om

pen

sate

fo

rfa

llin

g r

even

ues

fro

mp

ayro

ll ta

x.

The

rate

of

dis

cou

nt

incr

ease

d f

rom

50%

to

75

% r

edu

ctio

n o

f in

sura

nce

pre

miu

ms

for

fin

anci

ally

and

eco

no

mic

ally

vu

lner

able

ind

ivid

ual

s an

d s

oci

ally

dis

adva

nta

ged

cat

ego

ries

o

f se

lf-e

mp

loye

d, m

ost

lyfr

om

th

e co

un

trys

ide

and

the

agri

cult

ura

l sec

tor.

The

tari

ffs

for

med

ical

serv

ices

pro

vid

ed o

nth

e b

asis

of

ou

t-o

f-p

ock

et p

aym

ent

are

con

tro

lled

by

the

stat

ean

d a

re p

erio

dic

ally

revi

sed

dep

end

ing

on

cert

ain

mac

ro-e

cono

mic

crit

eria

. Ad

dit

ion

ally

,as

a m

easu

re t

oim

pro

ve f

inan

cial

ris

kp

rote

ctio

n, i

n 2

010,

the

Min

istr

y o

f H

ealt

hin

tro

du

ced

pri

celim

itat

ion

fo

r m

ost

imp

ort

ant

and

esse

nti

al d

rug

s an

dp

har

mac

euti

cals

imp

ort

ed a

nd

dis

trib

ute

d w

ith

inp

har

mac

ies

net

wo

rk.

Policy summary

62

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Ro

man

iaM

inis

try

of

Hea

lth

bu

dg

etre

du

ced

fro

m R

ON

4,9

69m

illio

n in

200

8 to

RO

N 4

,417

mill

ion

in 2

011.

Th

e h

ealt

hse

cto

r w

as p

rote

cted

inco

mp

aris

on

to

oth

er p

ub

licse

cto

rs in

ter

ms

of

bu

dg

etar

y cu

ts.

The

shri

nki

ng

eco

no

my

has

resu

lted

in lo

wer

leve

ls o

fco

ntr

ibu

tio

ns

of

emp

loye

rsan

d e

mp

loye

es t

o t

he

HIF

.Th

e g

ove

rnm

ent

inte

rven

edw

ith

su

bsi

die

s fr

om

th

e st

ate

bu

dg

et t

o t

he

HIF

in 2

009

and

201

0 to

co

ver

the

insu

rer’

s d

ebts

to

ph

arm

acie

san

d w

ho

lesa

lers

. In

201

0 th

esu

bsi

dy

amo

un

ted

to

ab

ou

t24

% o

f th

e to

tal h

ealt

hb

ud

get

. Nev

erth

eles

s, t

he

HIF

bu

dg

et d

ecre

ased

fro

mRO

N 1

6,77

5 m

illio

n in

200

8 to

RO

N 1

6,49

7 m

illio

n in

201

1.

Plan

s to

rai

se a

dd

itio

nal

fin

anci

al r

eso

urc

es (

bet

ter

colle

ctio

n o

f p

rem

ium

s,en

larg

emen

t o

f th

ep

rem

ium

co

llect

ion

bas

is b

yre

du

cin

g t

he

nu

mb

er o

f ta

xan

d c

on

trib

uti

on

exc

epti

on

s,b

ette

r m

anag

emen

t o

f th

esy

stem

) w

ere

ann

ou

nce

d in

2010

. Fro

m 1

Jan

uar

y 20

11,

pen

sio

ner

s w

ith

an

inco

me

of

ove

r R

ON

740

per

mo

nth

will

co

ntr

ibu

te 5

.5%

of

thei

rp

ensi

on

to

th

e H

IF.

New

use

r ch

arg

es

to b

e im

ple

men

ted

du

rin

g 2

011

incl

ud

edth

e fo

llow

ing

co

-p

aym

ents

: RO

N 5

fo

ra

visi

t to

a G

P, R

ON

15

for

a h

om

e vi

sit

by

aG

P, R

ON

10

for

on

ed

ay in

ho

spit

al, R

ON

50 f

or

con

tin

uo

us

ho

spit

aliz

atio

n f

or

seve

ral d

ays.

Th

em

axim

um

leve

l of

co-p

aym

ent

will

n

ot

exce

ed R

ON

600

per

ind

ivid

ual

per

ye

ar. T

he

law

on

co

-pay

men

ts a

lso

stip

ula

tes

exce

pti

on

s,su

ch a

s ve

tera

ns,

reti

red

per

son

s w

ith

less

th

an R

ON

700

inco

me

per

mo

nth

,ch

ildre

n, e

tc. I

n 2

010

a lim

it o

n t

he

nu

mb

ero

f re

imb

urs

ed v

isit

s to

a G

P an

d s

pec

ialis

tp

hys

icia

n f

or

the

sam

e co

nd

itio

n w

asin

tro

du

ced

fo

r th

efi

rst

tim

e: a

max

imu

mo

f fi

ve v

isit

s. In

201

1th

e m

axim

um

nu

mb

ero

f vi

sits

dec

reas

ed t

oth

ree.

If a

pat

ien

tw

ants

to

use

mor

e th

an


63

the

stat

ed n

um

ber

of

visi

ts s

/he

has

to

pay

ou

t o

f p

ock

et.

Ru

ssia

nFe

der

atio

nTh

ere

wer

e ex

pec

tati

on

s o

fsl

igh

t in

crea

se in

th

e h

ealt

hb

ud

get

in 2

011

and

inu

pco

min

g y

ears

du

e to

an

incr

ease

in c

om

pu

lso

ryh

ealt

h in

sura

nce

con

trib

uti

on

s. H

ow

ever

, it

is n

ot

clea

r h

ow

mu

chre

gio

nal

go

vern

men

ts

will

dec

reas

e h

ealt

h c

are

fun

din

g o

nce

gre

ater

fu

nd

s ar

e av

aila

ble

inin

sura

nce

sys

tem

.

New

law

on

hea

lth

insu

ran

ce p

rop

ose

d in

Jan

uar

y 20

11 a

nd

isex

pec

ted

to

be

pas

sed

inau

tum

n 2

012.

Th

e p

ayro

llC

om

pu

lso

ry M

edic

alIn

sura

nce

(C

MI)

tax

will

incr

ease

fro

m 3

.1%

to

5.

1%. T

he

reve

nu

e fr

om

th

ead

dit

ion

al t

wo

per

cen

tag

ep

oin

ts w

ill b

e ac

cum

ula

ted

in a

sp

ecia

l fu

nd

an

d

use

d f

or

the

Pres

iden

tial

pro

gra

mm

e o

f h

ealt

h c

are

mo

der

niz

atio

n c

on

sist

ing

o

f re

no

vati

on

of

faci

litie

s,st

and

ard

izat

ion

of

care

an

d in

form

atiz

atio

n.

A n

ew la

w t

o b

eco

me

op

erat

ion

al 2

012

will

leg

aliz

e o

ut-

of-

po

cket

fees

in s

tate

-ow

ned

faci

litie

s.

Serb

iaTh

e fi

nan

cial

cri

sis

has

red

uce

d t

he

volu

me

of

hea

lth

sec

tor

inve

stm

ents

sin

ce20

09, a

lth

ou

gh

th

ere

are

larg

e va

riat

ion

sin

th

e ch

ang

e in

inve

stm

ent

by

reg

ion

.Th

e Eu

rop

ean

Inve

stm

ent

Ban

k an

dW

orl

d B

ank

hav

eco

nti

nu

ed t

o p

rovi

de

fun

din

g, f

avo

ura

ble

loan

s, a

nd

sp

on

sore

do

ther

pro

ject

s.

Policy summary

64

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Slo

vaki

aD

ue

to a

dec

reas

e in

con

trib

uti

on

s fr

om

emp

loye

es a

nd

th

e se

lf-

emp

loye

d, t

he

rate

of

incr

ease

in h

ealt

h in

sura

nce

com

pan

ies’

(H

ICs)

rev

enu

esd

eclin

ed in

200

9 (i

t w

as o

nly

+2.

6%, c

om

par

ed t

o +

12.5

%in

200

8). H

IC r

even

ues

wer

ep

rote

cted

to

so

me

exte

nt

by

the

hig

h c

on

trib

uti

on

rate

by

the

stat

e fo

r th

eec

on

om

ical

ly in

acti

vep

op

ula

tio

n w

hic

h in

200

9w

as 4

.9%

of

the

aver

age

nat

ion

al in

com

e o

f th

ep

revi

ou

s tw

o y

ears

. Th

isre

sult

ed in

an

an

ti-c

yclic

alch

arac

ter

of

stat

e p

aym

ents

.

Wh

ile t

he

stat

e’s

con

trib

uti

on

rat

e fo

r th

e ec

on

om

ical

ly in

acti

vep

op

ula

tio

n h

as b

een

gra

du

ally

incr

easi

ng

sin

ce19

93 (

wh

en it

was

4%

) an

d r

each

ed 4

.9%

in 2

009,

in 2

010

the

go

vern

men

td

ecid

ed t

o r

edu

ce it

to

4.78

%.

Slo

ven

iaM

easu

res

ado

pte

d b

y th

eN

HIF

res

ult

ed in

to

tal

savi

ng

s o

f EU

R 1

35.9

mill

ion

in 2

009

and

EU

R 2

39 m

illio

nin

201

0.

In 2

009

the

NH

IF in

tro

du

ced

the

follo

win

g m

easu

res

to im

pro

ve c

olle

ctio

n o

fre

ven

ues

: mo

re in

ten

sive

coo

per

atio

n w

ith

th

e ta

xad

min

istr

atio

n; i

nvo

lvem

ent

of

add

itio

nal

inco

me

cate

go

ries

in c

om

pu

lso

ryco

ntr

ibu

tio

n s

chem

es

(e.g

. sel

f-em

plo

yed

entr

epre

neu

rs a

nd

inve

stin

gp

artn

ers

in c

om

pan

ies)

.

In 2

009

the

NH

IFin

tro

du

ced

ch

ang

es

trea

tmen

t, c

erta

inm

edic

ines

, no

n-

urg

ent

amb

ula

nce

serv

ices

, den

tal

pro

sth

esis

, cer

tain

op

hth

alm

olo

gic

alap

plia

nces

). A

s a

resu

lt,

a h

igh

er p

erce

nta

ge

of

cost

s is

pai

d by

pat

ient

s(m

ost

of

wh

om

are

sub

seq

uen

tly

reim

-b

urs

ed b

y vo

lun

tary

hea

lth

insu

ran

ce).


Spai

nTh

e h

ealt

h s

yste

m is

dec

entr

aliz

ed t

o t

he

leve

l o

f au

ton

om

ou

s re

gio

ns.

Th

ere

gio

ns

hav

e re

spo

nsi

bili

tyfo

r b

ud

get

s an

d a

pp

lyin

gco

st-c

on

tain

men

t m

easu

res.

To d

ate

the

on

ly r

egio

n t

hat

has

dra

fted

an

Act

ion

Pla

nfo

r b

uild

ing

su

stai

nab

ility

o

f th

e h

ealt

h s

yste

m is

Cat

alo

nia

(A

pri

l 201

1).

Un

der

th

e p

lan

, th

e 20

11h

ealt

h b

ud

get

is 1

0% lo

wer

com

par

ed t

o 2

010

(an

d,

in n

om

inal

ter

ms,

is e

qu

al

to t

he

2007

bu

dg

et).

Th

em

easu

res

are

just

ifie

d b

ased

on

th

e fo

llow

ing

init

ial

fin

anci

al s

itu

atio

n o

f th

eC

atal

an h

ealt

h s

yste

m:

bet

wee

n 2

003

and

201

0 th

e C

atal

an h

ealt

h b

ud

get

incr

ease

d b

y 76

.5%

an

d

the

def

icit

was

red

uce

d

by

EUR

2.6

1 m

illio

n.

Nev

erth

eles

s, 2

010

end

ed w

ith

a d

efic

it

of

EUR

850

mill

ion

.

65

Policy summary

66

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Swed

enIn

crea

sed

fu

nd

ing

(SE

K 7

bill

ion

) g

iven

by

the

stat

e to

mu

nic

ipal

itie

s/co

un

tyco

un

cils

in 2

009

toco

mp

ensa

te f

or

red

uce

dlo

cal t

ax r

even

ues

. Fro

m20

11 o

nw

ard

s th

e an

nu

alst

ate

gra

nts

are

incr

ease

db

y SE

K 5

bill

ion

. Ab

ou

t a

thir

d o

f th

ese

reve

nu

es

are

dir

ecte

d t

o t

he

cou

nty

cou

nci

ls, w

ho

se m

ain

expe

nses

con

cern

hea

lth

care

.

Swit

zerl

and

Du

e to

th

e fi

nan

cial

cri

sis,

HIF

s su

ffer

ed lo

sses

on

th

ein

vest

men

ts t

hey

mad

e w

ith

the

mo

ney

th

ey n

eed

to

hav

e in

res

erve

as

asse

ts;

to c

om

pen

sate

, pre

miu

ms

wo

uld

hav

e h

ad t

o b

e ra

ised

by

10–2

0% in

201

0 ra

ther

than

ab

ou

t 4%

as

in p

revi

ou

sye

ars.

As

a re

sult

, in

May

2009

th

e g

ove

rnm

ent

pro

po

sed

mea

sure

s to

low

erth

e h

ealt

h c

ost

s o

f h

ealt

hin

sure

rs. T

he g

over

nmen

t al

sop

lan

ned

to

incr

ease

pre

miu

msu

bsi

die

s fo

r lo

w-i

nco

me

ho

use

ho

lds

by

CH

F 20

0m

illio

n; h

ow

ever

aft

er m

any

deb

ates

bet

wee

n t

he

two

Ch

amb

ers

of

the

Swis

sPa

rlia

men

t th

ese

mea

sure

sw

ere

ult

imat

ely

refu

sed

in

A u

ser

char

ges

ref

orm

was

ag

reed

by

the

Parl

iam

ent

inSe

pte

mb

er 2

011:

th

eco

-in

sura

nce

rat

e w

asp

lan

ned

to

incr

ease

fro

m 1

0% t

o 1

5% f

or

peo

ple

wh

o o

pt

for

trad

itio

nal

pla

ns

(th

isen

cou

rag

es p

eop

le

to s

ub

scri

be

to a

man

aged

car

e m

od

elo

f in

sura

nce

).


Oct

ob

er 2

010.

Mea

sure

s to

red

uce

hea

lth

insu

rers

’ co

sts

wer

e in

stea

d in

tro

du

ced

in20

11 (

see

nex

t co

lum

n).

The

form

erYu

go

slav

Rep

ub

lic o

fM

aced

on

ia

Des

pit

e fl

uct

uat

ion

s in

fun

din

g f

or

dif

fere

nt

pri

ori

ty a

reas

, th

e h

ealt

hb

ud

get

was

incr

ease

d f

or

2010

, 201

1 an

d 2

012,

wit

hEU

R 2

1.8

mill

ion

allo

cate

dfo

r h

ealt

h in

th

e 20

10b

ud

get

, EU

R 3

4 m

illio

n in

2011

an

d E

UR

36

mill

ion

in20

12. A

rou

nd

70–

80%

of

the

2012

hea

lth

bu

dg

etin

crea

ses

are

for

med

ical

equ

ipm

ent

and

tec

hn

olo

gy.

Ove

rall,

du

rin

g t

he

cris

is,

fun

ds

for

soci

al s

afet

y n

ets

wer

e p

rote

cted

wh

ile n

on

-p

rio

rity

exp

end

itu

res

wer

eel

imin

ated

.

Hea

lth

car

e co

ntr

ibu

tio

ns

hav

e b

een

red

uce

d f

rom

9.2%

to

7.5

% in

200

9 an

d

a fu

rth

er r

edu

ctio

n t

o 6

%

in 2

011

was

pla

nn

ed in

ord

er t

o in

crea

se f

ore

ign

inve

stm

ents

an

d e

con

om

icac

tivi

ty a

s w

ell a

s ta

xco

llect

ion

.

Turk

eyTh

e M

inis

try

of

Hea

lth

bu

dg

et in

crea

sed

fro

m

TRY

11,

994

mill

ion

(20

08)

to T

RY 1

4,59

4 m

illio

n(2

009)

, bu

t o

nly

slig

htl

y in

2010

to

TRY

14,

768

mill

ion

.H

ealt

h e

xpen

dit

ure

as

ash

are

of

the

go

vern

men

tb

ud

get

ro

se in

200

9 b

ut

fell

slig

htl

y in

201

0 (1

2.8%

in 2

008,

12.

8% in

200

9).

Glo

bal

bu

dg

ets

for

ho

spit

als

hav

e in

crea

sed

eve

ry y

ear

thro

ug

h 2

011,

alt

ho

ug

h

In e

arly

201

0, h

ealt

h c

are

pay

men

ts o

n t

he

par

t o

fg

ove

rnm

ent

emp

loye

es

and

th

eir

dep

end

ants

w

ere

tran

sfer

red

fro

m t

he

Min

istr

y o

f Fi

nan

ce t

o t

he

Soci

al S

ecu

rity

Inst

itu

tio

n.

Co

-pay

men

t fo

ro

utp

atie

nt

visi

ts(e

xcep

t p

rim

ary

care

vis

its)

beg

an in

the

last

qu

arte

r o

f20

08. C

o-p

aym

ents

for

ou

tpat

ien

tm

edic

ines

an

dp

rost

hes

is/o

rth

oti

csw

ere

un

chan

ged

as

a re

sult

of

the

cris

is.

67

Policy summary

68

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Turk

ey (

con

t.)

wh

ile t

he

2009

(9%

) an

d20

10 (

17%

) b

ud

get

sin

crea

sed

at

a h

igh

rat

e,

the

2011

bu

dg

et w

as s

late

dto

incr

ease

at

a m

uch

slo

wer

rate

(1%

).

Ukr

ain

ePu

blic

exp

end

itu

re o

nh

ealt

h a

s a

pro

po

rtio

n o

fto

tal e

xpen

dit

ure

incr

ease

dan

nu

ally

bet

wee

n 2

003

and

2007

. Ho

wev

er, i

n 2

008

itb

egan

to

dec

reas

e: it

was

57.2

% in

200

8 an

d 5

4.9%

in

200

9, w

hic

h c

orr

esp

on

ds

wit

h t

he

low

est

ind

ex f

or

the

pas

t se

ven

yea

rs. T

he

shar

e o

f p

riva

te r

eso

urc

es

in h

ealt

h f

inan

cin

g in

200

8–20

09 r

each

ed 4

2.5%

an

d45

.1%

, mo

st o

f w

hic

h

(~94

%)

is in

dir

ect

pay

men

tso

f h

ou

seh

old

s (o

ut

of

po

cket

).

Sin

ce 2

010

the

nat

ion

alb

ud

get

has

no

t b

een

set

ann

ual

ly, b

ut

is g

ove

rned

by

gen

eral

law

“Th

e B

ud

get

Co

de

of

Ukr

ain

e”. T

he

law

det

erm

ines

th

at t

he

amo

un

to

f p

rote

cted

exp

end

itu

res

can

no

t b

e ch

ang

ed b

yre

du

cin

g t

he

app

rove

db

ud

get

allo

cati

on

s. T

he

list

of

such

exp

end

itu

res

was

An

SH

I sys

tem

is

no

t u

sed

in U

krai

ne.

Ho

wev

er, s

ince

200

0,U

krai

ne

has

had

a

pro

gra

mm

e o

fvo

lun

tary

med

ical

insu

ran

ce f

or

railw

ay w

ork

ers.

Th

e p

rem

ium

s fo

rvo

lun

tary

hea

lth

insu

ran

ce in

crea

sed

du

rin

g t

he

cris

is:

in 2

007–

2008

th

em

on

thly

co

ntr

ibu

tio

nw

as U

AH

16

(UA

H 8

each

fro

m e

mp

loye

ean

d e

mp

loye

r); i

n20

09 it

was

UA

H 2

4(a

gai

n s

plit

eq

ual

lyb

etw

een

em

plo

yee

and

em

plo

yer)

; fro

mSe

pte

mb

er 2

010

itw

as U

AH

32

(UA

H 2

0fr

om

th

e em

plo

yee

and

UA

H 1

2 fr

om

th

e em

plo

yer)

. Th

ep

rem

ium

incr

ease

is

pri

mar

ily d

ue

to


sig

nif

ican

tly

exp

and

ed a

nd

incl

ud

es: s

alar

ies

of

staf

fd

ealin

g w

ith

th

e b

ud

get

,d

rug

s an

d b

and

agin

gm

ater

ial p

rocu

rem

ent,

fo

od

pro

visi

on

, uti

litie

s an

d e

lect

rici

ty o

f fa

cilit

ies,

serv

icin

g t

he

stat

e d

ebt,

curr

ent

tran

sfer

s to

th

ep

op

ula

tio

n, c

urr

ent

tran

sfer

s to

loca

l bu

dg

ets,

fun

din

g in

stit

uti

on

s o

fh

igh

er e

du

cati

on

of

I–IV

accr

edit

atio

n le

vels

,p

rovi

din

g t

he

dis

able

d

wit

h t

ech

nic

al a

nd

oth

erre

hab

ilita

tio

n it

ems,

med

ical

pro

du

cts

for

per

son

al u

se, b

asic

res

earc

h,

app

lied

res

earc

h a

nd

tech

no

log

ical

dev

elo

pm

ent.

a sh

arp

ris

e in

th

ep

rice

of

dru

gs.

Info

rmal

pay

men

tsp

er c

apit

a (e

xclu

din

gco

sts

of

dru

gs

pu

rch

asin

g)

incr

ease

d b

y 70

%(f

rom

UA

H 9

4.4

in20

08 t

o U

AH

153

.6

in 2

009)

.

Un

ited

Kin

gd

om

(En

gla

nd

)

Aft

er y

ears

of

unpr

eced

ente

db

ud

get

gro

wth

(6.

6% p

erye

ar in

199

9–20

07),

th

e N

HS

has

en

tere

d a

new

era

of

aust

erit

y. In

Oct

ob

er 2

010

the

Dep

artm

ent

of

Hea

lth

pu

blis

hed

th

e Sp

end

ing

Rev

iew

set

tlem

ent

for

the

NH

S w

hic

h in

volv

es a

nav

erag

e 0.

1% r

eal t

erm

sin

crea

se o

ver

the

nex

t fo

ur

year

s an

d a

req

uir

emen

t to

fin

d u

p t

o G

BP

5 b

illio

np

rod

uct

ivit

y im

pro

vem

ents

a ye

ar t

hro

ug

h t

o 2

014/

2015

to m

eet

incr

ease

d d

eman

d

The

rece

ssio

n h

asre

sult

ed in

are

du

ctio

n in

exp

ecte

d r

ecei

pts

and

a li

mit

ed in

crea

sein

dis

cret

ion

ary

spen

din

g in

200

9–20

10 c

om

par

ed w

ith

pre

vio

us

year

s.C

on

seq

uen

tly,

wh

erea

s p

lan

ned

tota

l go

vern

men

tre

ceip

ts f

or

2008

–20

09 w

ere

GB

P 57

5b

illio

n, j

ust

GB

P 53

3.8

A p

rog

ram

me

toex

pan

d t

he

ran

ge

of

lon

g-t

erm

co

nd

itio

ns

that

ben

efit

fro

m

free

pre

scri

pti

on

s w

asan

no

un

ced

by

the

pre

vio

us

go

vern

men

tb

ut

no

t im

ple

men

ted

;th

is w

ill n

ow

no

lon

ger

be

take

nfo

rwar

d.

69

Policy summary

70

Co

un

try

Hea

lth

bu

dg

etFi

scal

po

licy

SHI c

on

trib

uti

on

sU

ser

char

ges

Oth

er

Un

ited

Kin

gd

om

(En

gla

nd

)(c

on

t.)

and

imp

rove

th

e q

ual

ity

of

its

serv

ices

.

Ove

rall,

NH

S sp

end

ing

will

incr

ease

by

0.4%

in r

eal

term

s o

ver

the

cou

rse

of

the

Spen

din

g R

evie

wp

erio

d; t

his

is t

he

low

est

incr

ease

sin

ce t

he

1950

s.H

ow

ever

, acc

ord

ing

to

m

any

com

men

tato

rs, t

he

Spen

din

g R

evie

w p

lan

s fo

rth

e N

HS

amo

un

t to

a d

efa

cto

cu

t in

NH

S sp

end

ing

inre

al t

erm

s. M

anag

ers

of

NH

So

rgan

izat

ion

s n

ow

hav

e to

pla

n f

or

wh

at, i

n e

ffec

t,am

ou

nts

to

a 2

0–30

%re

du

ctio

n in

NH

S sp

end

ing

for

the

five

-yea

r p

erio

dfr

om

201

1.

To m

eet

the

risi

ng

co

sts

of

hea

lth

car

e an

d in

crea

sin

gd

eman

d o

n it

s se

rvic

es, t

he

NH

S w

ill h

ave

to r

elea

se u

pto

GB

P 20

bill

ion

of

ann

ual

effi

cien

cy s

avin

gs

ove

r th

en

ext

fou

r ye

ars,

all

of

wh

ich

will

be

rein

vest

ed t

o m

eet

risi

ng

leve

ls o

f d

eman

d a

nd

to s

up

po

rt im

pro

vem

ents

inq

ual

ity

and

ou

tco

mes

.

bill

ion

was

rai

sed

. It

is e

stim

ated

th

atth

ere

was

a f

urt

her

red

uct

ion

in t

ota

lre

ceip

ts in

200

9–20

10to

GB

P 51

4.6

bill

ion

,o

f w

hic

h G

BP

95.6

bill

ion

was

gen

erat

ed f

rom

Nat

ion

al In

sura

nce

Co

ntr

ibu

tio

ns,

G

BP

145.

6 b

illio

nfr

om

inco

me

tax

and

the

rest

fro

m a

ran

ge

of

taxe

s, in

clu

din

gco

rpo

rati

on

, exc

ise,

VA

T an

d p

rop

erty

rate

s (c

ou

nci

l tax

an

d b

usi

nes

s ra

tes)

.

Uzb

ekis

tan


Tab

le A

.2. P

olic

ies

targ

etin

g v

olu

me

and

qu

alit

y o

f ca

re in

th

e co

nte

xt o

f th

e ec

on

om

ic c

risi

s, W

HO

Eu

rop

ean

Reg

ion

No

tes:

No

info

rmat

ion

was

ava

ilabl

e fo

r A

ndor

ra, K

azak

hsta

n, L

uxem

bour

g, M

onac

o, M

onte

negr

o, S

an M

arin

o, T

ajik

ista

n an

d Tu

rkm

enis

tan.

Text

not

in it

alic

s in

dica

tes

a po

licy

whi

ch w

as d

efin

ed b

y th

e re

leva

nt a

utho

ritie

s in

the

cou

ntry

as

a re

spon

se t

o th

e cr

isis

. Tex

t in

ital

ics

indi

cate

s a

polic

y w

hich

was

eith

er p

artia

lly a

res

pons

e to

the

cris

is, t

hat

is, i

t w

as p

lann

ed b

efor

e th

e cr

isis

but

impl

emen

ted

afte

r w

ithgr

eate

r/le

ss s

peed

/inte

nsity

tha

n pl

anne

d; o

r po

ssib

ly a

res

pons

e to

the

cris

is, t

hat

is, i

t w

as p

lann

ed a

nd im

plem

ente

d si

nce

the

star

t of

the

cris

is, b

ut n

ot d

efin

ed b

y th

e re

leva

nt a

utho

ritie

s as

a r

espo

nse

to t

he c

risis

. A b

lank

cel

l ind

icat

es n

o po

licy

resp

onse

to

the

cris

is (n

ot n

ore

spon

se t

o th

e su

rvey

).

Co

un

try

Ben

efit

s (c

ove

rag

e sc

op

e)Po

pu

lati

on

co

vera

ge

(co

vera

ge

bre

adth

)N

on

-pri

ce r

atio

nin

g(w

aiti

ng

tim

es)

Ch

ang

ing

ind

ivid

ual

s’b

ehav

iou

r (h

ealt

h p

rom

oti

on

and

pre

ven

tio

n)

Alb

ania

Arm

enia

Au

stri

a

Aze

rbai

jan

Bel

aru

sFr

om

200

9, c

itiz

ens

wit

h r

adia

tio

nsi

ckn

ess

as w

ell a

s ce

rtai

n d

isab

led

peo

ple

hav

e th

e ri

gh

t to

a 9

0%re

du

ctio

n in

th

e p

rice

of

med

icin

esp

resc

rib

ed b

y a

ph

ysic

ian

. Cit

izen

s w

ith

su

rgic

al d

isea

ses

also

hav

e th

eri

gh

t to

a 9

0% r

edu

ctio

n in

th

e p

rice

o

f b

and

agin

g m

ater

ials

.

Bel

giu

mSo

me

emp

has

is s

et o

n c

ance

rsc

reen

ing

, pro

mo

tio

n o

fh

ealt

h f

oo

d, p

hys

ical

act

ivit

yan

d p

reve

nti

on

of

fata

lac

cid

ents

sin

ce 2

007.

71

Policy summary

72

Co

un

try

Ben

efit

s (c

ove

rag

e sc

op

e)Po

pu

lati

on

co

vera

ge

(co

vera

ge

bre

adth

)N

on

-pri

ce r

atio

nin

g(w

aiti

ng

tim

es)

Ch

ang

ing

ind

ivid

ual

s’b

ehav

iou

r (h

ealt

h p

rom

oti

on

and

pre

ven

tio

n)

Bo

snia

an

dH

erze

go

vin

aSi

nce

th

e st

art

of

the

cris

is, a

list

of

esse

nti

al d

rug

s th

at a

re p

rovi

ded

fre

eo

f ch

arg

e b

y th

e C

HIF

has

bee

n c

reat

ed.

Sin

ce t

he

star

t o

f th

e cr

isis

,am

end

men

ts t

o t

he

Law

on

Hea

lth

Insu

ran

ce p

rovi

ded

cove

rag

e fo

r ch

ildre

n (

even

if

th

eir

par

ents

do

no

t h

ave

cove

rag

e), t

ho

se o

ver

65 y

ears

of

age

and

th

e u

nin

sure

d.

The

Law

on

Hea

lth

Insu

ran

cew

as r

evis

ed a

s p

art

of

gen

eral

refo

rms,

bu

t vu

lner

able

gro

up

sb

ecam

e a

foca

l po

int

as a

resu

lt o

f th

e cr

isis

. Ho

wev

er,

a la

ck o

f re

liab

le s

ou

rces

of

fun

din

g h

as le

d t

o d

iffi

cult

ies

in im

ple

men

tin

g t

he

law

.

In 2

008

and

200

9, m

edia

cam

pai

gn

s an

d o

ther

hea

lth

pro

mo

tio

n a

nd

pre

ven

tio

nac

tivi

ties

wer

e ai

med

at

imp

rovi

ng

po

pu

lati

on

hea

lth

by

advo

cati

ng

hea

lth

ier

lifes

tyle

s. T

hes

e ca

mp

aig

ns

hav

e al

so p

rovi

ded

th

e p

ub

licw

ith

info

rmat

ion

on

hea

lth

sect

or

refo

rms.

Bu

lgar

iaTh

e M

inis

try

of

Hea

lth

is p

lan

nin

g

to d

evel

op

a p

osi

tive

list

of

med

ical

dev

ices

(si

mila

r to

th

e p

osi

tive

list

o

f d

rug

s).

Wit

h t

he

amen

dm

ent

of

the

Hea

lth

Act

in 2

010

tob

acco

smo

kin

g w

as p

roh

ibit

ed in

ind

oo

r p

ub

lic p

lace

s ex

cep

tis

ola

ted

“sm

oki

ng

ro

om

s”.

In c

afes

an

d r

esta

ura

nts

wit

har

ea o

f le

ss t

han

50

sq. m

, th

e o

wn

er c

an c

ho

ose

if t

he

wh

ole

est

ablis

hm

ent

is f

or

smo

kers

or

no

n-s

mo

kers

.B

ecau

se o

f th

e cr

isis

(res

tau

ran

ts’ f

inan

cial

pro

ble

ms)

th

e g

ove

rnm

ent

dec

ided

to

po

stp

on

e fu

llp

roh

ibit

ion

. In

200

9 th

eg

ove

rnm

ent

incr

ease

d t

he

pri

ce o

f ci

gar

ette

s b

y 25

%,

and

in 2

010

by

38%

.


Cro

atia

Imp

rove

men

ts in

ph

arm

aceu

tica

lp

rici

ng

an

d r

eim

bu

rsem

ent

gen

erat

edsa

vin

gs

wh

ich

mad

e it

po

ssib

le t

o a

dd

64 n

ew d

rug

s to

th

e b

enef

it li

st a

t th

een

d o

f 20

10.

Cyp

rus

In 2

011

the

go

vern

men

t m

ade

the

deci

sion

to

agai

n po

stpo

neth

e im

ple

men

tati

on

of

the

new

Nat

ion

al H

ealt

h In

sura

nce

syst

em. C

ypru

s, w

hic

h d

oes

no

th

ave

a h

ealt

h c

are

syst

em t

hat

off

ers

un

iver

sal c

ove

rag

e, in

1991

vo

ted

fo

r th

e la

w t

hat

wo

uld

cre

ate

a n

ew N

atio

nal

Hea

lth

Insu

ran

ce S

chem

e b

ut

this

has

no

t b

een

imp

lem

ente

dto

dat

e. A

cco

rdin

g t

o M

inis

try

of

Hea

lth

est

imat

es, i

n 2

007

83%

of

the

po

pu

lati

on

had

com

pre

hen

sive

co

vera

ge

free

of

char

ge

at t

he

po

int

of

serv

ice.

Th

e re

st o

f th

ep

op

ula

tio

n h

as a

cces

s to

p

ub

lic h

ealt

h s

ervi

ces

eith

er

on

red

uce

d o

r fu

ll ra

tes

(2%

and

15%

of

the

po

pu

lati

on

,re

spec

tive

ly).

73

Policy summary

74

Co

un

try

Ben

efit

s (c

ove

rag

e sc

op

e)Po

pu

lati

on

co

vera

ge

(co

vera

ge

bre

adth

)N

on

-pri

ce r

atio

nin

g(w

aiti

ng

tim

es)

Ch

ang

ing

ind

ivid

ual

s’b

ehav

iou

r (h

ealt

h p

rom

oti

on

and

pre

ven

tio

n)

Cze

ch R

epu

blic

Th

e b

asic

ben

efit

pac

kag

e an

d li

st o

fre

imb

urs

ed s

ervi

ces

will

be

asse

ssed

fro

m t

he

per

spec

tive

of

hea

lth

tech

no

log

y as

sess

men

t (u

sin

g e

vid

ence

fro

m a

bro

ad)

in 2

012/

2013

. In

form

atio

nto

pat

ien

ts o

n w

hic

h s

ervi

ces

are

reim

bu

rsed

will

be

imp

rove

d in

201

2.Th

is m

ay r

esu

lt in

a r

eallo

cati

on

of

pu

blic

an

d p

riva

te e

xpen

dit

ure

.M

and

ato

ry u

se o

f p

osi

tive

list

s o

f d

rug

s fo

r M

inis

try

of

Hea

lth

pro

vid

ers

(un

iver

sity

ho

spit

als,

rep

rese

nti

ng

50%

of

the

mar

ket)

intr

od

uce

d in

201

1(p

revi

ou

sly

the

list

was

vo

lun

tary

).Fu

rth

er li

sts

pla

nn

ed f

or

2012

.

Enti

tlem

ent

to p

ub

licly

fin

ance

d c

ove

rag

e fo

r h

igh

-ris

k co

nd

itio

ns

red

uce

dfo

r fo

reig

n c

itiz

ens

and

resp

on

sib

ility

fo

r co

vera

ge

tran

sfer

red

to

pri

vate

insu

ran

ce in

201

1 (r

esu

ltin

g

in h

igh

er p

rem

ium

s fo

r fo

reig

n c

itiz

ens)

.

Co

nsu

mp

tio

n t

axes

incr

ease

(to

bac

co, a

lco

ho

l) p

lan

ned

fo

r 20

12.

Den

mar

k

Esto

nia

EHIF

red

uce

d t

he

ben

efit

pac

kag

e in

tw

o w

ays.

Fir

st, t

he

syst

em f

or

tem

po

rary

sic

k le

ave

ben

efit

s w

asre

form

ed. F

rom

1 J

uly

200

9 n

o b

enef

itis

pai

d d

uri

ng

th

e fi

rst

thre

e d

ays

of

sick

nes

s o

r in

jury

(p

revi

ou

sly

firs

t d

ayo

nly

), t

he

emp

loye

r p

ays

the

ben

efit

fro

m d

ay f

ou

r to

day

eig

ht

(new

co

st-

shar

ing

mec

han

ism

, em

plo

yer

did

no

tp

arti

cip

ate

pre

vio

usl

y) a

nd

th

e EH

IFst

arts

to

pay

th

e b

enef

it f

rom

day

nin

e(p

revi

ou

sly

fro

m d

ay t

wo

). T

he

rate

of

sick

nes

s b

enef

it w

as r

edu

ced

fro

m 8

0%to

70%

of

the

insu

red

per

son

’s in

com

e.Th

e ra

te o

f si

ckn

ess

ben

efit

in t

he

case

of

cari

ng

fo

r a

child

un

der

12

year

s o

f

Max

imu

m w

aiti

ng

tim

es f

or

ou

tpat

ien

tsp

ecia

lists

’ vis

its

incr

ease

d in

Mar

ch20

09 b

y th

e d

ecis

ion

of

the

EHIF

su

per

viso

ryb

oar

d f

rom

fo

ur

to

six

wee

ks.

VA

T o

n a

lco

ho

l in

crea

sin

gsi

nce

200

5 b

ut

gre

ates

t ri

sew

as in

200

8 an

d t

ob

acco

VA

Tin

crea

sin

g s

ince

201

1.


age

was

red

uce

d f

rom

100

% t

o 8

0%.

The

max

imu

m le

ng

th o

f m

ater

nit

yle

ave

was

red

uce

d f

rom

154

day

s to

140

day

s. E

xpec

ted

sav

ing

: EEK

50

mill

ion

. Sec

on

d, u

nti

l 1 J

anu

ary

2009

al

l in

sure

d p

erso

ns

of

at le

ast

19 y

ears

of

age

cou

ld a

pp

ly f

or

the

den

tal c

are

ben

efit

of

EEK

300

(EU

R 1

9.18

), b

ut

fro

m 2

009,

on

ly in

sure

d p

erso

ns

ove

r63

yea

rs o

f ag

e an

d p

erso

ns

elig

ible

fo

r a

pen

sio

n f

or

inca

pac

ity

for

wo

rk

or

an o

ld-a

ge

pen

sio

n r

etai

ned

th

isri

gh

t. E

xpec

ted

sav

ing

: EEK

4 m

illio

n.

The

Min

istr

y o

f So

cial

Aff

airs

was

dev

elo

pin

g a

co

mp

reh

ensi

ve h

ealt

hte

chn

olo

gy

asse

ssm

ent

syst

em in

201

1w

ith

th

e h

elp

of

Tart

u U

niv

ersi

ty.

Fin

lan

d

Fran

ceLe

Rev

enu

Min

imu

m d

’Inse

rtio

n(R

MI)

or

bas

ic b

enef

it w

asre

pla

ced

in J

un

e 20

09 b

y th

eR

even

u d

e So

lidar

ité

Act

ive

(RSA

), r

esu

ltin

g in

an

incr

ease

in t

he

nu

mb

er o

f o

vera

llre

cip

ien

ts. W

ith

th

is c

han

ge,

ben

efic

iari

es o

f th

e n

ew R

SAau

tom

atic

ally

hav

e th

e ri

gh

t to

rec

eive

sta

te-f

un

ded

C

MU

(C

ou

vert

ure

Mal

adie

Un

iver

selle

) –

un

iver

sal

hea

lth

insu

ran

ce –

an

dco

mp

lem

enta

ry in

sura

nce

CM

U-C

.

Fro

m 2

011,

tax

on

to

bac

co w

illin

crea

se b

y 6%

.

Ger

man

y

75

Policy summary

76

Co

un

try

Ben

efit

s (c

ove

rag

e sc

op

e)Po

pu

lati

on

co

vera

ge

(co

vera

ge

bre

adth

)N

on

-pri

ce r

atio

nin

g(w

aiti

ng

tim

es)

Ch

ang

ing

ind

ivid

ual

s’b

ehav

iou

r (h

ealt

h p

rom

oti

on

and

pre

ven

tio

n)

Geo

rgia

Stat

e fu

nd

ing

fo

r in

sura

nce

cove

rag

e fo

r ce

rtai

n g

rou

ps

of

pu

blic

em

plo

yees

(te

ach

ers,

po

lice

forc

e an

d m

ilita

ry),

an

da

stat

e-su

bsi

diz

ed p

rog

ram

me

for

low

-inco

me

fam

ilies

(Med

ical

Insu

ran

ce f

or

the

Poo

r) w

ere

intr

od

uce

d (

2007

an

d 2

008

resp

ecti

vely

). T

his

was

acco

mp

anie

d b

y in

terv

enti

on

sto

incr

ease

aw

aren

ess

amo

ng

po

or

peo

ple

ab

ou

t su

bsi

diz

edh

ealt

h in

sura

nce

. In

201

0 M

IPco

vere

d 2

1% o

f p

op

ula

tio

n,

wh

ile in

200

7 o

nly

385

000

o

r 8.

8% h

ad t

his

insu

ran

ce.

An

exp

ansi

on

of

the

po

pu

lati

on

co

vere

d u

nd

erin

sura

nce

is e

xpec

ted

in 2

012

–ta

rget

ing

mo

stly

th

e el

der

lyan

d t

he

you

ng

.

Gre

ece

Un

ific

atio

n o

f b

enef

it p

acka

ges

am

on

gth

e va

rio

us

SHI f

un

ds

(in

Ju

ne

2011

).Fr

om

201

1, t

he

po

or

and

un

insu

red

are

on

ly a

llow

ed

to b

e tr

eate

d in

des

ign

ated

ho

spit

als

and

pre

scri

bed

gen

eric

s.

The

Mem

ora

nd

um

imp

ose

s a

limit

of

no

mo

re t

han

tw

om

on

ths

for

sub

mit

tin

g a

nin

voic

e fo

r re

imb

urs

emen

t fo

r h

osp

ital

ch

arg

es t

o s

oci

alin

sura

nce

fu

nd

s in

Gre

ece

as

For

the

per

iod

200

8–20

12,

hea

lth

pro

mo

tio

n in

itia

tive

s:ca

rdio

vasc

ula

r, ca

nce

r, o

bes

ity,

nu

trit

ion

, ora

l hea

lth

,m

ater

nal

an

d c

hild

hea

lth

,in

clu

din

g a

sm

oki

ng

law

ban

.


wel

l as

oth

er E

U M

emb

erSt

ates

an

d p

riva

te H

ICs

for

no

n-n

atio

nal

s an

d n

on

-p

erm

anen

t re

sid

ents

.

Hu

ng

ary

In 2

009

sick

-pay

ben

efit

s w

ere

red

uce

d.

Prev

iou

sly

the

HIF

co

uld

pro

vid

e si

ck-

pay

fo

r u

p t

o o

ne

year

fo

r em

plo

yees

wit

h v

alid

insu

ran

ce. W

ith

ou

t in

sura

nce

it w

as o

nly

45

day

s. T

his

ch

ang

ed t

o

30 d

ays.

Wit

h a

min

imu

m t

wo

-yea

rp

erio

d o

f in

sura

nce

th

e am

ou

nt

was

70%

of

inco

me.

In c

ase

of

a sh

ort

erin

sura

nce

per

iod

or

inp

atie

nt

care

itw

as 6

0%. A

fter

th

e m

od

ific

atio

n t

hes

ew

ere

dec

reas

ed t

o 6

0% a

nd

50%

.

Icel

and

To m

inim

ize

the

effe

ct o

f th

e cr

isis

an

dcu

ts in

exp

end

itu

re o

n h

ealt

h s

ervi

ces,

a d

ocu

men

t w

as p

ub

lish

ed in

ear

ly 2

009

focu

sin

g o

n p

ub

lic h

ealt

h, e

qu

ity,

an

dla

bo

ur

issu

es. A

nu

mb

er o

f ac

tio

ns

hav

eb

een

tak

en a

s a

resu

lt, s

uch

as

pro

vid

ing

acce

ss t

o d

enta

l car

e fr

ee o

f ch

arg

e fo

rlo

w-i

nco

me

fam

ilies

sin

ce 2

009.

Ther

e h

as b

een

incr

ease

d e

mp

has

is

on

occ

up

atio

nal

reh

abili

tati

on

by

the

Icel

and

ic R

ehab

ilita

tio

n F

un

d t

osy

stem

atic

ally

dec

reas

e th

e p

rob

abili

tyo

f em

plo

yees

losi

ng

th

eir

job

s d

ue

toin

cap

acit

y an

d s

ickn

ess.

To

th

is e

nd

, th

e Ic

elan

dic

Reh

abili

tati

on

Fu

nd

w

as e

stab

lish

ed in

200

8 to

pro

vid

eco

nsu

ltin

g s

ervi

ces

to e

mp

loye

es w

ho

are

on

ext

end

ed s

ick

leav

e so

th

ey d

on

ot

lose

th

eir

job

s. S

ince

th

e fi

nan

cial

cris

is, a

ctiv

ity

at t

he

fun

d h

as in

crea

sed

.

77

Policy summary

78

Co

un

try

Ben

efit

s (c

ove

rag

e sc

op

e)Po

pu

lati

on

co

vera

ge

(co

vera

ge

bre

adth

)N

on

-pri

ce r

atio

nin

g(w

aiti

ng

tim

es)

Ch

ang

ing

ind

ivid

ual

s’b

ehav

iou

r (h

ealt

h p

rom

oti

on

and

pre

ven

tio

n)

Irel

and

Fro

m 2

010,

a c

ut

of

EUR

30

mill

ion

to

den

tal c

are

for

med

ical

car

d h

old

ers.

Fro

m 2

009,

rem

ova

l of

med

ical

card

s fo

r th

e 12

100

wea

lth

iest

(3.4

%)

peo

ple

ag

ed o

ver

70.

Med

ical

car

ds

con

fer

free

acc

ess

to G

Ps a

nd

wai

ve h

osp

ital

inp

atie

nt

fees

fo

r th

ose

un

der

cert

ain

inco

me

thre

sho

lds.

New

go

vern

men

t el

ecte

d in

2011

has

pro

po

sed

a u

niv

ersa

lh

ealt

h in

sura

nce

sys

tem

.

Isra

el

Ital

y

Kyr

gyz

stan

Latv

iaA

n e

arly

can

cer

det

ecti

on

(cer

vica

l an

d b

reas

t ca

nce

r)p

rog

ram

me

star

ted

in 2

009.

Lith

uan

iaIn

200

9 so

me

chan

ges

wer

e im

plem

ente

dre

du

cin

g p

aym

ent

of

illn

ess

ben

efit

,w

hic

h is

pai

d f

or

soci

ally

insu

red

tem

po

rari

ly s

ick

peo

ple

fro

m t

he

Soci

alIn

sura

nce

Fu

nd

. Fo

r ex

amp

le, p

revi

ou

sly

illn

ess

ben

efit

was

85%

of

the

sala

ry o

fa

soci

ally

insu

red

per

son

in t

he

maj

ori

tyo

f ca

ses.

Aft

er t

he

chan

ges

wer

eim

ple

men

ted

, du

rin

g t

he

firs

t se

ven

day

sill

nes

s b

enef

it is

on

ly 4

0% o

f sa

lary

an

d,

afte

r th

e ei

gh

th d

ay, 8

0% o

f th

e sa

lary

.


Mal

ta

Net

her

lan

ds

Fro

m 2

010,

lim

ited

rei

mb

urs

emen

t fo

rIV

F; p

hys

io s

essi

on

s to

be

pai

d f

or

by

the

pat

ien

t in

crea

sed

to

15;

co

vera

ge

of

care

ou

tsid

e th

e EU

rem

ove

d a

nd

req

uir

es b

ilate

ral a

dju

stm

ents

wit

hce

rtai

n c

ou

ntr

ies;

men

tal h

ealt

hse

rvic

es r

estr

icte

d a

nd

psy

cho

log

ical

care

rei

mb

urs

emen

t re

du

ced

fro

mei

gh

t to

fiv

e se

ssio

ns.

No

rway

Pola

nd

Port

ug

alFr

om

201

1, t

he

follo

win

g h

ealt

hse

rvic

es u

nd

er A

DSE

(th

e h

ealt

h s

yste

mfo

r p

ub

lic s

ecto

r w

ork

ers)

will

cea

se t

ob

e co

vere

d: s

ervi

ces

reg

ard

ing

wo

rkin

gac

cid

ents

an

d p

rofe

ssio

nal

dis

ease

s,cl

inic

al t

rial

s, u

nco

nve

nti

on

alth

erap

euti

cs a

nd

aes

thet

ic s

urg

ery.

AD

SE r

efor

m in

201

1: b

enef

itin

gfr

om

AD

SE b

eco

mes

op

tio

nal

.B

elo

ng

ing

to

th

is s

yste

m w

asal

read

y o

pti

on

al f

or

wo

rker

sen

teri

ng

pu

blic

ad

min

istr

atio

nfr

om

200

6, b

ut

un

til n

ow

was

still

man

dat

ory

fo

r w

ork

ers

wh

o h

ad e

nte

red

pu

blic

adm

inis

trat

ion

bef

ore

200

6.Sp

ecia

lists

th

ink

that

few

peo

ple

will

leav

e A

DSE

.

79

Policy summary

80

Co

un

try

Ben

efit

s (c

ove

rag

e sc

op

e)Po

pu

lati

on

co

vera

ge

(co

vera

ge

bre

adth

)N

on

-pri

ce r

atio

nin

g(w

aiti

ng

tim

es)

Ch

ang

ing

ind

ivid

ual

s’b

ehav

iou

r (h

ealt

h p

rom

oti

on

and

pre

ven

tio

n)

Rep

ub

lic o

fM

old

ova

In 2

009

pri

mar

y h

ealt

h c

are

rece

ived

pri

ori

ty f

inan

cin

g f

rom

man

dat

ory

HIF

s,in

crea

sin

g t

he

com

pen

sate

d m

edic

ines

spec

tru

m a

nd

intr

od

uci

ng

gen

eric

dru

gs

aim

ed a

t tr

eati

ng

th

e m

ost

imp

ort

ant

dis

ease

s re

late

d t

o t

he

dis

ease

bu

rden

and

pu

blic

hea

lth

ris

ks.

The

hea

lth

car

e b

enef

it p

acka

ge

for

the

un

insu

red

was

ext

end

ed t

o t

he

pro

visi

on

of

emer

gen

cy c

are

and

fu

ll co

vera

ge

of

pri

mar

y ca

re, i

ncl

ud

ing

co

mp

ensa

ted

reim

bu

rsed

med

icin

es f

or

ou

tpat

ien

tca

re. (

Prev

iou

sly

all u

nin

sure

d c

itiz

ens

had

the

righ

t on

ly t

o cl

inic

al e

xam

inat

ion

wit

h r

eco

mm

end

atio

ns

for

asse

ssm

ent

and

tre

atm

ent

at t

he

pri

mar

y ca

rele

vel.)

Sin

ce 2

010,

ho

wev

er, t

he

leve

l of

com

pen

sate

d d

rug

s h

as b

een

red

uce

d.

Esse

nti

ally

th

is n

ew le

gis

lati

on

was

no

tb

acke

d u

p w

ith

ad

dit

ion

al b

ud

get

.

In 2

009

ther

e w

as a

rev

iew

of

Nat

ion

alH

ealt

h P

rog

ram

mes

res

ult

ing

in a

nex

ten

sio

n o

f th

e lis

t o

f p

rofi

le d

isea

ses

and

of

resp

ecti

ve p

atie

nt

cate

go

ries

.

Du

rin

g 2

009

and

201

0, t

he

Min

istr

y of

Hea

lth

in c

oope

rati

onw

ith

Nat

ion

al H

ealt

h In

sura

nce

Co

mp

any

mad

e se

vera

l am

end

-m

ents

to

th

e La

w o

n M

HI.

The

law

no

w e

nsu

res

that

mem

ber

so

f h

ou

seh

old

s el

igib

le f

or

soci

alb

enef

its

will

au

tom

atic

ally

be

insu

red

wit

h t

he

MH

I sys

tem

and

rec

eive

fu

lly s

ub

sid

ized

hea

lth

insu

ran

ce. T

wo

add

itio

nal

gro

up

s o

f p

erso

ns

wer

e al

so g

ran

ted

insu

ran

ce in

MH

I: m

oth

ers

of

fou

r o

r m

ore

child

ren

an

d f

ull-

tim

e d

oct

ora

lst

ud

ents

. Th

ese

exte

nsi

on

s in

cove

rag

e ar

e fu

nd

ed b

yin

crea

sed

tra

nsf

ers

fro

m t

he

stat

e b

ud

get

to

th

e m

and

ato

ryH

IFs.

As

a re

sult

, hea

lth

insu

ran

ce c

ove

rag

e, in

clu

din

gfo

r th

e m

ost

vu

lner

able

, has

incr

ease

d (

esti

mat

ed f

igu

res

sug

ges

t in

201

0 it

ro

se t

o 8

2%fr

om

72%

in 2

009)

.

Rev

iew

of

the

fin

anci

ng

of

pre

ven

tive

pro

gra

mm

es,

incr

easi

ng

th

e p

op

ula

tio

nim

mu

niz

atio

n c

ove

rag

e an

du

nd

erta

kin

g m

easu

res

for

pro

mo

tio

n o

f h

ealt

hy

lifes

tyle

edu

cati

on

, acc

ord

ing

to

Euro

pea

n s

tan

dar

ds.

Ro

man

ia


Ru

ssia

nFe

der

atio

nPr

ior

to t

he

fin

anci

al c

risi

s in

200

7 th

ere

wer

e d

iscu

ssio

ns

of

com

pre

hen

sive

fr

ee p

har

mac

euti

cal p

rovi

sio

n f

or

ou

tpat

ien

ts in

th

e fr

amew

ork

of

com

pu

lso

ry m

edic

al in

sura

nce

; ho

wev

erth

ese

dis

cuss

ion

s w

ere

dis

con

tin

ued

,p

oss

ibly

bec

ause

of

the

rece

ssio

n.

In m

id 2

011

the

dis

cuss

ion

s w

ere

re-l

aun

ched

an

d a

rei

mb

urs

emen

tp

rog

ram

me

is s

ched

ule

d f

or

2013

–201

5.

Shar

p in

crea

ses

in a

lco

ho

l an

dto

bac

co e

xcis

e ta

xes

pro

po

sed

in 2

009,

to

be

imp

lem

ente

d in

2011

–201

2.

Serb

ia

Slo

vaki

a

Slo

ven

ia

Spai

nC

atal

on

ia: d

eman

ded

com

pen

sati

on

fo

r tr

eati

ng

pat

ien

ts r

esid

ing

in o

ther

auto

no

mo

us

reg

ion

s fr

om

2011

.

Cat

alan

pla

n: f

rom

2011

, ap

ply

a w

aiti

ng

list

man

agem

ent

syst

em a

nd

mak

ech

ang

es in

wai

tin

g li

stp

rio

riti

zati

on

cri

teri

a.

Fro

m A

pri

l 201

0, in

Cat

alo

nia

: red

uct

ion

in n

on

-urg

ent

care

(eye

su

rger

ies,

h

ip a

nd

kn

eere

pla

cem

ent)

.

Swed

en

81

Policy summary

82

Co

un

try

Ben

efit

s (c

ove

rag

e sc

op

e)Po

pu

lati

on

co

vera

ge

(co

vera

ge

bre

adth

)N

on

-pri

ce r

atio

nin

g(w

aiti

ng

tim

es)

Ch

ang

ing

ind

ivid

ual

s’b

ehav

iou

r (h

ealt

h p

rom

oti

on

and

pre

ven

tio

n)

Swit

zerl

and

Sin

ce t

he

beg

inn

ing

of

2011

, eye

gla

sses

are

no

lon

ger

co

vere

d b

y m

and

ato

ryh

ealt

h in

sura

nce

. Th

is is

on

e o

f se

vera

lm

easu

res

inte

nd

ed t

o s

low

wh

at h

ave

oth

erw

ise

bee

n c

on

sist

ent

ann

ual

incr

ease

s in

hea

lth

insu

ran

ce p

rem

ium

s.M

any

op

tici

ans

hav

e re

spo

nd

ed b

yre

du

cin

g e

yeg

lass

pri

ces

for

child

ren

.

The

form

erYu

go

slav

Rep

ub

lic o

fM

aced

on

ia

In J

anu

ary

2011

, th

e M

inis

try

of

Hea

lth

star

ted

a c

amp

aig

n f

or

peo

ple

inre

mo

te r

egio

ns

to h

ave

bet

ter

acce

ss

to c

are.

Th

is in

clu

des

fre

e ch

eck-

up

s in

so

me

villa

ges

.

Un

iver

sal c

ove

rag

e p

rovi

din

ges

sen

tial

ben

efit

s fo

r al

l cit

izen

sw

as in

tro

du

ced

in M

ay 2

009

and

fin

ance

d f

rom

th

e ce

ntr

alb

ud

get

. Th

e o

vera

ll n

um

ber

of

peo

ple

insu

red

has

incr

ease

das

a r

esu

lt. U

niv

ersa

l co

vera

ge

incl

ud

es p

reve

nti

ve c

hec

k-u

ps,

imm

un

izat

ion

, co

vera

ge

of

par

to

f th

e p

osi

tive

list

of

dru

gs

and

tre

atm

ent

for

a ra

ng

e o

f co

mm

un

icab

le d

isea

ses.

Turk

ey

Ukr

ain

eIn

Mar

ch 2

008

Parl

iam

ent

pas

sed

a la

w r

estr

icti

ng

th

ead

vert

isin

g o

f to

bac

co a

nd

alco

ho

l. In

ord

er t

o in

crea

sere

ven

ues

an

d r

edu

ce n

egat

ive

imp

acts

on

hea

lth

, du

rin

g 2

008

and

200

9 th

e g

ove

rnm

ent

and

Parl

iam

ent

reg

ula

rly

rais

edta

xes

on

to

bac

co a

nd

alc

oh

ol


pro

du

cts.

As

a re

sult

, th

em

inim

um

exc

ise

du

ty o

nto

bac

co p

rod

uct

s h

as in

crea

sed

mo

re t

han

six

tim

es, t

he

aver

age

pri

ce o

f a

pac

k o

fci

gar

ette

s in

crea

sed

2.5

tim

es.

Smo

kin

g r

estr

icti

on

s w

ere

also

intr

od

uce

d in

pu

blic

pla

ces.

Pro

gra

mm

es a

nd

cen

tral

ized

mea

sure

s to

co

mb

attu

ber

culo

sis

and

on

imm

un

izat

ion

rec

eive

d

pri

ori

ty f

un

din

g in

200

9.

Un

ited

Kin

gd

om

(En

gla

nd

)

A p

rog

ram

me

of

on

e-to

-on

e n

urs

ing

for

can

cer

pat

ien

ts a

nd

a o

ne-

wee

kw

ait

for

can

cer

dia

gn

ost

ics

was

ann

ou

nce

d b

y th

e p

revi

ou

sg

ove

rnm

ent

bu

t n

ot

imp

lem

ente

d;

it w

ill n

ow

no

t b

e ta

ken

fo

rwar

d.

Var

iou

s re

po

rts

of

cuts

in s

ervi

ces

are

emer

gin

g, p

rob

ably

du

e to

less

sp

end

ing

po

wer

res

ult

ing

inso

me

form

of

rati

onin

go

r re

stri

ctio

n in

serv

ices

in t

he

NH

S,al

tho

ug

h m

ore

evid

ence

is n

eed

ed

to c

on

firm

th

is.

Uzb

ekis

tan

83

Policy summary

84

Tab

le A

.3. P

olic

ies

inte

nd

ed t

o a

ffec

t th

e co

sts

of

pu

blic

ly f

inan

ced

hea

lth

car

e in

th

e co

nte

xt o

f th

e ec

on

om

ic c

risi

s, W

HO

Euro

pea

n R

egio

n

No

tes:

No

info

rmat

ion

was

ava

ilabl

e fo

r A

ndor

ra, K

azak

hsta

n, L

uxem

bour

g, M

onac

o, M

onte

negr

o, S

an M

arin

o, T

ajik

ista

n an

d Tu

rkm

enis

tan.

Text

not

in it

alic

s in

dica

tes

a po

licy

whi

ch w

as d

efin

ed b

y th

e re

leva

nt a

utho

ritie

s in

the

cou

ntry

as

a re

spon

se t

o th

e cr

isis

. Tex

t in

ital

ics

indi

cate

s a

polic

y w

hich

was

eith

er p

artia

lly a

res

pons

e to

the

cris

is, t

hat

is, i

t w

as p

lann

ed b

efor

e th

e cr

isis

but

impl

emen

ted

afte

r w

ithgr

eate

r/le

ss s

peed

/inte

nsity

tha

n pl

anne

d; o

r po

ssib

ly a

res

pons

e to

the

cris

is, t

hat

is, i

t w

as p

lann

ed a

nd im

plem

ente

d si

nce

the

star

t of

the

cris

is, b

ut n

ot d

efin

ed b

y th

e re

leva

nt a

utho

ritie

s as

a r

espo

nse

to t

he c

risis

. A b

lank

cel

l ind

icat

es n

o po

licy

resp

onse

to

the

cris

is (n

ot n

ore

spon

se t

o th

e su

rvey

).

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Alb

ania

Sala

ries

of

heal

th c

are

prof

essi

onal

s ha

ve s

tead

ilyin

crea

sed

in t

he p

ast

few

year

s, w

ith

heal

thw

orke

rsa

lari

es a

t le

vels

appr

oxim

atel

y tw

ice

ashi

gh a

s in

200

5. S

alar

ies

are

expe

cted

to

cont

inue

to in

crea

se, a

ccor

ding

to

appr

oved

bud

gets

.

Arm

enia

Dur

ing

2009

the

Arm

enia

n dr

am w

asfo

rced

to

floa

t as

a r

esul

tof

the

fin

anci

al c

risi

s,le

adin

g to

imm

edia

tein

crea

ses

in t

he c

osts

of

impo

rted

goo

ds,

incl

udin

g m

edic

ines

.

In 2

008,

cas

e-ba

sed

paym

ent

to h

ealt

hfa

cilit

ies

(pol

yclin

ics

and

mat

erni

ty c

linic

s)

for

mat

erni

ty s

ervi

ces

was

intr

oduc

ed b

ased

on

mar

ket

pric

es u

nder

the

Basi

c Be

nefi

t Pa

ckag

e(B

BP),

whi

ch id

enti

fies

Ong

oing

nat

iona

lpr

ogra

mm

espr

iori

tize

pr

imar

y ca

re

and

impr

ovem

ents

in m

ater

nal a

ndch

ild h

ealt

h.


heal

th s

ervi

ces

that

shou

ld b

e pr

ovid

edw

itho

ut c

harg

e to

a li

stof

vul

nera

ble

grou

ps

or c

ateg

orie

s, s

uch

asdi

sabl

ed p

eopl

e, o

rpha

nsun

der

18, v

eter

ans

and

fam

ilies

of

war

vic

tim

s,fa

mili

es w

ith

mor

e th

anth

ree

child

ren,

and

child

ren

unde

r 18

wit

hon

e pa

rent

. Pre

viou

sly,

mat

erni

ty s

ervi

ces

had

been

fin

ance

d in

the

sam

e m

anne

r as

all

othe

rBB

P-co

vere

d se

rvic

es(lo

wer

tha

n ac

tual

cos

ts)

prov

idin

g in

cent

ives

for

info

rmal

pay

men

ts.

Aus

tria

The

Fede

rati

on o

f So

cial

Hea

lth

Insu

ranc

e Fu

nds

nego

tiat

ed w

ith

phar

ma -

ceut

ical

com

pani

es t

olo

wer

pri

cing

and

reim

burs

emen

t an

dre

duce

the

cos

t of

dru

gpr

escr

ibin

g by

phy

sici

ans.

Cost

sav

ings

of

EUR

132

mill

ion

in 2

010

and

proj

ecte

d EU

R 22

2m

illio

n by

201

3.

Long

-ter

m c

ontr

acts

wer

e es

tabl

ishe

d fo

rpu

rcha

sing

CT

and

MRI

scan

ners

and

for

med

ical

aids

. Tar

get

to r

educ

esp

endi

ng b

y 0.

5%an

nual

ly b

etw

een

2010

and

2013

. No

savi

ngs

have

yet

bee

n re

port

ed.

The

Fede

rati

on o

f So

cial

Hea

lth

Insu

ranc

e Fu

nds

nego

tiat

ed w

ith

the

Doc

tor’

s A

ssoc

iati

on o

ver

cost

-con

trol

mea

sure

spe

rmit

ting

HIF

s to

mon

itor

cos

t-co

ntro

lpr

acti

ces

and

revi

ew k

eyfi

gure

s. R

esul

ted

insa

ving

s of

EU

R 9

mill

ion

in 2

010.

Curr

ent

gove

rnm

ent

disc

ussi

ons

wit

h th

eLä

nder

are

dev

elop

ing

mod

els

of f

inan

cing

an

d de

liver

ing

care

to

enha

nce

effi

cien

cy a

ndqu

alit

y by

201

2/20

13.

The

Länd

er h

old

hosp

ital

budg

ets

whi

ch h

ave

incr

easi

ngly

gon

e in

to

85

Policy summary

86

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Aus

tria

(con

t.)

debt

; the

se d

ebt

leve

lsin

crea

sed

the

gros

sge

nera

l gov

ernm

ent

debt

by a

bout

EU

R 3

billi

on in

2010

; a f

isca

l equ

aliz

atio

nag

reem

ent

in 2

008

valid

thro

ugh

2014

sti

pula

tes

that

the

gov

ernm

ent

need

s to

dev

elop

ast

rate

gy f

or t

he n

ext

agre

emen

t du

e in

201

4to

alt

er g

over

nanc

e of

heal

th f

inan

cing

on

the

basi

s of

an

eval

uati

on

of t

he u

se o

f ad

diti

onal

mon

ies

the

Länd

erre

ceiv

e an

nual

ly

(EU

R 10

0 m

illio

n) t

ofi

nanc

e ho

spit

al c

are;

corr

ecti

ng im

bala

nces

in

the

sup

ply

chai

n.

Aze

rbai

jan

Ack

now

ledg

ing

the

very

low

leve

l of

sala

ries

, the

gove

rnm

ent

has

been

stea

dily

incr

easi

ng s

taff

sala

ries

for

pub

lic s

ecto

rem

ploy

ees.

Suc

h sa

lary

incr

ease

s w

ere

mad

e in

the

year

s pr

eced

ing

the

fina

ncia

l cri

sis

as w

ell a

sin

201

0. H

owev

er, i

n20

09, n

o re

sour

ces

wer

e

Dur

ing

2009

–201

1, t

hego

vern

men

t co

ntin

ued

to a

lloca

te s

ubst

anti

alre

sour

ces

to u

pgra

deph

ysic

al in

fras

truc

ture

and

equi

pmen

t in

the

publ

ic h

ealt

h se

ctor

,w

hich

suf

fere

d se

vere

lyfr

om u

nder

-inve

stm

ent

duri

ng t

he 1

990s

and

earl

y 20

00s.


allo

cate

d to

rai

se s

alar

ies

of t

he h

ealt

h ca

repe

rson

nel;

this

mig

htha

ve b

een

rela

ted

to

the

decr

ease

in p

ublic

reve

nues

rel

ated

to

asi

gnif

ican

t dr

op in

oil

pric

es in

200

9.

Am

ong

the

maj

orch

ange

s im

plem

ente

d in

publ

ic h

ealt

h se

ctor

inre

cent

yea

rs w

as t

hecl

osur

e of

the

maj

orit

y of

sm

all r

ural

hos

pita

ls,

whi

ch r

esul

ted

in a

lmos

ta

50%

red

ucti

on in

the

num

ber

of b

eds

in t

heco

untr

y. O

ptim

izat

ion

of t

he p

ublic

hea

lth

care

netw

ork

is p

art

of t

hena

tion

al h

ealt

h se

ctor

refo

rm a

nd w

as p

lann

edbe

fore

the

cri

sis

bega

n.Th

is is

sup

port

ed t

hrou

gha

Wor

ld B

ank

proj

ect.

Bela

rus

From

200

9, m

edic

ines

whi

ch a

re n

ot n

orm

ally

reim

burs

ed c

an b

ere

gist

ered

and

pre

scri

bed

on p

refe

rent

ial t

erm

s to

indi

vidu

al p

atie

nts

deem

ed t

o be

inpa

rtic

ular

nee

d.

The

prop

orti

on o

fdo

mes

tica

lly p

rodu

ced

med

icin

es in

the

tot

alpu

rcha

sed

amou

nt is

stea

dily

incr

easi

ng (i

n20

09 –

26.

5%, i

n 20

10 –

28.2

%),

and

ther

e is

al

so a

n in

crea

se in

dom

esti

cally

pro

duce

dm

edic

al e

quip

men

t.

From

200

9, r

efor

ms

toin

crea

se t

he e

ffic

ienc

y of

role

s an

d di

stri

buti

on o

fhu

man

res

ourc

es f

orhe

alth

: elim

inat

ion

ofin

effe

ctiv

e po

siti

ons;

intr

oduc

tion

of

stan

dard

son

pop

ulat

ion-

to-s

taff

rati

os a

t ou

tpat

ient

heal

th c

are

inst

itut

ions

;in

trod

ucti

on o

f ne

wpo

siti

ons

wit

hin

exis

ting

staf

fing

leve

ls d

ue t

ofi

lling

vac

ant

orin

effi

cien

tly

used

posi

tion

s); c

onti

nued

incr

ease

s in

bas

ic s

alar

ies

for

heal

th w

orke

rs; t

hein

trod

ucti

on o

f th

epo

siti

on o

f do

ctor

’sas

sist

ant

at o

utpa

tien

tpr

imar

y he

alth

car

ein

stit

utio

ns c

onti

nued

in

Tran

siti

on t

o pe

r ca

pita

budg

ets

has

ensu

red

the

econ

omic

inde

pend

ence

and

incr

easi

ngre

spon

sibi

lity

of h

ealt

hca

re in

stit

utio

ns in

deliv

erin

g m

edic

al c

are.

From

200

9,re

duct

ion

ofov

erhe

ad c

osts

isbe

ing

carr

ied

out

(pri

mar

ily d

ue

to r

educ

tion

s of

adm

inis

trat

ive

cost

s). E

xpen

ditu

reon

fue

l and

ene

rgy

reso

urce

s, t

rans

port

,bu

sine

ss t

rips

,co

mm

unic

atio

nse

rvic

es, e

tc. h

asbe

en r

educ

ed.

Prop

orti

on o

f ex

pens

ive

inpa

tien

t se

rvic

es h

asde

crea

sed

and

reso

urce

sha

ve b

een

redi

rect

ed

to t

he o

utpa

tien

t le

vel

(a t

otal

of

35.0

% o

ut

of t

otal

exp

endi

ture

on

heal

th w

ere

allo

cate

d to

the

out

pati

ent

inst

itut

ions

in 2

009

asco

mpa

red

wit

h 31

.4%

in

200

8).

Plan

s fo

r in

vest

men

t in

exp

ensi

ve f

acili

ties

,co

nstr

ucti

on a

ndeq

uipm

ent,

etc

. hav

ebe

en d

efer

red.

Budg

etar

y fu

nds

have

been

allo

cate

d to

spe

cifi

cpr

ojec

ts a

ccor

ding

to

econ

omic

eva

luat

ions

by

exp

erts

.

87

Policy summary

88

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Bela

rus

(con

t.)

2010

(in

2010

a t

otal

of

732

posi

tion

s of

doc

tor’

sas

sist

ant

wer

e in

trod

uced

as c

ompa

red

wit

h 62

pos

itio

ns in

200

9).

Belg

ium

In 2

010,

a n

ew c

ost-

cont

ainm

ent

mea

sure

intr

oduc

ed a

bia

nnua

lap

plic

atio

n of

aco

mpu

lsor

y pr

ice

redu

ctio

n fo

r “o

ld”

drug

s: d

rugs

rei

mbu

rsed

for

over

12

year

s an

d le

ssth

an 1

5 ye

ars

had

thei

rex

-fac

tory

pri

ce a

ndre

imbu

rsem

ent

basi

sre

duce

d by

15%

, and

drug

s re

imbu

rsed

for

over

15

year

s un

derw

ent

a 17

% r

educ

tion

. New

rule

s in

pla

ce f

orre

imbu

rsem

ent

for

impl

ants

and

med

ical

devi

ces

sinc

e 20

08. P

rice

redu

ctio

ns h

ave

occu

rred

but

the

effe

ct o

n vo

lum

eis

unc

lear

.

Impr

oved

coo

rdin

atio

nof

car

e w

ith

grou

ping

of

GPs

and

the

fin

anci

ng o

fgl

obal

med

ical

rec

ords

.


Bosn

ia a

ndH

erze

govi

naV

AT

spen

ding

by

heal

thca

re in

stit

utio

ns in

crea

sed

sign

ific

antl

y in

200

9be

caus

e, f

rom

200

9,fu

nds

to s

ubsi

dize

V

AT

for

heal

th c

are

inst

itut

ions

are

no

long

erin

clud

ed in

fed

eral

and

cant

onal

bud

gets

and

heal

th c

are

inst

itut

ions

no lo

nger

hav

e th

e ri

ght

to V

AT

refu

nds.

HIF

s in

trod

uced

addi

tion

al c

ontr

actu

alm

easu

res

to m

anag

e,re

duce

and

con

trol

cos

tsof

hea

lth

care

pro

vide

rs(t

arge

ting

cap

ital

inve

stm

ents

and

over

head

cos

ts s

uch

asw

ater

, ele

ctri

city

and

phar

mac

euti

cals

and

devi

ces)

and

qua

lity

(min

imum

req

uire

dam

ount

of

stoc

k) s

ince

the

star

t of

the

cri

sis.

As

part

of

gene

ral

refo

rms,

edu

cati

onca

mpa

igns

hav

eta

rget

ed h

ealt

hw

orke

rs (i

.e. f

amily

prac

titi

oner

s,he

alth

inst

itut

ion

and

fund

man

ager

s, e

tc.),

plac

ing

part

icul

arem

phas

is o

nim

prov

ing

heal

thin

stit

utio

nm

anag

emen

t,st

rate

gic

plan

ning

,ne

goti

atin

g sk

ills,

and

mon

itor

ing

and

eval

uati

on.

Bulg

aria

In 2

011

the

Min

istr

y of

Hea

lth

was

pre

pari

ng

to in

trod

uce

diag

nosi

s-re

late

d gr

oups

as p

aym

ent

met

hods

for

acu

teho

spit

al c

are

in 2

012.

In 2

010

the

Min

iste

r of

Hea

lth

intr

oduc

ed a

fee

ceili

ng f

or a

ll ho

spit

alco

ntra

ctor

s of

NH

IF. T

hem

axim

um f

ee f

or a

tea

mof

phy

sici

ans

is B

GN

900

and

BGN

700

for

one

phys

icia

n. P

revi

ousl

y th

e

In 2

009

the

new

gove

rnm

ent

anno

unce

d pl

ans

to r

educ

ead

min

istr

ativ

e an

dov

erhe

ad c

osts

inal

l gov

ernm

ent

inst

itut

ions

by

10%

. In

resp

onse

to t

his

in 2

010

ther

e w

as c

hang

eof

adm

inis

trat

ive

and

man

ager

ial

stru

ctur

e of

the

NH

IF w

hich

aim

ed

Seve

ral r

efor

ms

have

been

intr

oduc

ed in

the

hosp

ital

sec

tor.

In 2

009,

2010

and

201

1 th

e N

HIF

impl

emen

ted

capp

edho

spit

al b

udge

ts b

ylim

itin

g th

e nu

mbe

rs o

fpa

tien

ts f

unde

d. In

201

0a

new

law

and

sta

ndar

dsof

com

pete

nce

wer

ein

trod

uced

wit

h th

e ai

mof

red

ucin

g th

e ov

eral

lnu

mbe

r of

hos

pita

ls a

ndN

HIF

-fun

ded

med

ical

faci

litie

s. In

a r

efor

m

89

Policy summary

90

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Bulg

aria

(con

t.)

fees

wer

e se

t by

eve

ryho

spit

al w

itho

utre

gula

tion

.

In 2

011

the

gove

rnm

ent

was

pla

nnin

g to

ref

orm

purc

hasi

ng o

f m

edic

alde

vice

s by

cen

tral

izin

gce

rtif

icat

ion

of m

edic

aleq

uipm

ent,

labs

and

high

ly s

peci

aliz

edm

edic

al a

ctiv

itie

s an

din

trod

ucin

g a

posi

tive

lis

t of

med

ical

dev

ices

.Th

e go

vern

men

t w

aspl

anni

ng t

o de

cent

raliz

efu

ndin

g fo

r dr

ugs

for

rare

dis

ease

s an

d ca

ncer

from

the

Min

istr

y of

Hea

lth

to t

he N

HIF

.

An

amen

dmen

t of

the

Hea

lth

Insu

ranc

e A

ct

in 2

009

intr

oduc

edde

term

inat

ion

by t

heM

inis

try

of F

inan

ce o

fhe

alth

ser

vice

s pr

ices

fund

ed b

y th

e N

HIF

. The

Min

istr

y of

Fin

ance

was

init

iato

r of

thi

s po

licy.

Unt

il th

at t

ime

pric

esw

ere

nego

tiat

edbe

twee

n th

e N

HIF

and

doct

ors’

org

aniz

atio

ns

to r

educ

e ov

erhe

adco

sts

by s

ever

alth

ousa

nd B

GN

.Fu

rthe

rmor

e, in

2010

the

Min

iste

rof

Hea

lth

anno

unce

d pl

ans

to r

educ

ead

min

istr

ativ

eco

sts

of t

heM

inis

try

by

29.4

% a

mou

ntin

gto

a s

avin

g of

BG

N 4

mill

ion

annu

ally

.

fund

ed b

y BG

N 3

00m

illio

n fr

om t

heEu

rope

an C

omm

issi

onO

pera

tion

al P

rogr

amm

e“R

egio

nal d

evel

opm

ent”

,in

201

0 th

e go

vern

men

tpr

opos

ed: s

tabi

lizat

ion

and

mod

erni

zati

on

of s

tate

onc

olog

ical

hosp

ital

s an

d tr

eatm

ent

cent

res;

res

truc

turi

ng o

fso

me

mun

icip

alit

y an

dst

ate

acut

e an

d lo

ng-

term

car

e ho

spit

als;

clos

ure

of s

ome

smal

lho

spit

als;

mod

erni

zati

onof

sta

te a

nd m

unic

ipal

ity

hosp

ital

s; a

nd c

losu

re

of h

omes

for

soc

ial a

ndm

edic

al c

are

for

child

ren

repl

aced

by

new

day

cent

res.

In 2

011

the

heal

th m

ap w

as r

evis

edso

tha

t it

incl

udes

not

only

the

min

imum

, but

also

the

max

imum

num

ber

of b

eds,

doc

tors

and

heal

th e

stab

lishm

ents

for

each

reg

ion

ofBu

lgar

ia. T

he a

im o

f th

ere

form

was

to

real

loca

tere

sour

ces

acco

rdin

g to

nee

ds.


and

incl

uded

in t

heN

atio

nal F

ram

ewor

kCo

ntra

ct. T

he r

efor

m

was

met

wit

h gr

eat

diss

atis

fact

ion

by t

hem

edic

al u

nion

. As

are

sult

a n

ew a

men

dmen

tw

as m

ade

to t

he H

ealt

hIn

sura

nce

Act

in 2

011

and

the

pric

ing

proc

ess

ison

ce a

gain

impl

emen

ted

by n

egot

iati

on b

etw

een

NH

IF a

nd d

octo

rsor

gani

zati

ons.

In 2

011

the

Min

iste

r of

Hea

lth

post

pone

d a

stim

ulus

pol

icy

for

acut

eho

spit

al c

are

due

to

a la

ck o

f re

sour

ces.

Croa

tia

In 2

010

Croa

tia

subs

tant

ially

ref

orm

ed

its

pric

ing

and

reim

burs

emen

tre

gula

tion

for

pres

crip

tion

med

icin

es.

The

who

lesa

le p

rice

s of

all

med

icin

es a

re s

etth

roug

h in

tern

atio

nal

pric

e co

mpa

riso

ns (b

ased

on F

ranc

e, It

aly,

Slo

veni

a,Sp

ain

and

Czec

hRe

publ

ic) a

nd in

tern

alre

fere

nce

pric

ing.

Inte

rnat

iona

l pri

ceco

mpa

riso

ns a

re u

sed

for

sett

ing

max

imum

who

lesa

le p

rice

s.Fi

nanc

ing

of d

rugs

is

reg

ulat

ed b

y cr

oss-

prod

uct

agre

emen

ts a

ndpa

y ba

ck a

gree

men

ts

(i.e.

def

ined

max

imum

expe

ndit

ure

limit

s,ov

ersp

ends

pai

d ba

ck

by p

harm

aceu

tica

l

Ther

e ha

s be

enre

orga

niza

tion

inpr

imar

y ca

re w

hich

incl

udes

cap

itat

ion

paym

ents

to

prim

ary

care

pro

vide

rs t

hat

are

divi

ded

into

"fi

xed"

and

"flo

atin

g" p

aym

ents

.Fi

xed

paym

ents

are

base

d on

fix

ed c

osts

and

floa

ting

pay

men

ts a

reba

sed

on t

he n

umbe

r of

pat

ient

ref

erra

ls t

osp

ecia

lists

, pre

scri

ptio

nco

sts,

pre

vent

ion

care

and

grou

p pr

acti

ce.

Glo

bal b

udge

ts f

orho

spit

als

have

incr

ease

dev

ery

year

up

to 2

010.

Whi

le t

he 2

009

budg

ets

for

hosp

ital

hea

lth

care

incr

ease

d at

rat

e of

3.37

%, t

he 2

010

budg

etw

as r

educ

ed b

y 3.

28%

com

pare

d to

200

9.

As

of F

ebru

ary

2009

pre

scri

ptio

nsfo

r ce

rtai

nm

edic

ines

bec

ame

valid

for

long

er

(six

mon

ths)

, whi

chle

ssen

s th

e bu

rden

on f

amily

med

icin

edo

ctor

s, r

educ

esun

nece

ssar

y vi

sits

and

decr

ease

sad

min

istr

ativ

eco

sts.

In J

anua

ry 2

011

the

Croa

tian

Hea

lth

Insu

ranc

e In

stit

ute

and

Hea

lth

Prot

ecti

on a

t W

ork

mer

ged

to c

reat

eth

e N

HIF

(Cro

atia

nIn

stit

ute

for

Hea

lth

Insu

ranc

e).

An

elec

tron

ic r

ecor

dspr

ojec

t (i.

e. e

-pre

scri

ptio

nan

d e-

refe

rral

s) w

aspi

lote

d in

201

0.

E-pr

escr

ipti

on w

as f

ully

impl

emen

ted

in J

anua

ry20

11. A

s a

resu

lt, t

head

min

istr

ativ

e w

orkl

oad

for

phar

mac

ists

dec

lined

by o

ver

90%

.

91

Policy summary

92

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Croa

tia

(con

t.)

com

pani

es o

r av

oide

d by

tim

ely

dona

tion

s, s

tric

tpe

nalt

ies

for

delib

erat

esh

orta

ges)

. The

sem

easu

res

decr

ease

d dr

ug e

xpen

ditu

re b

y 7%

.

Cypr

usTh

e sa

lari

es o

f al

l pub

licse

ctor

hea

lth

prof

essi

onal

sw

ere

redu

ced.

Inad

diti

on, t

he M

inis

try

of H

ealt

h ha

s ch

ange

ddo

ctor

s’ o

vert

ime

rem

uner

atio

n.

Czec

hRe

publ

icD

rugs

: sim

plif

ied

appr

oval

pro

cess

for

gene

ric

drug

s to

ent

erth

e Cz

ech

mar

ket

intr

oduc

ed in

201

0(f

urth

er m

easu

res

plan

ned

for

2012

).

Med

ical

equ

ipm

ent:

auct

ions

for

pur

chas

ing

new

med

ical

equ

ipm

ent

intr

oduc

ed in

201

1(f

urth

er m

easu

res

plan

ned

for

2012

).

Dec

reas

e of

10%

inex

pend

itur

e on

sal

arie

sof

pub

lic a

dmin

istr

atio

nem

ploy

ees,

incl

udin

gth

ose

wor

king

in h

ealt

hse

ctor

(exc

ept

heal

thpr

ofes

sion

als

such

as

phys

icia

ns, n

urse

s et

c.)

in 2

009.

Phy

sici

ans

wer

eth

reat

ened

wit

h sa

lary

cuts

res

ulti

ng f

rom

prop

osed

red

ucti

ons

of p

aym

ents

to

hosp

ital

sbu

t re

sist

ed (2

0% o

fth

em h

ande

d in

the

irno

tice

). A

s a

resu

ltin

sura

nce

fund

s di

d no

tre

duce

pay

men

ts a

nd

No

incr

ease

in b

udge

t fo

r re

imbu

rsem

ent

ofho

spit

als

by in

sura

nce

fund

s in

201

0. C

hang

e of

rei

mbu

rsem

ent

mec

hani

sms

in h

ospi

tals

from

glo

bal b

udge

tsto

war

ds d

iagn

osis

-re

late

d gr

oups

pla

nned

for

2012

.

Chan

ge in

law

to

enab

le m

ergi

ng

of S

HI f

unds

inor

der

to im

prov

eef

fici

ency

pla

nned

for

2012

.

Rest

ruct

urin

g of

inpa

tien

t be

ds is

bei

ngco

nsid

ered

(ana

lysi

sbe

ing

done

in 2

011)

in

ord

er t

o de

crea

senu

mbe

r of

acu

te c

are

beds

and

incr

ease

num

ber

of b

eds

for

follo

w-u

p ca

re.


sala

ries

did

not

dec

reas

e.H

owev

er, p

art

of t

hene

goti

atio

n w

as t

hat

phys

icia

ns a

ccep

ted

othe

r re

form

s.Im

plem

ente

d in

201

1.

Den

mar

kA

s pa

rt o

f on

goin

gpo

licie

s ac

cele

rate

d af

ter

2008

, eff

orts

to

impr

ove

rati

onal

phar

mac

othe

rapy

.

Onl

y lim

ited

incr

ease

s in

sal

arie

s fo

r he

alth

prof

essi

onal

s as

a r

esul

tof

neg

otia

tion

s in

201

1.

As

part

of

ongo

ing

polic

ies

acce

lera

ted

afte

r20

08, i

ncre

ased

use

of

tend

er t

o st

reng

then

com

peti

tion

bet

wee

npr

ovid

ers

(pub

licho

spit

als

outs

ide

each

regi

on, p

riva

te h

ospi

tals

and

supp

liers

to

publ

icho

spit

als

in e

ach

regi

on).

Revi

ews

of h

ospi

tal

budg

ets

to id

enti

fypo

tent

ial s

avin

gs.

As

part

of

ongo

ing

polic

ies

acce

lera

ted

afte

r20

08, c

entr

aliz

atio

n(h

ospi

tal a

ndde

part

men

t cl

osur

es)

to a

chie

ve e

cono

mie

s of

sca

le a

nd r

educ

em

aint

enan

ce c

osts

.

IT im

prov

emen

ts m

ade

aspa

rt o

f on

goin

g po

licie

sac

cele

rate

d af

ter

2008

.

Esto

nia

In M

arch

201

0 th

eM

inis

try

of S

ocia

l A

ffai

rs (M

OSA

) ini

tiat

edam

endm

ents

to

the

min

iste

rial

dec

ree

ondr

ug p

resc

ript

ions

to

sup

port

act

ive

ingr

edie

nt-b

ased

pres

crib

ing

and

disp

ensi

ng. T

heam

endm

ent

did

not

chan

ge p

resc

ribi

ng r

ules

,bu

t do

es r

equi

reph

arm

acie

s to

pro

vide

pati

ents

wit

h th

e dr

ugw

ith

the

low

est

leve

l of

cost

sha

ring

and

to

note

if p

atie

nts

refu

se c

heap

eral

tern

ativ

es. I

n A

pril

2010

the

Hea

lth

EHIF

red

uced

hea

lth

serv

ices

pri

ces

by 6

%fr

om 2

009.

The

obj

ecti

vew

as t

o ba

lanc

e th

ehe

alth

insu

ranc

e bu

dget

wit

hout

dim

inis

hing

acce

ss t

o ca

re. B

efor

e th

e cr

isis

, hea

lth

serv

ice

expe

ndit

ures

(als

o pr

ices

)in

crea

sed

very

rap

idly

and

ther

efor

e th

at 6

%cu

t w

as n

ot a

big

econ

omic

sho

ck f

orpr

ovid

ers.

Sin

ce 2

011

the

pric

e of

hea

lth

serv

ices

has

redu

ced

by 5

%, w

ith

exce

ptio

n of

pri

mar

yca

re w

here

the

red

ucti

onra

te is

low

er (3

%).

93

Policy summary

94

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Esto

nia

(con

t.)

Insu

ranc

e A

ct w

asam

ende

d to

ext

end

the

appl

icat

ion

of

pric

e ag

reem

ents

and

refe

renc

e pr

icin

g to

med

icin

es in

the

low

est

(50%

) rei

mbu

rsem

ent

cate

gory

(som

e ef

fect

ive

drug

s an

d m

any

less

cos

t-ef

fect

ive

drug

s). P

rice

agre

emen

ts p

revi

ousl

yon

ly a

pplie

d to

dru

gsre

imbu

rsed

at

high

erra

tes

(100

%, 9

0% a

nd75

%).

In S

epte

mbe

r 20

10EH

IF la

unch

ed a

n an

nual

gene

ric

drug

pro

mot

ion

cam

paig

n on

tel

evis

ion

and

billb

oard

s in

coop

erat

ion

wit

h M

OSA

,th

e St

ate

Med

icin

esA

genc

y (S

AM

) and

the

Ass

ocia

tion

of

Fam

ilyPh

ysic

ians

(SFM

). A

t th

ebe

ginn

ing

of 2

010

EHIF

and

MO

SA la

unch

ed a

new

e-p

resc

ript

ion

syst

em, w

hich

cur

rent

lyop

erat

es a

long

side

pap

erpr

escr

ibin

g. T

he n

ewsy

stem

mak

es a

ctiv

ein

gred

ient

-bas

edpr

escr

ibin

g ea

sier

.


Finl

and

Serv

ice

vouc

hers

intr

oduc

ed f

or s

ocia

lca

re: c

arin

g fo

r cl

ose

rela

tive

s; d

omes

tic

serv

ices

; sup

port

ser

vice

sto

hou

sing

ser

vice

s an

d ho

usin

g se

rvic

e fo

r di

sabl

ed p

eopl

e.In

trod

ucti

on f

or h

ealt

hse

rvic

es w

as p

lann

ed f

or20

11. U

se o

f vo

uche

rs

is in

tend

ed t

o m

itig

ate

publ

ic s

ecto

r pr

essu

res

and

incr

ease

fre

edom

of

cho

ice

of s

ervi

ces

user

s. T

wen

ty-s

even

mun

icip

alit

ies

use

them

; 32

to e

xpan

d or

intr

oduc

e th

em; 6

and

10

for

spe

cial

ized

car

e;

2 an

d 5

for

reha

bilit

atio

n;4

and

13 f

or d

enta

l car

e.

Sign

ific

ant

diff

eren

ces

exis

t ac

ross

mun

icip

alit

ies

due

to v

aria

tion

infi

nanc

ial r

esou

rces

and

avai

labi

lity

of h

ealt

hpr

ofes

sion

als.

Thi

s ha

sle

d to

a r

estr

uctu

ring

and

mer

gers

of

mun

icip

alit

ies

to p

ool

reso

urce

s. B

etw

een

2005

and

2011

the

num

ber

ofm

unic

ipal

itie

s de

crea

sed

from

432

to

336.

Fran

ceSa

ving

s an

tici

pate

d in

2011

due

to

decr

easi

ngco

st o

f he

alth

pro

duct

s,in

clud

ing

grea

ter

use

ofge

neri

c dr

ugs.

From

201

1, d

ecre

ase

in t

he f

ee f

or s

ervi

ces

of c

erta

in h

ealt

hpr

ofes

sion

als.

Five

-yea

r ho

spit

al s

ecto

rin

vest

men

t pl

an (2

008–

2012

) of

EUR

16 b

illio

n of

whi

ch o

nly

EUR

6 m

illio

n is

to b

e sp

ent

in 2

010–

2012

.

Geo

rgia

In 2

009

redu

ced

mar

ket

entr

y ba

rrie

rs a

nd

capi

tal r

equi

rem

ents

fo

r ph

arm

acy

netw

ork

to in

crea

se m

arke

tco

mpe

titi

vene

ss, w

hich

pote

ntia

lly c

ould

bri

ngpr

ices

dow

n. R

ecen

tan

alys

is s

how

s th

at p

rice

sha

ve c

ome

dow

n sl

ight

lyfo

r br

ande

d m

edic

ines

,bu

t no

t fo

r ge

neri

cs.

In r

elat

ion

to c

apit

al a

ndov

erhe

ad c

osts

, in

2007

the

gove

rnm

ent

aim

edto

incr

ease

inve

stm

ents

in u

pgra

ding

or

cons

truc

ting

hea

lth

care

faci

litie

s an

d op

tim

ize

exce

ss p

rovi

der

capa

city

thro

ugh

priv

atiz

atio

n. T

heH

ospi

tal D

evel

opm

ent

Plan

cal

led

for

the

com

plet

e re

plac

emen

t of

95

Policy summary

96

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Geo

rgia

(con

t.)

exis

ting

hos

pita

l inf

ra -

stru

ctur

e w

ithi

n a

thre

e-ye

ar p

erio

d (2

007–

2009

),by

tra

nsfe

rrin

g fu

llow

ners

hip

righ

ts f

rom

the

stat

e to

the

pri

vate

sect

or t

hrou

gh a

tend

erin

g pr

oces

s.H

owev

er, a

s a

resu

lt

of w

ar in

200

8 an

d th

egl

obal

fin

anci

al c

risi

s,in

vest

ors

and,

pri

mar

ily,

deve

lope

rs h

ave

face

dse

riou

s liq

uidi

ty p

robl

ems,

whi

ch h

ave

had

sign

ific

ant

cons

eque

nces

wit

h re

gard

to

fulf

illin

gth

eir

cont

ract

ual

oblig

atio

ns u

nder

thi

spr

ogra

mm

e. A

s a

resu

lt,

impl

emen

tati

on o

f th

eho

spit

al m

aste

r pl

anst

alle

d an

d m

any

orig

inal

inve

stor

s, w

ho p

artic

ipat

edin

the

ten

ders

, had

to

wit

hdra

w a

nd f

ace

fina

ncia

l pen

alti

es. T

hego

vern

men

t su

bseq

uent

lyre

solv

ed t

his

issu

e by

iden

tify

ing

new

inve

stor

san

d cu

rren

tly

a la

rge

num

ber

of h

ospi

tals

ar

e be

ing

cons

truc

ted.


In 2

010,

the

way

the

Med

ical

Insu

ranc

e fo

r th

ePo

or is

impl

emen

ted

was

chan

ged.

A s

ingl

e co

ntra

ctpe

r re

gion

was

put

out

for

com

peti

tive

ten

der

by t

he g

over

nmen

t, t

hat

is, p

riva

te h

ealt

h in

sure

rsbi

d to

be

the

sole

insu

ranc

e pr

ovid

er o

f th

eM

IP in

any

giv

en r

egio

n.Pa

rt o

f th

e de

al f

orw

inni

ng t

he t

ende

r w

asth

at p

riva

te in

sure

rs h

adto

bui

ld n

ew h

ospi

tals

.Th

is p

rogr

amm

e fo

r ne

win

fras

truc

ture

sho

uld

befi

naliz

ed in

201

2.

Ger

man

y

Gre

ece

The

Mem

oran

dum

aim

sat

sav

ing

EUR

2 bi

llion

from

pha

rmac

euti

cal

prod

ucts

– E

UR

1 bi

llion

was

to

be s

aved

in 2

011

–re

duci

ng p

harm

aceu

tica

lex

pend

itur

e by

1%

of

GD

P.

From

201

1, p

osit

ive

list

of m

edic

ines

rei

ntro

duce

d(it

was

abo

lishe

d in

2006

), w

ith

a fo

cus

onge

neri

cs. R

educ

tion

inV

AT

for

med

icin

es

(11%

to

6.5%

); in

crea

sed

use

of g

ener

ics

(50%

of

med

icin

es in

pub

licho

spit

als

shou

ld b

ege

neri

cs);

max

imum

gene

ric

pric

e is

60%

From

201

1, s

alar

y cu

ts(e

.g. n

urse

s’ s

alar

y cu

t by

14%

com

pare

d w

ith

2009

). Te

mpo

rary

sta

ffem

ploy

ed u

nder

fix

ed-

term

con

trac

ts r

emov

ed.

Redu

ctio

n in

the

repl

acem

ent

of s

taff

w

ho a

re r

etir

ing

(for

fi

ve p

erso

ns w

ho a

rere

tiri

ng o

nly

one

is t

o be

app

oint

ed).

From

201

1, r

educ

tion

in

pha

rmac

ists

’ pro

fit

by15

–20%

. Lib

eral

izat

ion

of p

harm

acie

s: m

ore

than

one

pha

rmac

ist

can

wor

k at

the

sam

eph

arm

acy

and

phar

mac

ies

can

be e

stab

lishe

d in

clos

er p

roxi

mit

y to

ea

ch o

ther

. Ext

ensi

on

of h

ours

, dec

reas

e in

popu

lati

on t

hres

hold

for

sett

ing

up a

pha

rmac

y;re

bate

s av

aila

ble.

Dev

elop

men

t of

a p

rici

ngsy

stem

for

hos

pita

ls o

nba

sis

of m

edic

al c

ases

,w

hich

will

be

used

for

sett

ing

hosp

ital

bud

gets

from

201

3.

A n

ew h

ealt

h la

win

trod

uced

in 2

011

prov

ides

the

cons

titu

tion

of

a m

ain

prim

ary

heal

th c

are

body

nam

ed t

he N

atio

nal

Hea

lth

Serv

ice

Org

aniz

atio

n(E

OPY

Y),

unde

r th

e su

perv

isio

n of

the

Min

istr

ies

ofH

ealt

h an

d So

cial

Solid

arit

y an

dLa

bour

and

Soc

ial

Secu

rity

Ope

rati

on,

wit

h op

erat

ions

begi

nnin

g in

Jun

e20

11. T

he a

ims

ofth

e EO

PYY

are

to

In J

une

2010

, the

new

gov

ernm

ent

that

cam

e to

pow

er e

nact

ed

a la

w t

o es

tabl

ish

a ne

w a

rchi

tect

ure

for

mun

icip

alit

ies

and

regi

ons

(kno

wn

as t

he“K

allik

rati

s” P

lan)

.W

ith

the

Kal

likra

tis

Plan

, 13

regi

ons

have

bee

n cr

eate

din

pla

ce o

f 76

pref

ectu

res

and

the

1034

mun

icip

alit

ies

redu

ced

to f

ewer

than

370

. Und

erth

e re

orga

niza

tion

,

From

201

1, in

trod

ucti

onof

hos

pita

l mer

gers

and

clos

ures

, inc

ludi

ngm

ergi

ng s

ocia

l hea

lth

insu

ranc

e an

d na

tion

alhe

alth

ser

vice

hos

pita

ls.

Nat

iona

l hea

lth

serv

ice

hosp

ital

s’ o

peni

ng h

ours

have

bee

n ex

tend

ed.

Hea

lth

and

Wel

fare

Map

:fr

om 2

010,

a d

ata

and

inde

x sy

stem

is b

eing

deve

lope

d th

roug

hw

hich

(a) c

itiz

ens’

hea

lth

stat

us w

ill b

e re

cord

edan

d (b

) the

suf

fici

ency

,ef

fect

iven

ess

and

effi

cien

cy o

f he

alth

serv

ices

will

be

asse

ssed

.

97

Policy summary

98

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Gre

ece

(con

t.)

of b

rand

ed d

rugs

;ce

ntra

lized

pro

cure

men

tof

med

ical

ser

vice

s an

d go

ods;

pri

vate

indi

vidu

als

are

perm

itte

dto

pro

cure

con

trac

ts;

fine

s fr

om E

UR

500

toEU

R 50

000

if t

here

isde

viat

ion

from

the

appr

oved

bud

get

in a

proc

urem

ent

cont

ract

.

coor

dina

te p

rim

ary

care

, reg

ulat

eco

ntra

ctin

g of

heal

th c

are

prov

ider

s an

d se

t qu

alit

y an

d ef

fici

ency

stan

dard

s, w

ith

the

broa

der

goal

of

alle

viat

ing

pres

sure

on a

mbu

lato

ry a

ndem

erge

ncy

care

inpu

blic

hos

pita

ls.

The

heal

thdi

visi

ons

of t

hem

ain

SHI f

unds

are

tran

sfer

red

and

inte

grat

ed in

thi

sor

gani

zati

on.

regi

onal

hea

lth

auth

orit

ies

are

expe

cted

to

play

a

muc

h gr

eate

rro

le in

man

agin

gan

d or

gani

zing

the

hum

an r

esou

rces

of t

he n

atio

nal

heal

th s

ervi

ce.

New

mea

sure

s in

the

2011

hea

lth

law

allo

wth

e ex

pans

ion

of p

riva

tecl

inic

s in

the

bui

ldin

g of

infr

astr

uctu

re,

deve

lopi

ng n

ewde

part

men

ts, u

nits

an

d la

bora

tori

es, a

ndho

spit

al b

eds,

wit

hin

cert

ain

defi

ned

limit

s in

gro

wth

rat

es.

Expa

nsio

n of

the

elec

tron

ic p

resc

ript

ion

syst

em f

rom

201

1:

it s

houl

d be

use

d in

diag

nost

ic e

xam

inat

ions

and

in in

pati

ent

care

and

the

mai

n in

sura

nce

fund

sar

e ob

liged

to

use

it.

Hun

gary

From

201

0, f

inan

cial

rew

ards

wer

e in

trod

uced

for

the

rati

onal

use

of

dru

gs. D

octo

rs a

rere

war

ded

for

pres

crip

tion

of c

heap

er, b

utth

erap

euti

cally

equi

vale

nt s

ubst

itut

esan

d ph

arm

acie

s m

aypr

omot

e th

e us

e of

th

ese

drug

s by

alt

erin

gdo

ctor

s’ p

resc

ript

ions

. In

201

1 th

e go

vern

men

t

The

Sem

mel

wei

s Pl

anai

ms

at c

reat

ing

a ca

reer

pat

h m

odel

for

heal

th c

are

prof

essi

onal

sth

at, w

ith

chan

ges

inre

mun

erat

ion,

edu

cati

onan

d in

the

con

diti

ons

ofem

ploy

men

t, p

rovi

des

mot

ivat

ion

for

stay

ing

in t

he f

ield

and

wor

king

in H

unga

ry.

In 2

008

fina

ncin

gm

ulti

plie

rs (w

eigh

ting

fact

ors

for

Hom

ogen

eous

Dis

ease

Gro

ups,

HBC

S) f

orin

pati

ent

reha

bilit

atio

nw

ere

rais

ed. S

ince

200

8th

e H

ealt

h In

sura

nce

Fund

Adm

inis

trat

ion

is e

ntit

led

to a

brog

ate

a fi

nanc

ing

cont

ract

if q

ualit

y or

oth

ercr

iter

ia a

re n

ot m

et. I

nA

pril

2009

out

pati

ent

and

inpa

tien

t fi

nanc

ing

Adm

inis

trat

ive

cost

of

the

NH

IFad

min

istr

atio

n is

pla

nned

to

bere

duce

d fr

om

1.5%

to

1%.


anno

unce

d pl

ans

tore

form

the

pre

scri

ptio

ndr

ug s

ubsi

dy s

yste

m.

chan

ged.

The

re h

ad b

een

a pr

e-de

term

ined

fee

up

to a

cer

tain

vol

ume

limit

.Th

e vo

lum

e lim

it w

asre

duce

d an

d a

floa

ting

fee

for

serv

ices

abo

veth

is li

mit

was

intr

oduc

ed.

How

ever

the

red

ucti

onin

and

unp

redi

ctab

ility

of

the

spe

cial

ist

prov

ider

s’ b

udge

ts w

asun

man

agea

ble

and

inO

ctob

er t

hey

wer

eco

mpe

nsat

ed w

ith

atr

ansf

er o

f an

ext

ra

HU

F 10

.5 b

illio

n (i.

e.

not

incl

uded

in b

udge

tpr

ovis

ions

), th

e re

form

was

rev

erse

d an

d th

eor

igin

al s

yste

m r

esto

red.

In 2

010,

inpa

tien

tpr

ovid

ers

agai

n re

ceiv

edex

tra

fund

ing

in o

rder

to

avoi

d ba

nkru

ptcy

(HU

F27

.5 b

illio

n). I

t w

as s

pent

mai

nly

on t

he d

ebts

of

inst

itut

ions

and

shor

teni

ng s

ome

wai

ting

lists

. By

acce

ptin

g th

ishe

lp, i

nsti

tuti

ons

agre

edto

mak

e a

cons

olid

atio

npl

an, t

o pa

rtic

ipat

e in

are

gula

r de

bt-m

onit

orin

gsy

stem

and

to

coop

erat

ein

ter

rito

rial

cap

acit

yre

stru

ctur

ing.

The

2010

gov

ernm

ent

Sem

mel

wei

s Pl

anen

visa

ged

the

cont

inua

tion

of

thes

ere

form

s in

201

0/20

11.

Extr

a fu

ndin

g w

ill b

e

99

Policy summary

100

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Hun

gary

(con

t.)

used

pri

mar

ily in

thr

eepr

iori

ty a

reas

: to

mod

erni

ze t

he f

leet

of

the

Nat

iona

l Am

bula

nce

Serv

ice,

to

stre

ngth

enpr

imar

y ca

re a

nd e

xten

dit

s fu

ncti

ons

(in o

rder

to

redu

ce t

he b

urde

n of

spec

ializ

ed c

are)

, and

to

red

uce

the

debt

of

hosp

ital

s an

d he

alth

car

epr

ovid

ers.

To

esta

blis

hfi

nanc

ial s

usta

inab

ility

,ef

fect

ive

and

tran

spar

ent

reso

urce

allo

cati

onm

echa

nism

s ar

e pl

anne

dth

at a

re a

djus

ted

tone

eds.

To

achi

eve

this

,th

e pl

an a

ims

to a

bolis

hth

e st

rict

vol

ume

limit

inin

pati

ent

and

outp

atie

ntca

re. T

reat

men

ts a

bove

the

volu

me

limit

are

plan

ned

to b

e re

imbu

rsed

acco

rdin

g to

the

var

iabl

eco

st o

f th

e ca

se. T

hepr

esen

t fe

e-fo

r-se

rvic

esy

stem

in a

mbu

lato

ryca

re w

ould

be

repl

aced

by a

syst

em o

f am

bula

tory

Hom

ogen

eous

Dis

ease

Gro

ups

(Hun

gari

anve

rsio

n of

dia

gnos

is-

rela

ted

grou

ps).


Icel

and

As

of M

arch

200

9,

offi

cial

pre

scri

ptio

n ru

les

mus

t no

w b

e fo

llow

ed(i.

e. c

erta

in g

ener

ics

mus

t be

pre

scri

bed

befo

re t

ryin

g co

stlie

ral

tern

ativ

es),

othe

rwis

epa

tien

ts m

ust

pay

100%

of d

rug

cost

s. A

s a

resu

lt,

appl

icab

le d

rug

cost

sw

ere

redu

ced

by 1

0.7%

from

200

9 to

201

0.

In 2

009,

indi

vidu

al h

ealt

hca

re o

rgan

izat

ions

wer

eta

sked

wit

h cu

ttin

ghe

alth

wor

ker

sala

ries

. A

com

mon

app

roac

h w

as t

o cu

t ov

erti

me

and

nigh

t sh

ifts

, and

to

leng

then

shi

fts

that

requ

ire

few

er s

taff

,tr

avel

cos

ts, c

onti

nuin

ged

ucat

ion,

etc

. Thi

saf

fect

ed m

edic

al d

octo

rsan

d re

gist

ered

nur

ses,

as

wel

l as

othe

r he

alth

car

epr

ofes

sion

als

and

heal

thca

re s

taff

. A n

umbe

r of

the

se h

ealt

h ca

reem

ploy

ees

lost

the

ir jo

bs.

For

exam

ple,

ove

r 70

0pe

ople

hav

e lo

st t

heir

jobs

at

the

Nat

iona

lU

nive

rsit

y ho

spit

al in

th

e pe

riod

200

7–20

10(a

ppro

xim

atel

y 10

% o

fto

tal s

taff

). A

ccor

ding

to

surv

eys,

the

se c

uts

have

crea

ted

nega

tive

att

itud

esam

ong

staf

f. C

urre

ntly

ther

e ar

e ph

ysic

ian

vaca

ncie

s in

man

y he

alth

care

org

aniz

atio

nsar

ound

the

cou

ntry

. In

addi

tion

, the

ave

rage

age

of m

edic

al d

octo

rs

is in

crea

sing

dra

mat

ical

ly,

as m

edic

al d

octo

rsch

oose

not

to

retu

rn

to t

he c

ount

ry a

fter

obta

inin

g th

eir

spec

ializ

atio

n ab

road

.

In O

ctob

er 2

008,

the

Min

istr

y of

Hea

lth

and

Min

istr

yof

Soc

ial A

ffai

rsm

erge

d to

red

uce

adm

inis

trat

ive

cost

s an

d in

crea

seef

fici

ency

. The

rear

e in

tent

ions

to

mer

ge t

heD

irec

tora

te o

fH

ealt

h an

d th

ePu

blic

Hea

lth

Inst

itut

e of

Ic

elan

d in

201

1.

Ther

e ha

ve b

een

anu

mbe

r of

hea

lth

cent

re m

erge

rs.

For

exam

ple

ther

ew

ere

arou

nd 2

0ru

ral h

ealt

h ce

ntre

sin

200

7 bu

t by

2011

the

re w

ere

only

12.

101

Policy summary

102

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Irel

and

Rene

goti

atio

n of

dea

lsw

ith

phar

mac

euti

cal

com

pani

es f

rom

201

0.

In 2

009:

mor

ator

ium

on

rec

ruit

men

t an

dpr

omot

ion,

non

-re

plac

emen

t of

sta

ff

on le

ave,

end

ing

ofte

mpo

rary

con

trac

ts,

staf

f tr

ansf

er, v

olun

tary

redu

ndan

cy, c

utba

cks

ined

ucat

ion

and

trai

ning

.In

the

201

0 bu

dget

: low

erfe

es p

aid

to c

ontr

acte

dpr

ofes

sion

als

(GPs

and

othe

r hea

lth p

rofe

ssio

nals)

prod

ucin

g es

tim

ated

savi

ngs o

f EU

R 65

9 m

illio

n.In

the

201

1 bu

dget

:re

duce

d ag

ency

and

locu

m s

taff

ing,

red

uced

prof

essi

onal

fee

s, e

arly

reti

rem

ent

and

volu

ntar

yre

dund

ancy

pro

pose

d.

From

200

8, r

educ

edan

nual

fee

to

GPs

who

trea

t m

edic

al c

ard

hold

ers.

From

200

9, r

educ

tion

of

8% o

n al

l pro

fess

iona

lfe

es a

nd c

ut t

o ph

arm

acy

fees

of

24–3

4%. F

urth

ercu

ts in

fee

s of

5%

for

heal

th p

rofe

ssio

nals

wer

e in

trod

uced

in

2010

and

201

1.

HSE

com

mit

men

tin

200

9 to

red

uce

adm

inis

trat

ive,

man

agem

ent

and

adve

rtis

ing

cost

s by

at

leas

t 3%

.

Cuts

in a

dmin

istr

a -ti

ve s

pend

ing

intr

oduc

ed in

201

0bu

dget

, inc

ludi

ngre

duci

ng H

SE

staf

f by

600

0 (E

UR

300

mill

ion)

plus

add

itio

nal

effi

cien

cies

in t

heH

SE (E

UR

90 m

illio

n).

Cuts

inad

min

istr

atio

n(E

UR

43 m

illio

n)w

ere

prop

osed

inth

e 20

11 b

udge

t.

Mea

sure

s to

pro

vide

mor

e se

rvic

es w

ith

few

erre

sour

ces:

hos

pita

l day

care

incr

ease

d by

5%

inth

e fi

rst

six

mon

ths

of20

09 r

elat

ive

to 2

008

and

abov

e th

e 20

09ta

rget

. Out

pati

ent

(OPD

)ap

poin

tmen

ts in

crea

sed

by 3

% b

etw

een

the

firs

tsi

x m

onth

s of

200

8 an

d20

09, a

nd t

he n

umbe

r of

new

OPD

att

enda

nces

have

incr

ease

d by

6%

in

the

sam

e pe

riod

.H

ospi

tal c

apac

ity

redu

ced

by 5

19 b

eds

betw

een

Janu

ary

and

July

200

9.

Isra

el

Ital

yFr

om 2

010,

per

form

ance

mea

sure

men

t in

trod

uced

and

linke

d to

pay

men

t of

pro

vide

rs a

s a

cost

-co

ntai

nmen

t m

easu

re.

Kyr

gyzs

tan


Latv

iaIn

200

9 ph

arm

aco-

ther

apeu

tic

refe

renc

egr

oups

wer

e ex

tend

edan

d m

ore

atte

ntio

n w

as g

iven

to

the

inte

rnat

iona

l com

pari

son

of p

harm

aceu

tica

l pri

ces.

The

Cent

re o

f H

ealt

hEc

onom

ics

re-e

valu

ated

the

cost

–eff

ecti

vene

ssan

d pr

ices

for

the

trea

tmen

t of

HIV

/AID

S in

200

9 an

d sp

ecif

ied

reco

mm

enda

tion

s fo

r th

e pr

escr

ibin

g of

phar

mac

euti

cals

.Pr

evio

usly

, the

phar

mac

euti

cals

for

HIV

/AID

S w

ere

purc

hase

dce

ntra

lly b

ut h

ave

been

incl

uded

in t

here

imbu

rsem

ent

syst

emsi

nce

2010

. On

the

basi

sof

an

eval

uati

on o

f co

st–e

ffec

tive

ness

and

nego

tiat

ions

wit

hco

mpa

nies

on

pric

ere

duct

ions

bas

ed o

nin

tern

atio

nal

com

pari

sons

, the

Cen

tre

of H

ealt

h Ec

onom

ics

mad

e si

gnif

ican

t pr

ice

redu

ctio

ns –

fro

m 3

%

to 4

9% –

com

pare

d to

pric

es in

200

9. T

his

enab

led

trea

tmen

t fo

r an

incr

easi

ng n

umbe

r of

pat

ient

s fo

r th

e sa

me

amou

nt o

f m

oney

.

In 2

009

apr

ogra

mm

e to

incr

ease

resp

onsi

bilit

ies

and

duti

es f

or f

amily

doct

ors,

incl

udin

gin

crea

sed

supp

ort

for

the

prov

isio

n of

hea

lth

care

at

hom

e w

asin

trod

uced

.

The

Publ

ic H

ealt

hA

genc

y w

as c

lose

din

200

9. M

any

publ

iche

alth

fun

ctio

nsw

ere

dist

ribu

ted

amon

g ot

her

inst

itut

ions

and

som

e w

ere

lost

. A

s pa

rt o

f a

reor

gani

zati

on

of t

he in

stit

utio

nw

hich

dev

elop

sst

ate

polic

y on

avai

labi

lity

ofhe

alth

car

e se

rvic

esan

d m

anag

es t

hest

ate

fina

ncin

g of

heal

th c

are

aim

edat

dim

inis

hing

stat

e ad

min

istr

ativ

eex

pens

es, t

heH

ealt

h Pa

ymen

tCe

ntre

(HPC

) was

esta

blis

hed

in 2

009.

This

cha

nge

was

asso

ciat

ed w

ith a

cut

in t

he p

rogr

amm

esbu

dget

of

LVL

127.

8m

illio

n or

24.

8% in

2009

com

pare

d to

2008

and

sta

ffre

dund

anci

es.

Furt

herm

ore,

th

e to

tal n

umbe

rof

em

ploy

ees

decr

ease

d fr

om31

3 (2

008)

to

139

(200

9). T

here

was

also

reo

rgan

izat

ion

of e

mer

genc

yse

rvic

es. I

n Fe

brua

ry20

09 in

stea

d of

The

num

ber

of p

ublic

lyfu

nded

hos

pita

ls w

ith

inpa

tien

t ca

re p

rovi

sion

in L

atvi

a de

crea

sed

from

88 in

200

8 to

72

in 2

009

and

39 in

201

0. T

henu

mbe

r of

hos

pita

ls p

er10

0 00

0 in

habi

tant

s in

2009

was

3.1

8, c

ompa

red

to 1

.73

in 2

010.

The

num

ber

of h

ospi

tal b

eds

decr

ease

d fr

om 7

46/1

0000

0 in

habi

tant

s in

200

8to

625

in 2

009

and

493

in20

10. I

n 20

09 c

ompa

red

wit

h 20

08 t

he n

umbe

r of

hosp

ital

adm

issi

ons

and

bed

days

in in

pati

ent

hosp

ital

s de

crea

sed

by27

.1%

. Ave

rage

cos

ts

per

sing

le h

ospi

tal s

tay

decr

ease

d by

1.2

% b

utth

e co

st o

f on

e in

pati

ent

day

incr

ease

d by

6.8

%.

The

aver

age

leng

th o

fst

ay in

hos

pita

ls in

200

8w

as 9

.5 d

ays,

com

pare

dto

8.7

in 2

009

and

8.5

days

in 2

010.

In 2

009,

due

to t

he c

losu

re o

fse

vera

l reg

iona

lho

spit

als,

the

act

ivit

y of

and

serv

ices

pro

vide

d by

day

clin

ics

incr

ease

dsi

gnif

ican

tly.

In 2

009

the

num

ber

of p

atie

nts

trea

ted

at d

ay h

ospi

tals

was

39

507,

but

in t

hefi

rst

eigh

t m

onth

s of

2010

it w

as 5

0 93

8. In

2009

the

re w

as a

tot

al o

f37

3 31

3 ho

spit

aliz

atio

ns.

103

Policy summary

104

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Latv

ia (c

ont.

)39

inst

itut

ions

on

e Em

erge

ncy

Med

icar

e Se

rvic

ew

as e

stab

lishe

d in

orde

r to

gra

dual

lyta

ke o

ver e

mer

genc

ym

edic

ine

func

tion

sfr

om M

edic

are

inst

itut

ions

, to

cent

raliz

e th

eem

erge

ncy

syst

eman

d to

sav

e ad

min

-is

trat

ive

cost

s. T

his

redu

ced

the

num

ber

of e

mer

genc

ym

edic

al c

alls

by

10%

in 2

009.

Lith

uani

aTh

e Pl

an f

or t

heIm

prov

emen

t of

Phar

mac

euti

cal

Acc

essi

bilit

y an

d Pr

ice

Redu

ctio

n w

as a

ppro

ved

in J

uly

2009

. Fro

m 2

010

ther

e w

ere

new

requ

irem

ents

for

gen

eric

pric

ing,

e.g

. the

fir

stge

neri

c ha

s to

be

pric

ed 3

0% b

elow

the

orig

inat

or, w

hile

the

seco

nd a

nd t

hird

gen

eric

sm

ust

be p

rice

d at

leas

t10

% le

ss t

han

the

firs

t

Dec

reas

e of

10%

insa

lari

es o

f m

edic

al s

taff

in 2

009

and

6% d

ecre

ase

in 2

010.

Mov

ing

from

the

cur

rent

nati

onal

cas

e-ba

sed

paym

ent

for

hosp

ital

s to

an

inte

rnat

iona

llyre

cogn

ized

sta

ndar

ddi

agno

sis-

rela

ted

grou

ps s

yste

m w

as in

prep

arat

ion

in 2

011.

In 2

009

apr

ogra

mm

e of

reor

gani

zati

on

of t

he n

etw

ork

ofm

edic

al in

stit

utio

nsin

to d

istr

ict,

regi

onal

and

nati

onal

leve

ls

was

intr

oduc

ed.

Uni

ting

hos

pita

lsin

to la

rger

lega

len

titi

es r

educ

edth

e nu

mbe

r of

inst

itut

ions

prov

idin

g he

alth

Hea

lth

care

sys

tem

refo

rms

of 2

009

have

apr

imar

y go

al t

o re

duce

the

volu

me

of in

pati

ent

serv

ices

, whi

le d

irec

ting

avai

labl

e fu

nds

topr

imar

y he

alth

car

e,ou

tpat

ient

aid

(inc

reas

eby

at

leas

t 5%

), as

wel

l as

day

inpa

tien

t (in

crea

seth

e vo

lum

e by

at

leas

t8%

) and

nur

sing

ser

vice

s,an

d to

red

irec

t he

alth

care

spe

cial

ists

to

outp

atie

nt a

nd d

ay


gene

ric

to b

e re

imbu

rsed

.A

new

ly p

rice

d ca

talo

gue

of m

edic

ines

whi

ch a

rere

imbu

rsed

fro

m t

heCH

IF w

as e

nact

ed.

Med

icin

es s

tart

ed t

o be

reim

burs

ed a

ccor

ding

to

acti

ve s

ubst

ance

(IN

N) o

fth

e pr

oduc

t an

d pa

tien

tha

s th

e ri

ght

to c

hoos

em

edic

ine

for

whi

ch c

o-pa

ymen

t is

sm

alle

st. T

heba

se p

rice

of

mor

e th

an10

00 m

edic

ines

was

redu

ced.

Bef

ore

this

refo

rm, p

erso

nal e

xpen

ses

for

the

co-p

aym

ents

for

thes

e pr

oduc

ts c

ompr

ised

LTL

130

mill

ion

per

year

;it

is e

stim

ated

tha

t if

pati

ents

cho

ose

chea

per

med

icin

es f

rom

the

new

pric

e ca

talo

gue,

LTL

80

mill

ion

per

year

of

pers

onal

exp

ense

s w

ill

be s

aved

. Com

puls

ory

HIF

expe

ndit

ure

on d

rugs

and

med

ical

dev

ices

inth

e am

bula

tory

car

ese

ctor

dec

reas

ed f

rom

EUR

197.

88 m

illio

n in

200

8to

EU

R 20

1.64

mill

ion

in20

09 a

nd E

UR

189.

22m

illio

n in

201

0, w

hile

the

num

ber

of p

resc

ript

ions

rose

.

care

ser

vice

s by

24.

The

econ

omic

effe

ct is

ant

icip

ated

to b

e LT

L 13

7m

illio

n.

Rest

ruct

urin

g of

the

Min

istr

y of

Hea

lth

and

inst

itut

ions

acco

unta

ble

to

it w

as s

tart

ed in

2009

–201

0.

Reor

gani

zati

on

of p

ublic

hea

lth

–se

ven

publ

ic h

ealt

hin

stit

utio

ns w

ere

mer

ged

in 2

009–

2010

.

surg

ery

serv

ices

, as

wel

las

long

-ter

m c

are.

105

Policy summary

106

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Mal

taA

lega

l fra

mew

ork

to s

eta

max

imum

ref

eren

cepr

ice

at t

he p

oint

of

deci

sion

reg

ardi

ng e

ntry

into

the

for

mul

ary

was

esta

blis

hed

in 2

009.

Thi

sis

yie

ldin

g th

e de

sire

dre

sult

s. D

urin

g 20

10,

cert

ain

pric

es o

f m

edic

ines

decr

ease

d, r

esul

ting

inm

ore

favo

urab

le p

rice

sfo

r pu

blic

pro

cure

men

t.

Net

herl

ands

From

201

0, p

olic

ies

allo

win

g H

IFs

to h

ave

a gr

eate

r ro

le in

purc

hasi

ng c

are

acce

lera

ted,

pla

ying

an

impo

rtan

t ro

le in

the

redu

ctio

n of

pri

ces

of,

for

exam

ple,

med

icin

esan

d ex

ecut

ing

a“p

refe

rent

ial p

olic

y” t

oke

ep d

rug

pric

es u

nder

cont

rol.

From

201

0, a

s pa

rt o

f th

ech

ange

s to

pur

chas

ing

bySH

I fun

ds, p

harm

acis

tsre

ceiv

e a

pre-

defi

ned

fee

for

each

ser

vice

and

bonu

ses

are

rem

oved

.

From

201

0, g

reat

erin

tegr

atio

n of

pri

mar

yca

re a

t th

e co

mm

unit

yle

vel t

o re

duce

use

of

hosp

ital

car

e an

dpr

omot

ion

of e

-men

tal

heal

th t

o in

crea

se s

elf-

man

agem

ent.

In li

ne w

ith

the

refo

rm

of t

he D

utch

hea

lth

care

syst

em in

200

6, f

rom

2010

, the

pri

vate

mar

ket

was

fur

ther

sti

mul

ated

to

inve

st in

the

hea

lth

care

sec

tor.

Ther

efor

e a

syst

em o

f re

gula

ted

prof

it c

reat

ion

in h

ealt

hca

re w

as in

trod

uced

. Thi

ssh

ould

lead

to

exte

rnal


(pri

vate

) cap

ital

for

car

ein

nova

tion

s, q

ualit

yim

prov

emen

ts, p

atie

ntlo

gist

ics

and

bett

erse

rvic

e. N

o pr

ofit

s fo

rca

re p

rovi

ders

will

be

allo

cate

d du

ring

the

fir

stth

ree

year

s af

ter

the

date

of in

vest

ing.

Inst

rum

ents

and

regu

lati

ons

are

desi

gned

to

ensu

re c

riti

cal

care

whe

n fi

nanc

ial

prob

lem

s ap

pear

inho

spit

als,

str

essi

ng t

here

spon

sibi

lity

of h

ospi

tals

thro

ugh

an “

earl

yw

arni

ng s

yste

m”.

Exi

tbo

nuse

s fo

r m

anag

ers

inth

e he

alth

car

e se

ctor

are

rest

rict

ed t

o a

max

imum

of E

UR

75 0

00.

Nor

way

Pola

ndA

new

law

was

pre

sent

edby

the

gov

ernm

ent

in20

11, t

o re

gula

te t

here

imbu

rsed

dru

gs m

arke

t.Th

e ke

y el

emen

ts o

f th

ere

gula

tion

s ar

e as

follo

ws:

max

imum

lim

itof

NH

F ex

pend

itur

es f

ordr

ugs

reim

burs

emen

tw

as e

stab

lishe

d at

the

leve

l of

17%

of

tota

lex

pend

itur

es –

whe

n th

e lim

it is

exc

eede

d,pr

oduc

ers

ofph

arm

aceu

tica

ls in

clud

edin

the

rei

mbu

rsem

ent

syst

em w

ill b

e ob

liged

to

New

law

intr

oduc

ed in

2011

to

allo

w h

ospi

tals

to b

e co

rpor

atiz

ed.

They

will

con

tinu

e to

be

publ

icly

ow

ned

but

will

be s

ubje

ct t

o ba

nkru

ptcy

law

s. T

his

is in

tend

ed

to im

prov

e fi

nanc

ial

man

agem

ent.

107

Policy summary

108

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Pola

nd(c

ont.

)pa

y ba

ck c

erta

in a

mou

nts;

max

imum

mar

gin

ondr

ugs

sold

by

who

lesa

lers

and

phar

mac

ies;

pri

ces

ofre

imbu

rsed

dru

gs in

phar

mac

ies

will

be

fixe

d;no

dis

coun

ts a

re a

llow

edbe

twee

n w

hole

sale

rs a

ndph

arm

acie

s. T

he la

w is

very

muc

h cr

itic

ized

by

the

phar

mac

euti

cal

indu

stry

, pha

rmac

ies

and

othe

r in

tere

sted

par

ties

,bu

t ha

s a

stro

ng s

uppo

rtfr

om t

he g

over

nmen

tan

d th

e Pa

rlia

men

t.

Port

ugal

From

201

1, c

entr

aliz

edpr

ocur

emen

t of

med

icin

esan

d di

agno

stic

tes

ts;

redu

ctio

ns in

pri

cing

and

reim

burs

emen

t; f

aste

rav

aila

bilit

y of

gen

eric

s,pr

escr

ibin

g by

act

ive

ingr

edie

nt, p

resc

ribi

nggu

idel

ines

, e-p

resc

ribi

ng.

Mea

sure

s in

clud

ed in

the

2011

nat

iona

l bud

get:

(1) P

rice

red

ucti

on o

nge

neri

c dr

ugs

that

hav

ehi

gh p

rice

s co

mpa

red

wit

h in

tern

atio

nal o

nes,

From

201

0, m

easu

res

rega

rdin

g pu

blic

wor

kers

incl

udin

g he

alth

wor

kers

:

(1) F

reez

ing

sala

ries

.

(2) F

reez

ing

prom

otio

nsan

d ca

reer

pro

gres

sion

inpu

blic

adm

inis

trat

ion.

(3) F

reez

ing

adm

issi

ons

and

redu

cing

the

num

ber

of h

ired

peo

ple

(esp

ecia

llyw

orke

rs w

ith

mor

epr

ecar

ious

con

trac

ts).

(4) R

educ

ing

som

eex

pens

es s

uch

as s

ome

Mov

e to

per

cap

ita

paym

ent

in 2

011.

From

Dec

embe

r20

10: e

limin

atin

gth

e pr

acti

ce o

f“i

ndis

crim

inat

e”ch

eck-

ups

and

rout

ine

exam

sw

itho

utte

chni

cal/s

cien

tifi

cfo

unda

tion

;in

trod

ucin

gm

easu

res

inin

form

atio

nsy

stem

s to

pre

vent

the

pres

crip

tion

of

exa

ms

wit

h no

Targ

et t

o sa

ve

5% o

n cu

rren

tex

pend

itur

e co

sts

inev

ery

depa

rtm

ent/

med

ical

ser

vice

,ex

clud

ing

pers

onne

lco

sts,

in 2

011.

The

Off

ice

of t

heH

igh

Com

mis

sion

erfo

r H

ealt

h is

sche

dule

d fo

rcl

osur

e af

ter

publ

ishi

ng t

heN

atio

nal H

ealt

hPl

an 2

011–

2016

.

Follo

win

g pa

st t

rend

s in

rece

nt y

ears

, the

re h

asbe

en a

red

ucti

on in

hosp

ital

bed

s an

d m

ore

rece

ntly

clo

sure

of

prim

ary

care

cen

tres

.D

ata

rega

rdin

g be

ds p

er10

0 00

0 in

habi

tant

s sh

owa

decr

ease

fro

m 3

36.7

beds

in h

ospi

tals

in 2

008

to 3

34.8

in 2

009

and

from

5.5

bed

s in

pri

mar

yhe

alth

cen

tres

in 2

008

to4.

6 in

200

9. R

egar

ding

the

num

ber

of p

rim

ary


star

ting

wit

h th

e m

ost

sold

gen

eric

s om

epra

zol

and

sim

vast

atin

: pri

ces

shou

ld b

e at

leas

t 35

%lo

wer

tha

n th

e br

and

phar

mac

euti

cal d

rug.

(2) P

rice

red

ucti

on o

f7.

5% o

n bi

olog

ical

phar

mac

euti

cal d

rugs

.

(3) P

rice

red

ucti

on o

nsu

pple

men

tary

dia

gnos

tic

and

ther

apeu

tic

proc

edur

es: 5

% o

n cl

inic

aldi

agno

stic

tes

ts a

nd 3

%on

med

ical

imag

ing.

(4) P

rice

red

ucti

on o

f10

% o

n gl

ycae

mic

cont

rol c

onsu

mab

le

test

str

ips

for

diab

etic

s.

(5) P

rice

red

ucti

on o

nha

emod

ialy

sis.

(6) D

ecre

ase

the

pric

e of

phar

ma

good

s su

bsid

ized

by s

tate

by

6%.

trav

el a

nd e

atin

gex

pens

es, o

vert

ime

cost

s,el

imin

atin

g th

epo

ssib

ility

of

rece

ivin

gpu

blic

sal

arie

s w

hile

als

ore

ceiv

ing

pens

ions

. Thi

sle

d to

an

unex

pect

edin

crea

se in

ret

irem

ent

of d

octo

rs; n

earl

y 60

0do

ctor

s ha

d as

ked

for

reti

rem

ent

byN

ovem

ber

2010

.

adva

ntag

e to

th

e pa

tien

t;di

scip

linin

gco

nsum

ptio

n in

am

bula

tory

hosp

ital

; cha

rgin

ga

fina

ncia

l pen

alty

in c

ase

ofin

appr

opri

ate

use

of p

harm

aceu

tica

ldr

ugs.

heal

th c

entr

es, m

ore

rece

ntly

the

re h

as b

een

a sl

ight

dec

reas

e of

prim

ary

heal

th c

entr

es(f

or e

xam

ple

377

in 2

008

to 3

75 in

200

9), b

ut a

very

str

ong

decr

ease

inpr

imar

y he

alth

cen

tre

outp

osts

or

peri

pher

alun

its

(177

8 in

200

8 to

1318

in 2

009)

.

Repu

blic

of

Mol

dova

In 2

009,

dev

elop

men

t of

perf

orm

ance

ass

essm

ent

and

resu

lts-

base

dfi

nanc

ing,

aim

ing

atm

edic

al p

erso

nnel

mot

ivat

ion,

qua

lity

impr

ovem

ent

and

reso

urce

eff

icie

ncy.

Th

e he

alth

pro

vide

rsco

ntra

cted

wit

hin

man

dato

ry h

ealt

hin

sura

nce

are

paid

an

d re

imbu

rsed

in li

new

ith

tari

ffs

and

cost

The

Min

istr

y of

Hea

lth

has

draw

nup

a p

lan

of a

ctio

nto

com

bat

and

mit

igat

e th

eef

fect

s of

the

cri

sis

on p

ublic

hea

lth,

inac

cord

ance

wit

hth

e pr

ovis

ions

of

the

prog

ram

me

tost

abili

ze a

nd r

eviv

eth

e ec

onom

y of

the

coun

try

for

2009

–201

1. It

Des

pite

the

res

tric

tion

sin

trod

uced

by

the

Min

istr

y of

Fin

ance

on

capi

tal i

nves

tmen

ts, a

ndlim

itat

ions

on

staf

fing

and

trai

ning

exp

endi

ture

s,th

e M

inis

try

of H

ealt

hsu

ccee

ded

in m

aint

aini

ngan

d ev

en in

crea

sing

the

fina

ncin

g of

suc

h do

mai

nsby

pas

sing

a n

ewam

endm

ent

in t

he L

awon

Man

dato

ry H

ealt

hIn

sura

nce.

Thu

s a

law

109

Policy summary

110

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Repu

blic

of

Mol

dova

(con

t.)

of m

edic

al s

ervi

ces,

appr

oved

com

mon

ly b

yM

inis

try

of H

ealt

h an

dth

e N

atio

nal H

ealt

hIn

sura

nce

Com

pany

base

d on

a s

peci

alfo

rmul

a th

at in

clud

esca

ps o

n ov

erhe

ads

and

som

e ru

nnin

g co

sts,

and

adju

sted

eac

h ye

ar in

the

cont

ext

of t

he r

ate

ofin

flat

ion

and

tren

ds in

HIF

s’ a

ccum

ulat

ion

ofre

venu

e an

d sp

endi

ng.

envi

sage

sre

dist

ribu

ting

th

e fi

nanc

ing

ofdi

ffer

ent

type

s an

d le

vels

of

heal

th a

ssis

tanc

e,in

clud

ing

inpa

tien

tad

vanc

edte

chno

logy

and

expe

nsiv

e m

edic

alse

rvic

es. P

rior

ity

fund

ing

ofem

erge

ncy

and

prim

ary

heal

th c

are

(mor

e th

an 3

1% o

fth

e fu

nds

of C

MI)

perm

itte

d th

em

aint

enan

ce

of a

cces

s to

appr

opri

ate

med

ical

serv

ices

and

exte

nsio

n of

the

list

of c

ompe

nsat

edm

edic

atio

ns.

adop

ted

by t

hePa

rlia

men

t in

Jul

y 20

10le

giti

mat

ed t

he n

ew“f

und

for

deve

lopm

ent

and

mod

erni

zati

on o

f th

epu

blic

hea

lth

prov

ider

s”w

ithi

n th

e m

anda

tory

heal

th in

sura

nce

fram

ewor

k. T

he f

inan

cial

reso

urce

s co

llect

ed a

reus

ed p

redo

min

antl

y fo

rca

paci

ty d

evel

opm

ent

ofhe

alth

pro

vide

rs, i

nclu

ding

capi

tal i

nves

tmen

ts,

proc

urem

ent

of m

oder

nan

d ex

pens

ive

equi

pmen

t,sa

nita

ry t

rans

port

,in

form

atio

n te

chno

logi

es,

etc.

Inve

stm

ent

plan

s fo

rco

stly

equ

ipm

ent

wer

ere

view

ed a

nd p

ut o

nho

ld in

200

9.

Rom

ania

Und

er p

ress

ure

from

phar

mac

eutic

al c

ompa

nies

and

who

lesa

lers

, the

Min

istr

y of

Hea

lth

upda

ted

pric

es o

fph

arm

aceu

tica

ls t

o re

flec

tth

e ne

w e

xcha

nge

rate

In 2

010

the

gove

rnm

ent

cut

the

sala

ries

of

all

staf

f em

ploy

ed in

the

publ

ic s

ecto

r, in

clud

ing

hosp

ital

phy

sici

ans

and

othe

r ho

spit

al p

erso

nnel

by 2

5%. T

his

led

to

From

200

9 on

war

ds t

hepo

int

valu

e ba

se o

nw

hich

GPs

are

reim

burs

ed d

ecre

ased

as

per

the

fra

mew

ork

cont

ract

whi

ch s

tipu

late

sth

at a

ny f

luct

uati

on in

At

the

begi

nnin

gof

201

1 M

inis

try

ofH

ealt

h an

noun

ced

the

mer

ger

of

111

hosp

ital

s;

71 h

ospi

tals

will

be

con

vert

ed in

to

Befo

re t

he c

risi

s th

eM

inis

try

of H

ealt

han

noun

ced

a pl

an t

obu

ild a

bout

eig

ht n

ewho

spit

als

for

whi

ch a

prel

imin

ary

feas

ibili

tyst

udy

was

don

e. A

s a


(it h

ad w

orse

ned

due

to in

flat

ion)

cau

sing

an

incr

ease

in p

rice

s in

200

9.

In 2

011

the

NH

IF c

hang

edth

e re

fere

nce

pric

esy

stem

for

rei

mbu

rsed

drug

s in

ord

er t

o co

ntai

nco

sts

by s

tim

ulat

ing

the

pres

crip

tion

of

med

icin

esw

ith

pric

es b

elow

the

refe

renc

e pr

ice.

A c

law

-bac

k m

echa

nism

for

phar

mac

euti

cal

com

pani

es w

asin

trod

uced

in 2

010

(aft

er V

AT

dedu

ctio

n a

perc

enta

ge f

rom

the

tota

l sal

es o

f re

imbu

rsed

drug

s ha

s to

be

paid

bac

kto

Min

istr

y of

Hea

lth;

the

claw

-bac

k ra

te is

on

asl

idin

g sc

ale

depe

ndin

gon

val

ue o

f to

tal s

ales

).

a de

crea

se in

the

cont

ribu

tion

for

hea

lth

(to

unde

rsta

nd t

he

scal

e of

thi

s it

is w

orth

men

tion

ing

that

in 2

010

wer

e ab

out

1.4

mill

ion

publ

ic e

mpl

oyee

s ou

t of

abo

ut 4

mill

ion

cont

ribu

tors

to

the

HIF

).

the

inco

me

of t

he N

HIF

can

be r

efle

cted

in t

hepa

ymen

t le

vel o

f th

epr

imar

y ca

re.

A n

ew s

yste

m o

f G

Ppa

ymen

t (r

educ

ing

the

per

capi

ta c

ompo

nent

of

GP

reve

nue

in f

avou

r of

fee-

for-

serv

ice

linke

dw

ith

som

e pe

rfor

man

ceev

alua

tion

) and

alim

itat

ion

of n

umbe

r of

hour

s w

orke

d pe

r w

eek

was

pro

pose

d as

par

t of

a re

vise

d G

P fr

amew

ork

cont

ract

in 2

010;

it w

asre

ject

ed b

y G

Ps a

nd w

asbe

ing

revi

sed

in 2

011.

nurs

ing

hom

es f

orth

e el

derl

y.

Incr

ease

dac

coun

tabi

lity

inth

e m

anag

emen

tof

hos

pita

ls w

astr

ansf

erre

d to

loca

lgo

vern

men

t as

part

of

an o

ngoi

ngpr

oces

s of

dece

ntra

lizat

ion.

Plan

to

intr

oduc

e a

new

hea

lth

info

rmat

ion

syst

eman

d an

“in

sure

rca

rd”

in o

rder

to

incr

ease

eff

icie

ncy

in t

he s

yste

m a

ndre

duce

bur

eauc

racy

anno

unce

d in

2010

.

resu

lt o

f th

e fi

nanc

ial

cris

is t

his

plan

was

aban

done

d. P

urch

ase

of e

quip

men

t w

as a

lso

redu

ced.

Russ

ian

Fede

rati

on

An

esse

ntia

l dru

gs li

stpr

icin

g re

gula

tion

,re

gist

erin

g pr

oduc

ers’

pric

es a

nd li

mit

ing

max

imum

who

lesa

le

and

reta

il m

ark-

ups

was

impl

emen

ted

in 2

010.

Libe

raliz

atio

n of

the

lega

l sta

tus

of s

tate

an

d m

unic

ipal

fac

iliti

es:

they

will

bec

ome

eith

er“a

uton

omou

s no

n-pr

ofit

-m

akin

g” “

budg

etar

y” o

r“g

over

nmen

t” f

acili

ties

.Th

e fo

rmer

tw

o ty

pes

will

hav

e th

e ri

ght

toch

arge

cit

izen

s fo

r pu

blic

serv

ices

and

will

be

perm

itted

to g

o ba

nkru

pt.

They

are

to

be p

aid

acco

rdin

g to

fix

ed b

lock

gran

ts f

or a

cer

tain

volu

me

of s

ervi

ces,

wit

h

Ove

rall

RUB

460

billi

on(U

SD 1

5 bi

llion

) is

expe

cted

to

be u

sed

for

a m

oder

niza

tion

pro

ject

over

tw

o ye

ars

(201

1–20

13).

The

split

of

the

addi

tion

al t

axes

col

lect

edis

ske

wed

tow

ards

cap

ital

inve

stm

ent

(bui

ldin

g an

dre

nova

tion

, med

ical

equi

pmen

t –

RUB

300

billi

on),

wit

h th

ein

form

atio

n sy

stem

sde

velo

pmen

t co

mpo

nent

rece

ivin

g RU

B 34

bill

ion

and

the

Med

ical

111

Policy summary

112

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Russ

ian

Fede

rati

on(c

ont.

)

care

pro

vide

d ab

ove

the

thre

shol

d at

the

exp

ense

of t

he c

itiz

ens.

The

cate

gori

zati

on o

ffa

cilit

ies

into

the

thr

eegr

oups

was

exp

ecte

d in

2011

, but

is s

till

ongo

ing,

wit

h ef

fect

as

of 2

013.

Stan

dard

izat

ion

proj

ect

(the

leas

t cl

ear

in t

erm

sof

con

tent

) get

ting

RU

B 13

6 bi

llion

.

Serb

iaTh

e pu

blic

HIF

ask

edph

arm

aceu

tica

lco

mpa

nies

to

redu

ceth

eir

pric

es, a

nd in

resp

onse

pha

rmac

euti

cal

com

pani

es w

aive

d 10

%of

tot

al s

ales

for

Mar

ch20

11 t

hrou

gh M

arch

2012

wit

h th

e po

ssib

ility

of a

n ex

tens

ion

of t

his

arra

ngem

ent.

In s

imila

rfa

shio

n, t

he H

IF is

try

ing

to r

educ

e ex

pend

itur

esfo

r m

edic

al d

evic

es b

ut it

is u

ncle

ar y

et w

heth

erth

is w

ill b

e su

cces

sful

.

Sinc

e 20

10, h

ouse

keep

ing

and

IT s

uppo

rt w

orke

rsin

hea

lth

care

inst

itut

ions

(who

are

pri

vate

lyco

ntra

cted

) hav

e ac

cept

edlo

wer

wag

es s

o th

at t

hey

have

bee

n ab

le t

o ke

epth

eir

cont

ract

s. O

ften

this

has

mea

nt t

hat

thei

rco

ntra

cts

stay

ed t

hesa

me

in d

inar

s (R

SD) b

utde

crea

sed

in r

eal t

erm

sdu

e to

infl

atio

n an

d th

edi

nar

to e

uro

exch

ange

rate

.


Slov

akia

Re

fere

nce

base

d dr

ugpr

icin

g w

as in

trod

uced

in

200

9 an

d 20

10. I

t ha

sbe

en t

he k

ey p

olic

ych

ange

mit

igat

ing

the

impa

ct o

f th

e 20

09 c

risi

s.

Acu

te la

ck o

ffu

ndin

g in

the

Gen

eral

Hea

lth

Insu

ranc

e Co

mpa

nyle

d to

del

ayed

paym

ents

to

phar

mac

ies

and

prov

ider

s. T

hego

vern

men

tst

eppe

d in

to

resc

ueit

. Thi

s st

ep w

asdi

sgui

sed

by t

hem

erge

r w

ith

the

Com

mon

Hea

lth

Insu

ranc

e Co

mpa

ny(C

HIC

) on

1 Ja

nuar

y20

10. T

he m

erge

rse

cure

d EU

R 65

mill

ion

from

the

stat

e bu

dget

an

d an

othe

rap

prox

imat

ely

EUR

33 m

illio

n fr

om t

he f

inan

cial

rese

rves

of t

he C

HIC

.

Slov

enia

In

200

9 th

e N

HIF

rev

ised

lists

of

med

icin

es; r

educ

edpr

ices

of

med

icin

esth

roug

h ne

goti

atio

nw

ith

supp

liers

; pro

vide

din

form

atio

n to

the

pub

licre

gard

ing

prop

er u

se o

fm

edic

ines

; pro

vide

dtr

aini

ng in

rat

iona

lpr

escr

ibin

g fo

rph

ysic

ians

; and

red

uced

the

pric

e of

dia

lysi

s du

e to

low

er p

rice

s of

ery

thro

poie

tin.

Mea

sure

s ad

opte

d by

the

gove

rnm

ent

in t

he f

ield

of p

ublic

sec

tor

sala

ries

(tot

al s

avin

gs E

UR

23m

illio

n ea

ch y

ear)

: in

2009

the

re h

as b

een

noad

just

men

t of

bas

ic s

alar

yto

infl

atio

n; in

201

0 th

isad

just

men

t w

as lo

wer

than

infl

atio

n ra

te;

dela

ying

fur

ther

elim

inat

ion

of w

age

disp

arit

ies

(unt

ilec

onom

ic g

row

thim

prov

es s

ubst

anti

ally

);

In 2

009

the

NH

IF r

educ

edth

e pr

ice

of h

ealt

hse

rvic

es (g

ener

ally

) by

2.5%

and

impl

emen

ted

pena

ltie

s fo

r he

alth

car

epr

ovid

ers

rela

ted

to t

hebr

each

of

the

cont

ract

betw

een

the

fund

and

the

prov

ider

.

In 2

009:

sel

ecti

vere

duct

ion

inm

ater

ial c

osts

by

the

NH

IF, r

educ

tion

of d

irec

t co

sts

ofN

HIF

.

In 2

009

the

NH

IF r

educ

edex

pend

itur

e on

ter

tiar

yse

rvic

es b

y 5%

.

113

Policy summary

114

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Slov

enia

(con

t.)

abol

itio

n of

the

allo

wan

cefo

r ov

er-p

erfo

rman

cefr

om A

pril

2009

onw

ards

.N

HIF

intr

oduc

edm

easu

res

to r

educ

eab

sent

eeis

m:

stre

ngth

enin

g th

e la

yco

ntro

l of

abse

nce

from

wor

k; t

rain

ing

inas

sess

men

t m

etho

dsre

gard

ing

abse

nce

from

wor

k fo

r G

Ps.

Spai

nN

atio

nal l

evel

: att

empt

sto

red

uce

phar

mac

euti

cal

expe

ndit

ures

(thr

ough

mor

e fa

vour

able

nego

tiat

ion

wit

h th

e ph

arm

aceu

tica

lpr

ovid

ers,

but

not

thro

ugh

mor

e ef

fici

ent

use

of m

edic

ines

).

Cata

lan

plan

: fro

m

2011

, dev

elop

eff

icie

ntpr

escr

ibin

g st

rate

gies

base

d on

cos

tef

fect

iven

ess,

co

-res

pons

ibili

ty a

mon

gpr

ovid

ers

and

pati

ents

,us

e of

gen

eric

s or

low

er-

cost

alt

erna

tive

.

Nat

iona

l lev

el: s

hort

-te

rm r

educ

tion

of

sala

ries

to

all c

ivil

serv

ants

(hea

lth

pers

onne

l inc

lude

d)in

itia

ted

by t

he T

reas

ury

from

201

0.

Cata

loni

a: n

egot

iati

on o

fco

ntra

cts

wit

h pr

ovid

ers

and

redu

ctio

n in

pric

e pa

idpe

r m

edic

al a

ct r

educ

edby

2%

fro

m 2

011.

Cata

loni

a: f

rom

2011

, dev

elop

prio

riti

zati

onst

rate

gies

in c

linic

alpr

acti

ce; g

uara

ntee

bett

er p

roce

ssor

gani

zati

on;

impr

ove

the

qual

ity

and

effe

ctiv

enes

s of

clin

ical

man

agem

ent

of p

harm

aceu

tica

lpr

escr

ibin

g;m

onit

orin

g qu

alit

yan

d kn

owle

dge

ofhe

alth

pro

fess

iona

ls;in

terv

enti

ons

topr

omot

e re

spon

sible

use

of h

ealt

hse

rvic

es a

mon

g th

e po

pula

tion

.

Cata

loni

a: f

rom

2011

, int

rodu

ctio

nof

adm

inis

trat

ive

sim

plif

icat

ion

rule

s(e

xpec

ted

impa

ct is

to in

crea

se s

avin

gsby

25%

), in

clud

ing

aust

erit

y m

easu

res,

to t

he m

anag

emen

tof

hea

lth

cent

res

and

grea

ter

use

of e

lect

roni

cm

anag

emen

t.

From

201

1, in

Cat

alon

ia:

mor

e us

e of

IT s

yste

man

d e-

heal

th. P

rior

itiz

ein

vest

men

t in

repl

acem

ent

of e

xist

ing

infr

astr

uctu

re (r

athe

rth

an n

ew in

fras

truc

ture

).


Swed

enM

any

coun

ty c

ounc

ils a

repl

anni

ng r

educ

tion

s in

hum

an r

esou

rces

thr

ough

an e

mpl

oym

ent

free

ze,

e.g.

by

not

repl

acin

gre

tire

d st

aff

or n

ot u

sing

stan

d-in

s w

hen

pers

onne

lar

e on

sic

k le

ave.

Swit

zerl

and

The

form

erYu

gosl

avRe

publ

ic o

fM

aced

onia

In 2

010,

for

the

fir

st t

ime

the

HIF

use

d re

fere

nce

pric

es f

or d

rugs

on

apo

siti

ve li

st t

hat

isad

just

ed b

ased

on

drug

pri

ces

in S

love

nia,

Croa

tia,

Ser

bia,

Bul

gari

a.Th

is a

llow

ed t

he H

IF t

opu

rcha

se m

ore

new

drug

s w

ithi

n th

e sa

me

budg

et a

nd m

ore

drug

sfo

r th

e in

sure

d w

itho

utco

-pay

men

t (in

crea

se

of 7

6%).

In J

anua

ry 2

011,

to

try

to c

ompe

nsat

e fo

r th

eem

igra

tion

of

heal

thw

orke

rs, t

he M

inis

try

of H

ealt

h ap

prov

ed t

heem

ploy

men

t of

an

addi

tion

al 2

00 d

octo

rs,

60 n

urse

s, 2

0 X

-ray

and

lab

tech

nici

ans

in p

ublic

heal

th o

rgan

izat

ions

,w

hich

will

cos

t EU

R 2–

2.5

mill

ion

annu

ally

. Thi

s is

inte

nded

to

impr

ove

qual

ity

and

acce

ss in

publ

ic h

ealt

h in

stit

utio

ns,

as w

ell a

s to

pre

vent

qual

ifie

d m

edic

al s

taff

from

leav

ing

the

publ

icse

ctor

.

The

HIF

pai

d of

f al

l deb

tsof

hea

lth

inst

itut

ions

in

200

8, c

osti

ngap

prox

imat

ely

EUR

80m

illio

n. A

s a

resu

lt,

tran

sfer

s to

pub

lic h

ealt

hin

stit

utio

ns w

ere

redu

ced

in 2

009

by 6

.1%

.

In A

pril

2010

, the

val

ueof

a c

apit

atio

n po

int

was

dec

reas

ed b

y 10

%

(MK

D 5

) for

pri

mar

yhe

alth

car

e do

ctor

s fo

rsi

x m

onth

s, a

ltho

ugh

this

was

rev

erse

d af

ter

doct

ors

prot

este

d.

To in

crea

se t

he q

ualit

y of

heal

th s

ervi

ces

sinc

e th

ecr

isis

, the

re h

ave

been

mis

cella

neou

s he

alth

sect

or c

hang

es, i

nclu

ding

a re

orga

niza

tion

of

emer

genc

y m

edic

alse

rvic

es, t

hees

tabl

ishm

ent

of a

com

mit

tee

dedi

cate

d to

the

impr

ovem

ent

ofth

e he

alth

sec

tor,

and

impl

emen

tati

on o

f an

inte

grat

ed h

ealt

hm

anag

emen

tin

form

atio

n sy

stem

and

elec

tron

ic h

ealt

h ca

rd.

Turk

eyA

s of

200

9, t

here

imbu

rsem

ent

cap

in t

here

fere

nce

pric

e sy

stem

for

phar

mac

euti

cals

has

been

red

uced

(fro

m22

%) t

o 15

% o

f th

e pr

ice

of t

he m

ost

inex

pens

ive

med

icin

e th

at c

ould

be

pres

crib

ed f

or t

he s

ame

indi

cati

on. A

s a

resu

lt,

115

Policy summary

116

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Turk

ey (c

ont.

)so

me

phar

mac

euti

cal

com

pani

es w

hose

dru

gsw

ere

not

prev

ious

lyco

vere

d ha

ve v

olun

tari

lycu

t th

eir

pric

es in

ord

erto

be

cove

red

agai

n; t

his

has

led

to s

ubst

anti

alsa

ving

s, a

roun

dap

prox

imat

ely

TRY

1 b

illio

n.

Ukr

aine

In O

ctob

er 2

008

pric

esfo

r dr

ugs

and

med

ical

prod

ucts

incr

ease

ddr

amat

ical

ly d

ue t

ocu

rren

cy f

luct

uati

ons.

The

gove

rnm

ent

set

limit

s of

sup

ply

and

sale

sal

low

ance

s fo

r th

e dr

ugs

on t

he e

ssen

tial

dru

gsan

d m

edic

al p

rodu

cts

list

(not

hig

her

than

12%

of

who

lesa

le p

rice

s an

d no

tm

ore

than

25%

of

the

proc

urem

ent

pric

e;

for

drug

s an

d m

edic

alpr

oduc

ts, p

urch

ased

from

bud

geta

ry f

unds

–no

t ex

ceed

ing

10%

for

both

the

who

lesa

le a

ndpr

ocur

emen

t pr

ice)

. Th

e at

tem

pt o

f pr

ice

rete

ntio

n w

as n

otsu

cces

sful

and

res

ulte

d in

As

sala

ry f

alls

und

erpr

otec

ted

expe

ndit

ure,

in 2

009

sala

ryex

pend

itur

e ro

se a

tal

mos

t 3%

(the

n it

slig

htly

dec

reas

ed in

2010

). A

t th

e sa

me

tim

e, t

he g

over

nmen

t's

deci

sion

s re

late

d to

publ

ic s

ecto

r em

ploy

ees

adop

ted

in 2

009

(incr

ease

of

min

imal

an

d ba

sic

sala

ry) a

llow

edit

to

mai

ntai

n an

d ev

ensl

ight

ly r

aise

sal

arie

s (b

y4–

7%) f

or a

ll ca

tego

ries

of m

edic

al p

erso

nnel

.Th

e go

vern

men

tin

trod

uced

an

incr

ease

for

seni

orit

y (n

umbe

r of

wor

king

yea

rs) f

ordo

ctor

s an

d nu

rses

at

a ra

te o

f 10

% t

o 30

%

In 2

009,

des

pite

the

cris

is, t

heM

inis

try

of H

ealt

hde

velo

ped

ave

rtic

ally

org

aniz

edsy

stem

(ran

ging

from

the

Min

istr

yto

hea

lth

care

prov

ider

s) o

fm

anag

emen

t an

dco

ntro

l of

med

ical

care

qua

lity,

w

hich

incl

uded

mon

itor

ing

and

com

plia

nce

wit

hcl

inic

al p

roto

cols

and

med

ical

stan

dard

s.H

owev

er, n

osa

ncti

ons

for

non-

com

plia

nce

wit

hm

edic

al s

tand

ards

or m

otiv

atio

ns t

o

In 2

008

the

gove

rnm

ent

adop

ted

a pr

ogra

mm

e“O

verc

omin

g th

e im

pact

of t

he g

loba

l fin

anci

alcr

isis

and

ong

oing

deve

lopm

ent”

. A s

peci

alse

ctio

n w

as d

evot

ed t

oen

suri

ng t

he p

rovi

sion

of

hig

h-qu

alit

y an

dav

aila

ble

med

ical

serv

ices

, whe

re, i

npa

rtic

ular

, cer

tain

mea

sure

s to

opt

imiz

e th

ene

twor

k of

hea

lth

care

faci

litie

s w

ere

stip

ulat

ed.

In f

act,

the

pro

gram

me

was

not

impl

emen

ted.

In20

09, t

he n

umbe

r of

med

ical

fac

iliti

es h

ad n

otch

ange

d, t

he n

umbe

r of

beds

dec

reas

ed b

y 7%

due

to r

estr

uctu

ring

,in

itia

ted

by lo

cal


a re

duct

ion

of t

he r

ange

of d

rugs

ava

ilabl

e. It

als

oin

crea

sed

the

prop

orti

onof

hig

h-co

st d

rugs

,br

ough

t ab

out

are

duct

ion

in t

he n

etw

ork

of p

harm

acie

s, c

ause

d a

rise

of

unem

ploy

men

tin

thi

s se

ctor

and

cont

ribu

ted

to t

hegr

owth

of

soci

al t

ensi

on.

The

gove

rnm

ent,

hav

ing

resp

onde

d to

cri

tici

sm,

impl

emen

ted

a so

fter

and

mor

e m

arke

t-or

ient

ed m

echa

nism

of

pri

ce c

ontr

ol b

yin

trod

ucin

g a

form

ula

that

tak

es in

to a

ccou

ntcu

rren

cy f

luct

uati

ons.

In20

08 d

rug

pric

es r

ose

by15

% c

ompa

red

to t

hepr

evio

us y

ear,

in 2

009

by 4

2%, b

ut in

201

0 by

6.4%

. The

slo

wer

gro

wth

rate

of

pric

es w

as d

ue t

oth

e re

plac

emen

t of

dru

gspu

rcha

sed

in c

ount

ries

wit

h hi

gh c

osts

(Ger

man

yan

d Sw

itze

rlan

d) w

ith

drug

s fr

om c

ount

ries

wit

h lo

wer

cos

ts, i

npa

rtic

ular

fro

m In

dia,

as

wel

l as

drug

s pr

oduc

edlo

cally

.

of s

alar

y, s

igni

fica

ntly

rais

ing

the

sala

ry o

fm

edic

al s

taff

in 2

010

(by

24–5

3%).

Whi

le in

200

8in

USD

equ

ival

ent

the

sala

ries

of

med

ical

pers

onne

l hav

e be

enre

duce

d by

alm

ost

30%

,in

201

0 th

ey a

lmos

tre

turn

ed t

o th

e pr

e-20

08 le

vel.

follo

w t

hem

had

been

sti

pula

ted.

Ther

efor

e th

ispo

licy

had

nopr

acti

cal e

ffec

t on

the

act

ivit

ies

ofm

edic

al p

erso

nnel

.

auth

orit

ies,

whi

ch d

idno

t ha

ve s

uffi

cien

t fu

nds

for

the

mai

nten

ance

of

heal

th f

acili

ties

. As

are

sult

, the

num

ber

ofsm

all r

ural

hos

pita

lsde

crea

sed

by 5

0% a

sth

ey c

hang

ed t

heir

prof

ile t

o am

bula

tory

clin

ics.

Jud

ging

by

the

dyna

mic

s of

the

tot

alex

pend

itur

es, t

he m

ost

affe

cted

fun

ctio

ns a

rein

pati

ent

care

(red

ucti

onof

rea

l exp

endi

ture

s by

13%

, in

USD

equ

ival

ent

by 3

3.6%

), pr

ovis

ion

ofdr

ugs

(by

2.5%

and

25.5

% r

espe

ctiv

ely)

,pr

even

tion

ser

vice

s (9

% a

nd 3

0.3%

), bu

tm

ost

of a

ll, f

ixed

cap

ital

expe

ndit

ures

(by

22.4

%an

d 40

.7%

).

Dur

ing

the

cris

is t

here

have

bee

n ch

ange

s in

the

stru

ctur

e of

bud

geta

ryex

pend

itur

es f

or u

tilit

ies

of f

acili

ties

(gro

wth

in20

09 a

t 2%

wit

h so

me

decl

ine

in 2

010)

. Sha

re

of d

rug

and

food

expe

ndit

ure

has

stay

edre

lati

vely

sta

ble,

whi

leth

e sh

are

of f

ixed

cap

ital

expe

ndit

ures

tha

t do

no

t re

late

to

prot

ecte

dex

pend

itur

e de

clin

edsh

arpl

y in

200

8 (b

y m

ore

than

thr

ee t

imes

) and

in20

10 c

onti

nue

to r

emai

nlo

w (3

.7%

of

tota

l).

117

Policy summary

118

Coun

try

Pric

es o

f m

edic

al

good

sSa

lari

es a

nd m

otiv

atio

nof

hea

lth

sect

or w

orke

rsPa

ymen

ts t

o pr

ovid

ers

Prio

rity

set

ting

or

pro

toco

ls t

och

ange

acc

ess

to t

reat

men

ts,

coor

dina

tion

of

care

and

pat

tern

sof

use

Ove

rhea

d co

sts:

rest

ruct

urin

g th

eM

inis

try

of H

ealt

han

d pu

rcha

sing

agen

cies

Prov

ider

infr

astr

uctu

rean

d ca

pita

l inv

estm

ent

Uni

ted

Kin

gdom

(Eng

land

)

From

Apr

il 20

11, a

t le

ast

two-

year

pay

fre

ezes

for

heal

th p

rofe

ssio

nals

at

a ti

me

of r

isin

g in

flat

ion.

Plan

ned

mea

sure

s to

incr

ease

eff

icie

ncy

incl

ude

cont

inuo

usly

impr

ovin

g w

orkf

orce

prod

ucti

vity

.

Plan

ned

mea

sure

sto

incr

ease

effi

cien

cy in

clud

e:ap

plyi

ng b

est

prac

tice

thro

ugho

ut

the

NH

S in

the

man

agem

ent

of lo

ng-t

erm

cond

itio

ns;

driv

ing

dow

nin

cons

iste

ncie

s in

adm

issi

ons

and

outp

atie

ntap

poin

tmen

ts.

The

adm

inis

trat

ion

budg

et h

as b

een

redu

ced

by 3

3%

in t

he S

pend

ing

Revi

ew f

or t

hepe

riod

Apr

il 20

11 –

Mar

ch 2

014.

One

plan

ned

mea

sure

isa

redu

ctio

n in

the

num

ber

of a

rm’s

-le

ngth

bod

ies

(e.g

.H

ealt

h Pr

otec

tion

Age

ncy,

the

Foo

dSt

anda

rds

Age

ncy

and

the

Nat

iona

lTr

eatm

ent

Age

ncy

for

Subs

tanc

eM

isus

e) f

rom

18

to a

max

imum

of

10

by 2

014.

The

capi

tal s

pend

ing

budg

et h

as b

een

redu

ced

by 1

7% in

the

Spe

ndin

gRe

view

for

the

per

iod

Apr

il 20

11 –

Mar

ch 2

014.

Uzb

ekis

tan

Joint policy summaries

1. Addressing financial sustainability in health systemsSarah Thomson, Tom Foubister, Josep Figueras, Joseph Kutzin, Govin Permanand,Lucie Bryndová

2. Assessing future health workforce needsGilles Dussault, James Buchan, Walter Sermeus, Zilvinas Padaiga

3. Using audit and feedback to health professionals to improve the quality and safety of health careSigne Agnes Flottorp, Gro Jamtvedt, Bernhard Gibis, Martin McKee

4. Health system performance comparison: an agenda for policy, information and researchPeter C. Smith, Irene Papanicolas

HEN produces synthesis reports and summaries (available at http://www.euro.who.int/en/what-we-do/data-and-evidence/health-evidence-network-hen).

The Health Evidence Network (HEN) of theWHO Regional Office for Europe is a trustworthysource of evidence for policy-makers in the53 Member States in the WHO European Region.HEN provides timely answers to questions onpolicy issues in public health, health care andhealth systems through evidence-based reports orpolicy briefs, summaries or notes, and easy accessto evidence and information from a number ofweb sites, databases and documents on its website (http://www.euro.who.int/en/what-we-do/data-and-evidence/health-evidence-network-hen).

The European Observatory on Health Systemsand Policies is a partnership that supports andpromotes evidence-based health policy-makingthrough comprehensive and rigorous analysisof health systems in the European Region. Itbrings together a wide range of policy-makers,academics and practitioners to analyse trendsin health reform, drawing on experience fromacross Europe to illuminate policy issues. TheObservatory’s products are available on its website (http://www.healthobservatory.eu).

ISSN 2077-1584

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