Spain: health system review

This review of the Spanish health system analyses recent developments in health organization and governance, financing, health care provision, recent reforms and health system performance.Overall health status continues to improve in Spain, which presents the highest life expectancy in the European Union – although some socioeconomic inequalities in health persist and risk factors such as overweight, tobacco and alcohol consumption and illegal drug use remain a concern. Health system reforms since 2018 have focused on widening the population covered by the health system, reducing co-payments, improving the scope of coverage in terms of increasing provided services, and the reinforcement of primary care. Future challenges for the health system include addressing access gaps, such as the limited coverage of some services (such as dental and optical care), and large waiting lists for some services. Some gaps in efficiency remain, such as the low numbers of qualified personnel in some medical specialties, the shortage of mental health resources, the underuse of effective treatments, and the overuse of non-appropriate orineffective procedures.

EU joint actions 2.0: A booster for health in the EU?

Since 2008, the Joint Action (JA) mechanism in the EU Health Programme has been promoting collaboration among Member States. This article assesses whether it is well-equipped to strengthen European collaboration in the post-COVID world and suggest ways in which the Commission can further improve this instrument. They can have a significant impact on health policies in the EU, yet challenges remain related to sustainability, administrative burden, and co financing structure. In order to contribute to the EU Health Union, we believe they need to become more politically driven, outcome-focused, and contribute to a comprehensive long-term vision regarding the role of health in the EU.

Tackling the health workforce crisis: Towards a European health workforce strategy

Many countries in the European Union (EU) are experiencing a health workforce crisis, which is straining the performance and resilience of health systems. To support and complement the efforts of Member States to address the crisis, the EU should develop a comprehensive health workforce strategy. This strategy should include EU support for health workforce development, the alignment of the EU labour market with health system goals, and advance the review of the professional qualifications directive.

Revamping the EU's health security framework to manage future health crises

After the COVID-19 pandemic, the European Union (EU) introduced several reforms to improve its crisis response capabilities. However, doubts remain as to the complexity of current governance arrangements. We review recent reforms and propose 19 recommendations. These include clarifying the relationship between the institutions involved in crisis management; streamlining scientific advice; coordinating IT platforms on medical countermeasures used by the European Medicines Agency (EMA) and the Health Emergency Preparedness and Response Authority (HERA); streamlining and expanding funding sources for R&D; improving data flows; and strengthening the EU’s ability to communicate with the general public. All these measures can be adopted without EU Treaty reforms.

Identifying disease-specific patient and societal needs to foster needs-driven healthcare and innovation policies in the EU

Healthcare policy decisions in the European Union are largely supply-driven. To move towards needs-driven healthcare innovation and policy, patient and societal needs should be defined upfront and subsequently guide decisions of researchers, research funders, regulators and health technology assessment bodies. Evidence-based needs-driven policy assumes the availability of scientific evidence on disease-specific needs in a large range of diseases. Collaborative efforts at EU level are necessary to establish a needs assessment and appraisal framework, gather evidence, and incorporate these into assessment and decision-making processes. The EU pharmaceutical regulation, EU HTA regulation and EU research funding programmes can stimulate this effort.

A renewed call to action: How can the European Union scale-up action on non-communicable disease prevention?

Primary prevention is an effective strategy to maintain and improve population health and to achieve resilience in the face of crises. This article aims to highlight the progress of legal initiatives aimed at prevention of Non-communicable diseases (NCDs) risk factors and wider health determinants under the European Commission’s Europe’s Beating Cancer Plan. We also explore how the European Union (EU) can use its policy levers to strengthen prevention and tackle NCDs. Future potential actions for the next Commission, including addressing the impact of commercial determinants on the establishment of policies, are also suggested.

Ensuring affordable access to healthcare for everyone in the European Union: What gaps remain and how can the EU support Member States to overcome them?

European Union (EU) Member States have made multiplecommitments to progress towards universal health coverage (UHC),so that everyone can access quality healthcare without experiencingfinancial hardship. Yet, significant gaps in all three dimensions ofhealth coverage (population coverage, user charges, and benefitspackages) remain. This article highlights some of these gaps, looks athow access to healthcare has been addressed through the EU’s socio economic governance and funding instruments, and suggests ways inwhich the EU can further support national progress towards UHC.

France: health system review

This review of the French health system analyses recent developments in health organization and governance, financing, healthcare provision, recent reforms and health system performance.Overall health status continues to improve in France, although geographic and socioeconomic inequalities in life expectancy persist. The health system combines a social health insurance model with an important role fortax-based revenues to finance healthcare. The health system provides universal coverage, with a broad benefits basket, but cost-sharing is required for all essential services. Private complementary insurance to cover these costs results in very low average out-of-pocket payments, although there are concerns regarding solidarity, financial redistribution and efficiency in the health system. The macroeconomic context in the last couple of years in the country has been affected by the COVID-19 pandemic, which resulted in subsequent increases of total health expenditure in France in 2020 (3.7%) and 2021 (9.8%).Healthcare provision continues to be highly fragmented in France, with a segmented approach to care organization and funding across primary, secondary and long-term care. Recent reforms aim to strengthen primarycare by encouraging multidisciplinary group practices, while public health efforts over the last decade have focused on boosting prevention strategies and tackling lifestyle risk factors, such as smoking and obesity with limited success. Continued challenges include ensuring the sustainability of the health workforce, particularly to secure adequate numbers of health professionals in medically underserved areas, such as rural and less affluent communities, and improving working conditions, remuneration and career prospects, especially for nurses, to support retention. The COVID-19 pandemic has brought to light some structural weaknesses within the French health system, but it has also provided opportunities for improving its sustainability. There has been a notable shift in the will to give more room to decision-making at the local level, involving healthcare professionals, and to find new ways of funding healthcare providers to encourage care coordination and integration.

Building capacity and identifying appropriate support: How can the EU contribute to securing resources for health systems?

European health systems face increasing challenges and demands, while striving to provide high-quality care. The European Union (EU) offers support to complement national efforts, but accessing and utilising it can be challenging for Member States. Austria, Belgium, and Slovenia are collaborating on a multi-country project supported by the EU’s Technical Support Instrument, to create an EU Health Resources Hub. This advisory service aims to help Member States access EU funding instruments for their health needs. This article discusses the project’s goals and early learnings, offering insights that could inform future health funding opportunities and policies in Europe.

Health and care data: approaches to data linkage for evidence-informed policy

An indispensable prerequisite for answering research questions in health services research is the availability and accessibility of comprehensive, high quality data. It can be assumed that health services research in the comingyears will be increasingly based on data linkage, i.e., the linking, or connecting, of several data sources based on suitable common key variables. A range of approaches to data collection, storage, linkage and availability exists across countries, particularly for secondary research purposes (i.e., the use of data initially collected for other purposes), such as health systems research. The main goal of this review is to develop an overview of, and gain insights into, current approaches to linking data sources in the context of health services research, with the view to inform policy, based on existing practices in high-income countries in Europe and beyond. In doing so, another objective is to provide lessons for countries looking for possible or alternative approaches to data linkage. Thirteen country case studies of data linkage approaches were selected and analyzed. Rather than being comprehensive, this review aimed to identify varied and potentially useful case studies to showcase different approaches to data linkage worldwide. A conceptual framework was developed to guide the selection and description of case studies. Information was first identified and collected from publicly available sources and a profile was then created for each country and each case study; these profiles were forwarded to appropriate country experts for validation and completion.

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.

Effective pandemic preparedness demands that governments confront hard questions about sovereignty

No-one is safe until everyone is safe. But what can be donewhen a country fails to take measures to control a pandemic virus? It poses a threat to its own people but also to its neighbours and beyond. Countries do pool sovereignty, working through supra-national structures, such as international agencies, or using processes set out in treaties, recognising the mutual benefits of the international rules-based system. Here we review the ways in which governments have, or have not worked together on other issues that pose a threat to global health and discuss the implications for pandemic responses.

Responding to the COVID-19 pandemic in Europe: towards stronger policy that incorporates the impact of social disparities

The impact of the COVID-19 pandemic on countries in theEuropean Region has been devastating with substantial morbidity and mortality and broader societal and economic effects. This in part reflects poor public health leadership and politicised responses but more importantly, a failure to account for social disparities. The stop- start pattern of Public Health and Social Measures further exacerbates the disproportionate impact on those most vulnerable. A Health in All Policies lens offers an indication of the type of coherent multisectoral thinking needed to address these social disparities in the COVID-19 context as well as in pandemic planning measures going forwards.

Governing health workforce responses during COVID-19

Countries in Europe have rapidly scaled-up, redeployed,repurposed, retrained and retained their workforce during COVID-19 to create surge capacity, protect the health and well-being of the workforce, and ensure effective implementation of vaccination programmes. Doing so has had enormous governance implications, including the need for intra-governmental and cross-organisational governance actions, increased transparency for planning, and delegated leadership to health employers and health workers. It is important that stakeholders continue to learn and share their experiences on the effectiveness of different workforce governance responses to allow the health workforce to recover, rebuild and repurpose.

Health system resilience during the pandemic: it’s mostly about governance

Governance is the most important enabler of health system functioning. It provides a foundation and lever for resource generation, financing, and service delivery and ensures they operate well and in coordination with the rest of the system. It also extends beyond the health system through interactions between levels and actors. While there is no unanimously accepted framework for assessing governance, country examples can be used to illustrate how governance has contributed to health systems resilience during the crisis. Good governance prior to the pandemic, underpinned by strong state capacity, political leadership and community engagement, is keyto responding resiliently during a novel infectious disease outbreak, such as COVID-19.

Governing the public-private-partnerships of the future: learnings from the experiences in pandemic times

No-one is safe until everyone is safe. But what can be done when a country fails to take measures to control a pandemic virus? It poses a threat to its own people but also to its neighbours and beyond. Countries do pool sovereignty, working through supra-national structures, such as international agencies, or using processes set out in treaties, recognising the mutual benefits of the international rules-based system. Here we review the ways in which governments have, or have not worked together on other issues that pose a threat to global health and discuss the implications for pandemic responses.

‘Build forward better’ must include heavy investment in government capacities to engage with communities and civil society

Civil society and community groups are active players in the COVID-19 response, providing support, advice and information where government reach is poor. Yet most governments have not managed to bring civil society’s perspectives, insights, and experiences into the COVID-19 response in a systematic way. If the world is to ‘build forward better’, more regular and systematised government-civil society engagement will need to underpin a shifttowards more inclusive health governance. Doing so successfully will require heavy investments in capacity-building for government actors to value and feel comfortable managing and sustaining participatory spaces and in skills to bring forward the kind of governance needed to build resilience against the next pandemic.

Centralisation and decentralisation in a crisis: How credit and blame shape governance

The COVID-19 pandemic led to unprecedented challengesand political creativity worldwide. In governance, this often led to unexpected centralisation and decentralisation in response to case surges. Changes in the distribution of power and responsibility throughout governments changed quickly as the pandemic progressed. Centralisation and decentralisation occurred within governments and between governments, as power shifted. The main explanation for the patterns of centralisation and decentralisation is the politics of credit and blame. Politicians at all levels seek to centralise when there is credit to be had from forceful action and decentralise when there are unpopular policies or bad news coming.

WHO's emergency response framework: a case study for health emergency governance architecture

During COVID-19, attention was drawn to a lack offunctional governance frameworks for health emergencies. Routine governance structures were neither agile, nor flexible enough to operate with the speed required for urgent and coordinated action within complex and far-reaching responses. WHO’s Emergency Response Framework has significantly contributed to a stronger WHO response capacity in the European Region by providing accountabilities, responsibilities, delegation of authority, and rapid access to resources for response, while also allowing for participating members to be held accountable for their actions. We argue that now is the time to move health emergency management forwards by supporting States in strengthening their emergency governance architectures.

Drawing lessons on better governing for emergencies for improved resilience against health emergencies

The COVID-19 pandemic has taught us that preparednessfor and resilience against health emergencies is critical. To improve preparedness for health emergencies, the emergency preparedness and response governance architecture at all levels should be strengthened. It should be based on cross-cutting, whole-of-government, and whole-of-society approaches, moving away from siloed perspectives. Moreover, resilience against health emergencies should be based on universal health coverage and anchored in the International Health Regulations (IHR) 2005 core capacities implementation. Capacities and capabilities that are required to improve health services for national and global health security should also be strengthened.