Oral health care in Europe: financing, access and provision

With growing awareness of the large burden of oral diseases and how limited coverage affects both access and affordability, oral health policy has been receiving increased attention in recent years. This culminated in the adoption of the WHO resolution on Oral Health in 2021, which urges Member States to better integrate oral health into their universal health coverage and noncommunicable disease agendas. This study investigates major patterns and developments in oral health status, financing, coverage, access, and service provision of oral health care in 31 European countries. While most countries cover oral health care for vulnerable population groups, the level of statutory coverage varies widely across Europe resulting in different coverage and financing schemes for the adult population.

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.

The former Yugoslav Republic of Macedonia: health system review

This publication reviews recent developments in the organization and governance of the health system, health financing, health care provision, health reforms and health system performance of the former Yugoslav Republic of Macedonia. The country made important progress during its transition from a socialist system to a market-based system. Though total health expenditure has risen in absolute terms in recent decades, it has consistently fallen as a share of GDP, and high levels of private health expenditure remain. Despite this, population health has improved, with life expectancy and mortality rates for both adults and children reaching similar levels to those in the former communist EU countries. Inheriting a large health infrastructure, good public health services and well distributed health service coverage after independence in 1991, the country rebuilt a social health insurance system with a broad benefit package. Primary care providers were privatized and new private hospitals were allowed to enter the market. In recent years, the country reformed the organization of care delivery to better incorporate both public and private providers in an integrated system. Significant efficiency gains were reached with a pioneering health information system that has reduced waiting times and led to a better coordination of care. This multi-modular e-health system has the potential to further reduce existing inefficiencies and to generate evidence for assessment and research. Future challenges include sustainable planning and management of human resources as well as enhancing quality and efficiency of care through reform of hospital financing and organization.

Поранешна Југословенска Република Македонија: Преглед на здравствениот систем

Оваа анализа на здравствениот систем во поранешната југословенскарепублика Македонија, прави преглед на организацијата иуправувањето на здравственото финансирање, обезбедувањетоздравствена заштита, здравствените реформи и перформансите наздравствениот систем. Земјата има направено значаен напредок за време натранзицијата од социјалистички кон пазарно ориентиран систем. Иако во последнитедецении, вкупните здравствени трошоци се зголемени како апсолутнавредност, тие бележат константно опаѓање како процент од БДП, додекаприватните здравствени трошоци (плаќањата од џеб) и натаму се високи. Покрај ова, се забележува подобрување на здравјето кај населението низпоследните дeкади, достигнувајќи ниво на вредности за очекуваниотживотен век и стапките на морталитет за возрасни и за деца, сличен наоние во поранешните комунистички ЕУ земји, но со сé уште високи стапкина смртност предизвикана од нездраво однесување. Наследувајќи голема здравствена инфраструктура, добри услуги за јавноздравје и добра покриеност со здравствени услуги, по независноста во 1991година, земјата успеа одново да го изгради системот на социјално здравствено осигурување со широк основен пакет. Давателите на услуги во примарната здравствена заштита беа приватизирани, а приватниот капитал влезена пазарот преку нови приватни болници. Во последните години, земјата јареформираше организацијата на здравствени услуги во насока на подобравклученост на јавните и на приватните даватели на услуги во еден интегриран систем. Значајни придобивки во ефикасноста се постигнати со иновативниот здравствен информациски систем кој ги намали листите на чекањеи овозможи подобра координација во здравствената заштита. Овој, мултимодуларен електронски здравствен систем, има потенцијал за понатамошно намалување на постоечката неефикасност, како и можност за генерирањедокази што ќе служат за различни проценки и истражувања. Идните предизвици вклучуваат одржливо планирање и управување со човечките ресурси, како и поттикнувањена квалитетот и ефикасноста на здравствената заштита преку реформи вофинансирањето и организацијата на болниците.

Netherlands: health system review

This analysis of the Dutch health system reviews recent developmentsin organization and governance, health financing, health care provision,health reforms and health system performance. Without doubt, two majorreforms implemented since the mid-2000s are among the main issues today.The newly implemented long-term care reform will have to realize a transitionfrom publicly provided care to more self-reliance on the part of the citizens anda larger role for municipalities in its organization. A particular point of attentionis how the new governance arrangements and responsibilities in long-term carewill work together.The 2006 reform replaced the division between public and private insuranceby one universal social health insurance and introduced managed competitionas a driving mechanism in the health care system. Although the reform wasinitiated almost a decade ago, its stepwise implementation continues to bringchanges in the health care system in general and in the role of actors in particular.In terms of performance, essential health care services are within easy reachand waiting times have been decreasing. The basic health insurance packageand compensations for lower incomes protect citizens against catastrophicspending. Out-of-pocket payments are low from an international perspective.Moreover, the Dutch rate the quality of the health system and their health asgood. International comparisons show that the Netherlands has low antibioticuse, a low number of avoidable hospitalizations and a relatively low avoidablemortality. National studies show that health care has made major contributionsto the health of the Dutch population as reflected in increasing life expectancy.Furthermore, some indicators such as the prescription of generics and lengthof stay reveal improvements in efficiency over the past years. Nevertheless, theNetherlands still has one of the highest per capita health expenditures in Europe,although growth has slowed considerably after reverting to more traditionalsector agreements on spending.

Slovakia: health system review

This analysis of the Slovak health system reviews recent developmentsin organization and governance, health financing, health-care provision,health reforms and health system performance. The health care systemin Slovakia is based on universal coverage, compulsory health insurance, abasic benefit package and a competitive insurance model with selectivecontracting of health care providers. Containment of health spending becamea major policy goal after the 2008 financial crisis. Health spending stabilizedafter 2010 but remains well below European averages. Some health indicators,such as life expectancy, healthy life years and avoidable deaths are worrisome.Furthermore, weak hospital management, high numbers of unused acutebeds, overprescribing pharmaceuticals, and poor gatekeeping of the systemall lead to over-utilization of services and system inefficiency. This suggestssubstantial room for improvement in delivery of care, especially for primaryand long-term care. Additionally, there is inequity in the distribution of healthproviders, resulting in lengthy travelling distances and waiting times forpatients. Given the ageing workforce, this trend is likely to continue. Currentstrategic documents and reform efforts aim to address the lack of efficiencyand accountability. There has been a strong will to tackle these challenges butthis has often been hindered by a lack of political consensus over issues suchas the role of the state, the appropriate role of market mechanisms and profits,as well as the extent of out-of-pocket payments. Successive governments havetaken different positions on these issues since the establishment of the currenthealth system in 2002, and major reforms remain to be implemented.

Luxembourg: HiT in brief

The Luxembourgish health system is facing unique challenges amongst EU member states. First, it has the highest per capita health spending in PPP amongst European countries. Secondly, Luxembourg is lacking capacity to train health personnel and is facing shortages in some specialty care, which also necessitates a generous policy towards receiving care abroad. Reforms in 2008 and 2010 have targeted these challenges by establishing a single health insurance fund envisioned to play a stronger role in cost-containment and introducing e-health. Especially in hospital care there is room for efficiency gains. An average length of stay that remains high, combined with low bed occupancy rates reflect the lack of incentives in the financing mechanism which is based on patient-days from a global hospital budget. Current reforms aim at the implementation of national structured health information system for hospital services, which is prerequisite to further announced reforms such as the introduction of a DRGs based system. Additionally, patient empowerment was strengthened in 2014, which gave patients the right to receive all relevant information on health status and treatment options. In line with the 2011 European cross-border Directive, patients are now able to obtain information on treatment options abroad and related costs. In 2012, 16% of patients received care abroad, which is the highest number in the EU and far above the EU average of 4%.

Czech Republic: health system review

This analysis of the Czech health system reviews recent developments inorganization and governance, health financing, health-care provision,health reforms and health system performance. The Czech health-caresystem is based on compulsory statutory health insurance providing virtuallyuniversal coverage and a broad range of benefits, and doing so at 7.7% ofGDP in 2012 – well below the EU average – of which a comparatively high85% was publicly funded. Some important health indicators are better than theEU averages (such as mortality due to respiratory disease) or even among thebest in the world (in terms of infant mortality, for example). On the other hand,mortality rates for diseases of the circulatory system and malignant neoplasmsare well above the EU average, as are a range of health-care utilization rates,such as outpatient contacts and average length of stay in acute care hospitals. Inshort, there is substantial potential in the Czech Republic for efficiency gainsand to improve health outcomes. Furthermore, the need for reform in order tofinancially sustain the system became evident again after the global financialcrisis, but there is as yet no consensus about how to achieve this.