Pandemic preparedness and health system resilience in 14 European countries.

Objective: To assess national pandemic preparedness and response plans from a health system perspective to determine the extent to which implementation strategies that support health system performance have been included. Methods: We systematically mapped pandemic preparedness and response implementation strategies that improve resilience to pandemics onto the Health System Performance Assessment Framework for Universal Health Coverage. Using this framework, we conducted a document analysis of 14 publicly available national influenza pandemic preparedness plans, submitted to the European Centre for Disease Prevention and Control, to assess how well health system functions are accounted for in each plan. Findings: Implementation strategies found in national influenza pandemic preparedness plans do not systematically consider all health system functions. Instead, they mostly focus on specific aspects of governance. In contrast, little to no mention is made of implementation strategies that aim to strengthen health financing. There was also a lack of implementation strategies to strengthen the health workforce, ensure availability of medical equipment and infrastructure, govern the generation of resources and ensure delivery of public health services. Conclusion: While national influenza pandemic preparedness plans often include provisions to support health system governance, implementation strategies that support other health system functions, namely, resource generation, service delivery, and in particular, financing, are given less attention. These oversights in key planning documents may undermine health system resilience when public health emergencies occur.

HIV prevention and treatment in Southern Europe in the aftermath of bailout programmes.

BACKGROUND: The global financial crisis impacted public health in Europe, and had a particularly critical detriment to health systems in Southern Europe. We aim to describe HIV response and progress towards the current global HIV targets in specific Southern European countries, which received financial adjustment programmes. METHODS: We examined and compared a set of HIV indicators in Cyprus, Greece, Portugal and Spain. The indicators included: (i) HIV epidemiology; (ii) adoption of WHO's 'Treat All' recommendation; (iii) progress towards the UNAIDS global targets of 90-90-90; (iv) adoption/implementation of pre-exposure prophylaxis (PrEP); and (v) adoption/implementation of WHO's HIV self-testing (HIVST) recommendation. RESULTS: HIV incidence varied across countries since 2010, with sustained declines in Portugal and Spain, and marked increases in Greece and Cyprus. By 2016, all four countries have adopted WHO's 'Treat All' recommendation, leading to a marked increase in people receiving ART. Improvements were seen in all 90-90-90 targets, with Portugal achieving those in 2017, but Greece lagging somewhat behind, as of 2016. Portugal and Spain have also started implementing PrEP, and Greece has completed a pilot with no additional access to PrEP for pilot participants and no national programme in place. Cyprus has been the slowest in terms of adopting PrEP and HIVST. CONCLUSIONS: Countries need to focus on prioritizing effective and comprehensive prevention measures, including HIVST and PrEP, and scale-up access to quality treatment and care for those diagnosed, in order to accelerate the reduction of new HIVs infections and successfully meet the global targets for HIV treatment.

The epidemiological transition in Eastern and Western Europe: a historic natural experiment.

Background: The continent of Europe has experienced remarkable changes in the past 25 years, providing scope for natural experiments that offer insight into the complex determinants of health. Methods: We analysed trends in life expectancy at birth in three parts of Europe, those countries that were members of the European Union (EU) prior to 2004, countries that joined the European Union since then, and the twelve countries that emerged from the Soviet Union to form the Commonwealth of Independent States (CIS). The contribution of deaths at different ages to these changes was assessed using Arriaga's method of decomposing changes in life expectancy. Results: Europe remains divided geographically, with an East-West gradient. The former Soviet countries experienced a marked initial decline in life expectancy and have only recovered after 2005. However, the situation for those of working ages is little better than in 1990. The pre-2004 EU has seen substantial gains throughout the past 25 years, although there is some evidence that this may be slowing, or even reversing, at older ages. The countries joining the EU in 2004 subsequently began to see some improvements in the early 1990s, but have experienced larger gains since 2000. Conclusions: Europe offers a valuable natural laboratory for understanding the impact of political, economic, and social changes on health. While the historic divisions of Europe are still visible, there is also evidence that individual countries are doing better or worse than their neighbours, providing many lessons that can be learned from.

Austerity and health: the impact in the UK and Europe.

Austerity measures-reducing social spending and increasing taxation-hurts deprived groups the most. Less is known about the impact on health. In this short review, we evaluate the evidence of austerity's impact on health, through two main mechanisms: a 'social risk effect' of increasing unemployment, poverty, homelessness and other socio-economic risk factors (indirect), and a 'healthcare effect' through cuts to healthcare services, as well as reductions in health coverage and restricting access to care (direct). We distinguish those impacts of economic crises from those of austerity as a response to it. Where possible, data from across Europe will be drawn upon, as well as more extensive analysis of the UK's austerity measures performed by the authors of this review.

Health inequalities after austerity in Greece.

Since the beginning of economic crisis, Greece has been experiencing unprecedented levels of unemployment and profound cuts to public budgets. Health and welfare sectors were subject to severe austerity measures, which have endangered provision of as well as access to services, potentially widening health inequality gap. European Union Statistics on Income and Living Conditions data show that the proportion of individuals on low incomes reporting unmet medical need due to cost doubled from 7 % in 2008 to 13.9 % in 2013, while the relative gap in access to care between the richest and poorest population groups increased almost ten-fold. In addition, austerity cuts have affected other vulnerable groups, such as undocumented migrants and injecting drug users. Steps have been taken in attempt to mitigate the impact of the austerity, however addressing the growing health inequality gap will require persistent effort of the country's leadership for years to come.

Access to care in the Baltic States: did crisis have an impact?

BACKGROUND: In 2009, brief but deep economic crisis profoundly affected the three Baltic States: Estonia, Latvia and Lithuania. In response, all three countries adopted severe austerity measures with the shared goal of containing rising deficits, but employing different methods. AIMS: In this article, we analyze the impact of the economic crisis and post-crisis austerity measures on health systems and access to medical services in the three countries. METHODS: We use the EU-SILC data to analyze trends in unmet medical need in 2005-2012, and apply log-binomial regression to calculate the risk of unmet medical need in the pre- and post- crisis period. RESULTS: Between 2009 and 2012 unmet need has increased significantly in Latvia (OR: 1.24, 95% confidence interval (CI): 1.15-1.34) and Estonia (OR: 1.98, 95% CI: 1.72-2.27), but not Lithuania (OR: 0.84. 95% CI: 0.69-1.04). The main drivers of increased unmet need were inability to afford care in Latvia and long waiting lists in Estonia. CONCLUSION: The impact of the crisis on access to care in the three countries varied, as did the austerity measures affecting their health systems. Estonia and Latvia experienced worsening access to care, largely exacerbating already existing barriers. The example of Lithuania suggests that deterioration in access is not inevitable, once health policies prioritise maintenance and availability of existing services, or if there is room for reducing existing inefficiencies. Moreover, better financial preparedness of health systems in Estonia and Lithuania achieved some protection of the population from increasing unmet need due to the rising cost of medical care.

Effects of the Global Financial Crisis on Health in High-Income Oecd Countries: A Narrative Review.

A growing body of evidence documents how economic crises impact aspects of health across countries and over time. We performed a systematic narrative review of the health effects of the latest economic crisis based on studies of high-income countries. Papers published between January 2009 and July 2015 were selected based on review of titles and abstracts, followed by a full text review conducted by two independent reviewers. Ultimately, 122 studies were selected and their findings summarized. The review finds that the 2008 financial crisis had negative effects on mental health, including suicide, and to a varying extent on some non-communicable and communicable diseases and access to care. Although unhealthy behaviors such as hazardous drinking and tobacco use appeared to decline during the crisis, there have been increases in some groups, typically those already at greatest risk. The health impact was greatest in countries that suffered the largest economic impact of the crisis or prolonged austerity. The Great Recessions in high-income countries have had mixed impacts on health. They tend to be worse when economic impacts are more severe, prolonged austerity measures are implemented, and there are pre-existing problems of substance use among vulnerable groups.

Greece's health crisis: from austerity to denialism.

Greece's economic crisis has deepened since it was bailed out by the international community in 2010. The country underwent the sixth consecutive year of economic contraction in 2013, with its economy shrinking by 20% between 2008 and 2012, and anaemic or no growth projected for 2014. Unemployment has more than tripled, from 7·7% in 2008 to 24·3% in 2012, and long-term unemployment reached 14·4%. We review the background to the crisis, assess how austerity measures have affected the health of the Greek population and their access to public health services, and examine the political response to the mounting evidence of a Greek public health tragedy.

Why did life expectancy in Central and Eastern Europe suddenly improve in the 1990s? An analysis by cause of death.

BACKGROUND: The upturn of life expectancy in Central and Eastern Europe in the 1990s, after a period of stagnation or even decline, is one of the main events in European population history of the late 20th century, but has not been satisfactorily explained. DATA AND METHODS: Turning points in total and cause-specific mortality in the Czech Republic, Bulgaria, Hungary, Poland, Romania and Slovakia were determined using joinpoint regression. Changes in life expectancy in the 10 years following country-specific turning points were decomposed by age and cause of death using Arriaga's method. RESULTS: Among men, the turning points for all-cause mortality coincided with those for ischaemic heart disease in all six countries, and sometimes also with those for liver cirrhosis, road traffic accidents and lung cancer. Among women, the pattern was more diffuse. In the 10 years since the turning point for all-cause mortality, life expectancy increased by around four years for men and three years for women in most countries. Declines in mortality from cardiovascular disease explain between a third and a half of the increase in life expectancy in all countries, but beyond this the contributing causes of death often varied considerably. CONCLUSIONS: Although the upturn of life expectancy in Central and Eastern Europe started at different points in time, improvements in prevention and/or treatment of ischaemic heart disease appear to have played a role in all six countries. Other factors, such as changes in alcohol consumption and road traffic safety, have, however, also made important contributions in some countries.

How do economic crises affect migrants' risk of infectious disease? A systematic-narrative review.

BACKGROUND: It is not well understood how economic crises affect infectious disease incidence and prevalence, particularly among vulnerable groups. Using a susceptible-infected-recovered framework, we systematically reviewed literature on the impact of the economic crises on infectious disease risks in migrants in Europe, focusing principally on HIV, TB, hepatitis and other STIs. METHODS: We conducted two searches in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar, websites of key organizations and grey literature to identify how economic changes affect migrant populations and infectious disease. We perform a narrative synthesis in order to map critical pathways and identify hypotheses for subsequent research. RESULTS: The systematic review on links between economic crises and migrant health identified 653 studies through database searching; only seven met the inclusion criteria. Fourteen items were identified through further searches. The systematic review on links between economic crises and infectious disease identified 480 studies through database searching; 19 met the inclusion criteria. Eight items were identified through further searches. The reviews show that migrant populations in Europe appear disproportionately at risk of specific infectious diseases, and that economic crises and subsequent responses have tended to exacerbate such risks. Recessions lead to unemployment, impoverishment and other risk factors that can be linked to the transmissibility of disease among migrants. Austerity measures that lead to cuts in prevention and treatment programmes further exacerbate infectious disease risks among migrants. Non-governmental health service providers occasionally stepped in to cater to specific populations that include migrants. CONCLUSIONS: There is evidence that migrants are especially vulnerable to infectious disease during economic crises. Ring-fenced funding of prevention programs, including screening and treatment, is important for addressing this vulnerability.

The unequal health of Europeans: successes and failures of policies.

Europe, with its 53 countries and divided history, is a remarkable but inadequately exploited natural laboratory for studies of the eff ects of health policy. In this paper, the fi rst in a Series about health in Europe, we review developments in population health in Europe, with a focus on trends in mortality, and draw attention to the main successes and failures of health policy in the past four decades. In western Europe, life expectancy has improved almost continuously, but progress has been erratic in eastern Europe, and, as a result, disparities in male life expectancy between the two areas are greater now than they were four decades ago. The falls in mortality noted in western Europe are associated with many different causes of death and show the combined eff ects of economic growth, improved health care, and successful health policies (eg, tobacco control, road traffic safety). Less favourable mortality trends in eastern Europe show economic and health-care problems and a failure to implement effective health policies. The political history of Europe has left deep divisions in the health of the population. Important health challenges remain in both western and eastern Europe and signify unresolved issues in health policy (eg, alcohol, food) and rising health inequalities within countries.

Financial crisis, austerity, and health in Europe.

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

Health and health systems in the Commonwealth of Independent States.

The countries of the Commonwealth of Independent States differ substantially in their post-Soviet economic development but face many of the same challenges to health and health systems. Life expectancies dropped steeply in the 1990s, and several countries have yet to recover the levels noted before the dissolution of the Soviet Union. Cardiovascular disease is a much bigger killer in the Commonwealth of Independent States than in western Europe because of hazardous alcohol consumption and high smoking rates in men, the breakdown of social safety nets, rising social inequality, and inadequate health services. These former Soviet countries have embarked on reforms to their health systems, often aiming to strengthen primary care, scale back hospital capacities, reform mechanisms for paying providers and pooling funds, and address the overall shortage of public funding for health. However, major challenges remain, such as frequent private out-of-pocket payments for health care and underdeveloped systems for improvement of quality of care.

Health services for children in western Europe.

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems-practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

The rise of mortality from mental and neurological diseases in Europe, 1979-2009: observational study.

BACKGROUND: We studied recent trends in mortality from seven mental and neurological conditions and their determinants in 41 European countries. METHODS: Age-standardized mortality rates were analysed using standard methods of descriptive epidemiology, and were related to cultural, economic and health care indicators using regression analysis. RESULTS: Rising mortality from mental and neurological conditions is seen in most European countries, and is mainly due to rising mortality from dementias. Mortality from psychoactive substance use and Parkinson's disease has also risen in several countries. Mortality from dementias has risen particularly strongly in Finland, Iceland, Malta, Netherlands, Spain, Sweden and the United Kingdom, and is positively associated with self-expression values, average income, health care expenditure and life expectancy, but only the first has an independent effect. CONCLUSIONS: Although trends in mortality from dementias have probably been affected by changes in cause-of-death classification, the high level of mortality from these conditions in a number of vanguard countries suggests that it is now among the most frequent causes of death in high-income countries. Recognition of dementias as a cause of death, and/or refraining from life-saving treatment for patients with dementia, appear to be strongly dependent on cultural values.

We Need a Combination of Approaches to Evaluate Health System Resilience Comment on "Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic".

Health system resilience has become a desirable health system attribute in the current permacrisis environment. The article by Saulnier and colleagues reviews the literature on health system resilience and refines the concept, pinpointing dimensions of resilience governance that have not reached consensus, or that are missing from the literature. In this commentary we complement the findings by discussing different conceptual frameworks for understanding resilience and introducing resilience testing, a method to assess health system resilience using a hypothetical shock scenario. Resilience testing is a mixed-methods approach that combines a review of existing data with a structured workshop, where health system experts collaboratively assess the resilience of their health system. The new method is proposed as a tool for policy-making, as the results can identify attributes of the current health system that may hinder or boost a resilient response to the next crisis.

Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries.

Background: Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection. Methods: We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services. Findings: Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending. Interpretation: It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes. Funding: The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.

Assessing the equity and coverage policy sensitivity of financial protection indicators in Europe.

Progress towards universal health coverage is monitored by the incidence of catastrophic spending. Two catastrophic spending indicators are commonly used in Europe: Sustainable Development Goal (SDG) indicator 3.8.2 and the WHO Regional Office for Europe (WHO/Europe) indicator. The use of different indicators can cause confusion, especially if they produce contradictory results and policy implications. We use harmonised household budget survey data from 27 European Union countries covering 505,217 households and estimate the risk of catastrophic spending, conditional on household characteristics and the design of medicines co-payments. We calculate the predicted probability of catastrophic spending for particular households, which we call LISAs, under combinations of medicines co-payment policies and compare predictions across the two indicators. Using the WHO/Europe indicator, any combination of two or more protective policies (i.e. low fixed co-payments instead of percentage co-payments, exemptions for low-income households and income-related caps on co-payments) is associated with a statistically significant lower risk of catastrophic spending. Using the SDG indicator, confidence intervals for every combination of protective policies overlap with those for no protective policies. Although out-of-pocket medicines spending is a strong predictor of catastrophic spending using both indicators, the WHO/Europe indicator is more sensitive to medicines co-payment policies than the SDG indicator, making it a better indicator to monitor health system equity and progress towards UHC in Europe.

Childhood deaths from injuries: trends and inequalities in Europe.

BACKGROUND: In 1998, a UNICEF report quantified the large East-West gap in Europe in child mortality from external causes (injuries and violence). In the past decade, much has changed in central and eastern Europe, economically, politically and socially. This study updates the earlier analysis, tracking changes in deaths from external causes in the different parts of Europe. METHODS: The WHO mortality database was used to examine mortality from external causes for children aged 1-14 years between 1993 and 2008, by country, European subregion and cause. RESULTS: Deaths from external causes have fallen in all of Europe since 1993. However, a clear east-west divide persists, with higher death rates in the former Soviet countries, especially the Commonwealth of Independent States (CIS). Trends in specific causes also vary geographically; the greatest overall declines have been in transport-related deaths, drowning, poisoning and 'other' external causes. Transport, drowning and 'other' remain the commonest external causes of death in childhood. CONCLUSION: Child injury mortality rates have fallen across Europe. In the former Soviet countries, this is likely to reflect improvements in living conditions since transition. Yet, large geographical inequalities remain, highlighting the need for enhanced measures to prevent injuries, particularly in the CIS countries and the Baltic states. However, except in a few countries, there is still little research on the nature of the problem or the effectiveness of potential interventions. Child deaths from injuries are avoidable and measures to reduce them would have a significant impact upon the overall burden of child mortality in Europe.