Migration and health: enhancing intercultural competence and diversity sensitivity

Access to responsive, people-centred health systems is essential to ensure appropriate health care for refugees and migrants throughout the process of migration and settlement. Focusing on intercultural competence and diversity sensitivity, this toolkit contributes to a broader WHO strategy to develop an evidence-based response to the public health needs of refugees and migrants. Aimed at health authorities at national, subnational and local levels, as well as health care practitioners, researchers, patients and caregivers, it provides an accessible introduction to the key concepts underpinning intercultural competence and diversity sensitivity; provides an overview of the types of action that can be taken to improve health care at organizational, systemic, professional and individual health care provider levels; uses case studies to examine methods and techniques that can be used to promote migrant participation at different stages of policy and practice; and provides an overview of factors to be considered in any initiative developed to promote intercultural competence and diversity sensitivity in health care.

Prospects for change: localizing global ambitions to country contexts

The WHO Regional Office for Europe initiated the cultural contexts of health and well-being (CCH) project in 2015 to acknowledge the critical role played by cultural contexts (including value systems, traditions and beliefs) in health, and to integrate a CCH approach into public health policy-making. The fifth meeting of the expert group of the CCH project was held in June 2019 at the Regional Office in Copenhagen, Denmark, to discuss the project’s next five-year strategic plan, explore ways to strengthen dissemination, outreach and knowledge-translation activities, and gather technical input on upcoming research publications. Key to the upcoming strategizing work of the CCH project will be the identification of priority policy levels (local, national, regional, global) to maximize impact, given the project’s scope and resources. This report outlines the recommendations made at the fifth meeting of the expert group.

Norway: health system review

This analysis of the Norwegian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Norway is among the wealthiestnations in the world, with low levels of income inequality. Norwegians enjoy long and healthy lives, with substantial improvement made due to effective and high-quality medical care and the impact of broader public health policies. However, this comes at a high cost, as the Norwegian health system is among the most expensive in Europe, with most financing coming from public funds. Yet there are several areas requiring substantial co-payments, such as adult dental care, outpatient pharmaceuticals, and institutional care for older or disabled people. Recent and ongoing reforms have focused on aligning provision of care to changing population health needs, including adapting medical education,strengthening primary care and improving coordination between primary and specialist care sectors. There has been an increasing use of e-health solutions, and information and communication technologies. Improvementsin measuring performance and a more effective use of indicators is expected to play a larger role in informing policy and planning of health services.

Mexico: health system review

This analysis of the Mexican health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Mexican health system consists of three main components operating in parallel: 1) employmentbased social insurance schemes, 2) public assistance services for the uninsured supported by a financial protection scheme, and 3) a private sector composed of service providers, insurers, and pharmaceutical and medical device manufacturers and distributors. The social insurance schemes are managed by highly centralized national institutions while coverage for the uninsured is operated by both state and federal authorities and providers. The largest social insurance institution – the Mexican Social Insurance Institute (IMSS) – is governed by a corporatist arrangement, which reflects the political realities of the 1940s rather than the needs of the 21st century. National health spending has grown in recent years but is lower than the Latin America and Caribbean average and considerably lower than the OECD average in 2015. Public spending accounts for 58% of total financing, with private contributions being mostly comprised of out-of-pocket spending. The private sector, while regulated by the government, mostly operates independently. Mexico’s health system delivers a wide range of health care services; however, nearly 14% of the population lacks financial protection, while the insured are mostly enrolled in diverse public schemes which provide varying benefits packages. Private sector services are in high demand given insufficient resources among most public institutions and the lack of voice by the insured to ensure the fulfilment of entitlements.Furthermore, the system faces challenges with obesity, diabetes, violence, as well as with health inequity. Recognizing the inequities in access created by its segmented structure, both civil society and government are calling for greater integration of service delivery across public institutions, although no consensus yet exists as to how to bring this about.

Latvia: health system review

This analysis of the Latvian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. After regaining independence in 1991, Latvia experimented with a social health insurance type system. However, to overcome decentralization and fragmentation of the system, the National Health Service (NHS) was established in 2011 with universal population coverage. More recently, reforms in 2017 proposed the introduction of a Compulsory Health Insurance System, with the objective of increasing revenues for health, which links access to different health care services to the payment of social health insurance contributions. In June 2019 the implementation of this proposal was postponed to 2021. Latvia has recovered from the severe economic recession of 2008, whichresulted in the adoption of austerity measures that significantly affected the health care system. The recovery has created fiscal space to focus on policy challenges neglected in the past, especially regarding health. Despite recent increases in spending, the health system remains underfunded and resources have to be allocated wisely. Latvia’s health outcomes should be considered within this context of limited health system resources. While life expectancy at birth in Latviahas increased since 2000, reaching 74.9 years in 2017, it remains among the lowest in the EU. Recent reforms have focused on improving access to services in rural/remote areas, increasing funding for health care services, and tougher regulation of tobacco and alcohol. However, a number of longstanding unresolved problems still need to be addressed, including financial sustainability and low public funding, high levels of unmet need, high rates of preventable and treatable mortality, and challenges in both communicable and noncommunicable diseases.

Finland: health system review

This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state with a high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasiblepolicy consensus has been challenging.

Serbia: health system review

This analysis of the Serbian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The health of the Serbian population has improved over the last decade. Life expectancy at birth increased slightly in recent years, but it remains, for example, around 5 years below the average across European Union countries. Some favourable trends have been observed in health status and morbidity rates, including a decrease in the incidence of tuberculosis, but population ageing means that chronic conditions and long-standing disabilityare increasing. The state exercises a strong governance role in Serbia’s social healthinsurance system. Recent efforts have increased centralization by transferring ownership of buildings and equipment to the national level. The health insurance system provides coverage for almost the entire population (98%). Even though the system is comprehensive and universal, with free access to publicly provided health services, there are inequities in access to primary careand certain population groups (such as the most socially and economically disadvantaged, the uninsured, and the Roma) often experience problems in accessing care. The uneven distribution of health professionals across the country and shortages in some specialities also exacerbate accessibility problems. High out-of-pocket payments, amounting to over 40% of totalexpenditure on health, contribute to relatively high levels of self-reported unmet need for medical care. Health care provision is characterized by the role of the “chosen doctor” in primary health care centres, who acts as a gatekeeper in the system. Recent public health efforts have focused on improving access to preventive health services, in particular, for vulnerable groups. Health system reforms since 2012 have focused on improving infrastructure and technology, and on implementing an integrated health information system. However, the country lacks a transparent and comprehensive system for assessing the benefits of health care investments and determining how to pay for them.

Poland: health system review

This analysis of the Polish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In late 2017, the Polish governmentcommitted to increase the share of public expenditures on health to 6% of GDP by 2024. If the GDP continues to grow in the years to come, this will present an opportunity to tackle mounting health challenges such as socioeconomicinequalities in health, high rates of obesity, rising burden of mental disorders and population ageing that put strain on health care resources. It is also an opportunity to tackle certain longstanding imbalances in the health sector, including overreliance on acute hospital care compared with other types of care, including ambulatory care and long-term care; shortages of human resources; the negligible role of health promotion and disease prevention vis-à-vis curative care; and poor financial situation in the hospital sector.Finally, the additional resources are much needed to implement important ongoing reforms, including the reform of primary care. The resources have to be spent wisely and waste should be minimized.The introduction, in 2016, of a special system (IOWISZ) of assessing investments in the health sector that require public financing (including from the EU funds) as well as the work undertaken by the Polish health technology assessment (HTA) agency (AOTMiT), which evaluates health technologies and publicly financed health policy programmes as well as sets prices of goods and services, should help ensure that these goals are achieved. Recent reforms, such as the ongoing reform of primary care that seeks to improvecoordination of care and the introduction of the hospital network, go in the right direction; however, a number of longstanding unresolved problems, such as hospital indebtedness, need to be tackled.

Embedding a cultural contexts of health approach across the WHO European Region / Fourth meeting of the expert group: London, United Kingdom, 26-27 April 2018

In 2015, the WHO Regional Office for Europe pioneered a transformative initiative acknowledging the role and significance of cultural contexts (including value systems, traditions and beliefs) in shaping health outcomes. The cultural contexts of health and well-being (CCH) project places cultural contexts at the heart of achieving better health outcomes for all. Supported by an expert group, the Regional Office has made considerable steps in clarifying key CCH concepts and supporting CCH research and analysis. The fourth meeting of the expert group, held in April 2018 at the Wellcome Trust headquarters in London, United Kingdom, was convened to take stock of existing progress and to reflect on the future strategic direction of the CCH project, focusing in particular on its stated aim to break new ground practically as well as conceptually. This report outlines recommendations made at the fourth meeting of the expert group.

Eesti: tervisesüsteemi ülevaade

Eesti tervisesüsteemi analüüs käsitleb viimast arengut tervisesüsteemi korralduses,juhtimises ja rahastamises, tervishoiuteenuste osutamises, tervisesüsteemireformides ja tulemuslikkuses. Eesti valitsus astus 2017. aastal ajaloolisesammu ja laiendas tervisesüsteemi tulubaasi, mis on pikka aega olnudprobleem. Lisanduv raha on protsendina SKPst siiski väike ning pikaajalisestabiilsuse saavutamine võib endiselt jääda probleemiks. Kui lisaraha investeeritaksetargalt, võib see tervisesüsteemi täiustamisele positiivselt mõjuda.Ehkki Eestis on paljud tervisenäitajad oluliselt paranenud (nt oodatava elueasuurim pikenemine kõigist ELi riikidest, välditava suremuse oluline vähenemine),on nii mõndagi veel saavutada. Näiteks tuleks ületada suured erinevusedsotsiaal-majanduslike rühmade tervises, parandada elanikkonna kindlustuskatet,koostada põhjalik kava tööjõupuuduse lahendamiseks, pareminitegeleda kasvava hulga inimestega, kes põevad (mitut) mittenakkushaigust,ning paremini ära kasutada e-tervise süsteemi, eriti arstiabi integreerimiseksja kliiniliste otsuste tegemiseks. Kvaliteedi osas on tehtud suuri edusamme,kuid üldpilt on jätkuvalt ebaühtlane. Välditavate hospitaliseerimiste arv onüks Euroopa madalamaid astma ja kroonilise obstruktiivse kopsuhaigusepuhul, keskmine südamepuudulikkuse ja diabeedi puhul, kuid üks suuremaidkõrgvererõhktõve puhul. Lisaks on südameinfarkti ja insuldi 30-päevasesuremuse näitaja Eestis üks Euroopa halvimaid. Need tulemid viitavad sellele,et teenuste kvaliteedi ja ravi koordineerimise parandamiseks on veel paljuteha. Uuel rahvastiku tervise arengukaval, mis on praegu läbivaatamisel, ontulevaste reformide edukuses otsustav roll.

Estonia: health system review

This analysis of the Estonian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In 2017, the Estonian government took the historic step of expanding the revenue base of the health system,which has been a longstanding challenge. However, in terms of percentage of GDP it remains a small increase and long-term financial sustainability could still pose a problem. That said, if these additional funds are invested wisely, they could play a positive role in further improving the health system. Indeed, although Estonia has made remarkable progress on many health indicators (e.g. the strongest gains in life expectancy of all EU countries, strongly falling amenable mortality rates), there are opportunities for improvements. They include overcoming the large health disparities between socioeconomicgroups, improving population coverage, developing a comprehensive plan to tackle workforce shortages, better managing the growing number of people with (multiple) noncommunicable diseases and further reaping the benefits of the e-health system, especially for care integration and clinical decision-making. Also in terms of quality, large strides have been made but the picture is mixed. Avoidable hospital admissions are among the lowest in Europe for asthma and chronic obstructive pulmonary disease (COPD), about average for congestive heart failure and diabetes, but among the worst for hypertension. Moreover, the 30-day fatality rates for acute myocardial infarction and stroke are among the worst in the EU. These outcomes suggest substantial room to further improve service quality and care coordination. The new NHP, which is currently being revised, will play a crucial role in the success of future reform efforts.

Bulgaria: health system review

This analysis of the Bulgarian health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. With the 2015 National Health Strategy 2020 at its core, there have been ambitious reform plans to introduce more decentralization, strategic purchasing and integrated care into the Bulgarian social health insurance system. However, the main characteristics of the Bulgarian health system, including a high level of centralization and a single payer to administer social health insurance, remain intact and very few reforms have been implemented (for example, the introduction of health technology assessment). There are multiple reasons for this, of which political fragility and stakeholder resistance are among the most important. Overall, Bulgaria marked notable progress on some health indicators (for example, life expectancy and infant mortality) but generally progress lags behind EU averages. What is more, the system has not been effective in reducing amenable mortality, as reflected in the unsteady improvement patterns in mortality due to malignant neoplasms. This is despite an increase in total health expenditure as a percentage of gross domestic product to 8.2% in 2015. The overall high out-of-pocket spending (47.7% of total health spending in 2015) has been growing and is increasingly worrisome. It evidences the low degree of financial protection by the Bulgarian social health insurance system and exacerbates the already considerable inequities along socioeconomicand regional fault lines. For instance, there are regional imbalances of medical professionals, which are more concentrated in urban areas, and accessibility to physicians is further deteriorating, especially in rural areas. Current reforms have to tackle these challenges and build consensus among stakeholders of the health system to unlock the standstill.

Culture and reform of mental health care in central and eastern Europe / Workshop report: Klecany, Czechia, 2-3 October 2017

The WHO Regional Office for Europe, the WHO Collaborating Centre on Culture and Health at the University of Exeter (United Kingdom) and the National Institute of Mental Health (Czechia) convened a workshop on culture and reform of mental health care in central and eastern Europe on 2–3 October 2017 in Klecany, Czechia. The aim of this workshop was to improve understanding of the key cultural aspects that impact and drive mental health care reform in the central and eastern European region. This report outlines the key points and recommendations made by participants in relation to this objective.

Spain: health system review

This analysis of the Spanish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Overall health status continues to improve in Spain, and life expectancy is the highest in the European Union. Inequalities in self-reported health have also declined in the last decade, although long-standing disability and chronic conditions are increasing due to an ageing population. The macroeconomic context in the last decade in the country has been characterized by the global economic recession, which resulted in the implementation of health system-specific measures addressed to maintain the sustainability of the system. New legislation was issued to regulate coverage conditions, the benefits package and the participation of patients in the National Health System funding. Despite the budget constraints linked to the economic downturn, the health system remains almost universal, covering 99.1% of the population. Public expenditure in health prevails, with public sources accounting for over 71.1% of total health financing. General taxes are the main source of public funds, with regions (known as Autonomous Communities) managing most of those public health resources. Private spending, mainly related toout-of-pocket payments, has increased over time, and it is now above the EU average. Health care provision continues to be characterized by the strength of primary care, which is the core element of the health system; however, the increasing financing gap as compared with secondary care may challenge primary care in the long term. Public health efforts over the last decade have focused on increasing health system coordination and providing guidance on addressing chronic conditions and life style factors such as obesity. The underlying principles and goals of the national health system continue to focus on universality, free access, equity and fairness of financing. The evolution of performance measures over the last decade shows the resilience of the health system in the aftermath of the economic crisis, although some structural reforms may be required to improve chronic care management and the reallocation of resources to high-value interventions.

Austria: health system review

This analysis of the Austrian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Two major reforms implemented in 2013 and 2017 are among the main issues today. The central aim of the reforms that put in place a new governance system was to strengthen coordination and cooperation between different levels of government and self-governing bodies by promoting joint planning,decision-making and financing. Yet despite these efforts, the Austrian health system remains complex and fragmented in its organizational and financial structure.The Austrian population has a good level of health. Life expectancy at birth is above the EU average and low amenable mortality rates indicate that health care is more effective than in most EU countries. Yet, the number of people dying from cardiovascular diseases and cancer is high compared to the EU28 average. Tobacco and alcohol represent the major health risk factors. Tobacco consumption has not declined over the last decade like in most other EU countries and lies well above the EU28 average. In terms of performance, the Austrian health system provides good access to health care services. Austria’s residents report the lowest levels of unmet needs for medical care across the EU. Virtually all the population is covered by social health insurances and enjoys a broad benefit basket. Yet, rising imbalances between the numbers of contracted and non-contracted physicians may contribute to social and regional inequalities in accessing care. The Austrian health system is relatively costly. It has a strong focus on inpatient care as characterized by high hospital utilization and imbalances in resource allocation between the hospital and ambulatory care sector. The ongoing reforms therefore aim to bring down publicly financed health expenditure growth with a global budget cap and reduce overutilization of hospital care. Efficiency of inpatient care has improved over the reform period but the fragmented financing between the inpatient and ambulatory sector remain a challenge. Current reforms to strengthen primary health care are an important step to further shift activities out of the large and costly hospital sector and improve skill mix within the health workforce.

Georgia: health system review

This analysis of the Georgian health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. Since 2012, political commitment to improving access to health care, to protecting the population from the financial risks of health care costs and to reducing inequalities has led to the introduction of reforms to provide universal health coverage. Considerable progress has been made. Over 90% of the resident population became entitled to a tightly defined package of state-funded benefits in 2013; previously, only 45% of the population had been eligible. The package of services has variable depth of coverage depending on the groups covered, with the lowest income groups enjoying the most comprehensive benefits. To finance the broader coverage, the government increased health spending significantly, although this remains low in international comparisons. Out-of-pocket (OOP) payments have fallen as public spending has increased. Nevertheless, current health expenditure is still dominated by OOP payments (57% in 2015), two thirds of which are for outpatient pharmaceuticals. For this reason, in July 2017, the package of benefits was expanded for the most vulnerable households to cover essential medicines for four common chronic conditions. The system has retained extensive infrastructure with strong geographical coverage. Georgia also has a large number of doctors per capita, but an acute shortage of nurses. Incentives in the system for patients and providers favour emergency and inpatient care over primary care. There are also limited financial incentives to improve the quality of care and a lack of disincentives to inhibit poor quality care. Future reform plans focus on ensuring universal access to high-quality medical services, strengthening primary care and public health services, and increasing financial protection.

Greece: health system review

This analysis of the Greek health system reviews developments in itsorganization and governance, health financing, health care provision,health reforms and health system performance. The economic crisis hashad a major impact on Greek society and the health system. Health statusindicators such as life expectancy at birth and at age 65 are above the averagein the European Union but health inequalities and particular risk factorssuch as high smoking rates and child obesity persist. The highly centralizedhealth system is a mixed model incorporating both tax-based financing andsocial health insurance. Historically, a number of enduring structural andoperational inadequacies within the health system required addressing, butreform attempts often failed outright or stagnated at the implementation phase.The country’s Economic Adjustment Programme has acted as a catalyst totackle a large number of wide-ranging reforms in the health sector, aimingnot only to reduce public sector spending but also to rectify inequities andinefficiencies. Since 2010, these reforms have included the establishmentof a single purchaser for the National Health System, standardizing thebenefits package, re-establishing universal coverage and access to health care,significantly reducing pharmaceutical expenditure through demand and supply-sidemeasures, and important changes to procurement and hospital paymentsystems; all these measures have been undertaken in a context of severe fiscalconstraints. A major overhaul of the primary care system is the priority in theperiod 2018–2021. Several other challenges remain, such as ensuring adequatefunding for the health system (and reducing the high levels of out-of-pocketspending on health); maintaining universal health coverage and access toneeded health services; and strengthening health system planning, coordinationand governance. While the preponderance of reforms implemented so far havefocused on reducing costs, there is a need to develop this focus into longer-termstrategic reforms that enhance efficiency while guaranteeing the delivery ofhealth services and improving the overall quality of care.

Malta: health system review

Maltese life expectancy is high and people spend on average close to 90% of their lifespan in good health. Malta has recently increased the proportion of GDP spent on health to above the EU average, though the private part of that remains higher than in many EU countries. The total number of doctors and GPs per capita is at the EU average, but the number of specialists remains relatively low. The health system offers universal coverage to a comprehensive set of services, free at the point of use for people entitled to statutory provision. The historical pattern of integrated financing and provision is shifting towards a more pluralist approach; people often choose to visit private primary care providers and in 2016 a new public–private partnership contract for three existing hospitals was agreed. Important priorities for the coming years include further strengthening of primary and mental health sectors, and strengthening the health information system to support improved monitoring and evaluation. The priorities during the Presidency of the Council of the EU in 2017 include childhood obesity, and Structured Cooperation to enhance access to highly specialized and innovative services, medicines and technologies. Overall, the Maltese health system has made remarkable progress. The main challenges include: adapting the health system to an increasingly diverse population; increasing capacity to cope with a growing population; redistributing resources and activity from hospitals to primary care; ensuring access to expensive new medicines whilst making efficiency improvements; and addressing medium-term financial sustainability challenges from demographic ageing.

Portugal: health system review

This publication reviews recent developments in organization and governance of health system, health financing, health care provision, health reforms and health system performance in Portugal. Overall health indicators such as life expectancy have shown a notable improvement over the last decades. However, improvements in child poverty and its consequences, mental health and quality of life after 65 have been slower and health inequalities remain a problem. All residents in Portugal have access to health care provided by the National Health Service, financed mainly through taxation. Out-of-pocket payments have been increasing over time and the level of cost-sharing is highest for pharmaceutical products. Health care delivery is by both public and private providers. Public provision is predominant in primary care and hospital care, with a gatekeeping system in place for access to hospital care. Pharmaceutical products, diagnostic technologies and private practice by physicians constitute the bulk of private health care provision. In May 2011, the economic crisis led Portugal to sign a Memorandum of Understanding with the International Monetary Fund, the European Commission and the European Central Bank, in exchange for a loan of 78 billion euros. The agreed Economic and Financial Adjustment Programme included 34 measures aimed at increasing cost-containment, improving efficiency and increasing regulation in the health sector. Reforms implemented since 2011 by the Ministry of Health include improving regulation and governance, health promotion, rebalancing the pharmaceutical market, expanding and coordinating long-term and palliative care, and strengthening primary and hospital care.