Czechia: Health System Review.

This analysis of the Czech health system reviews developments in governance, organization, financing and delivery of care, health reforms and health system performance. Czechs have enjoyed a statutory health insurance system with a high level of financial protection, a broad benefits package and universal membership for over 30 years. The central level of the state, mostly represented through the Ministry of Health and its subordinated bodies, takes on the various roles of legislator, steward and even owner of various providers of care, while also making insurance contributions for the sizeable part of the population classified as economically inactive. Health insurance funds are responsible for contracting sufficient care provision for their members. The Czech health system has traditionally derived a majority of its financing from public sources, which stood at 81.5% of current health expenditure in 2019, as the latest available year of reference, with the rest coming from private sources. While health spending in Czechia is below the European Union (EU) average, the densities of acute care beds and primary care physicians are above respective EU averages. Ageing and a lack of qualified staff (for example, nurses in hospitals) are already putting pressure on the Czech health workforce, a bottleneck further exposed by the COVID-19 pandemic. Additionally, Czechia has embarked on a reform process to modernize and centralize specialized tertiary care and psychiatric care. Patients enjoy free choice of primary and specialized outpatient providers, though there are signs that accessibility is limited in some regions and for some specialties. Overall, health outcomes in terms of life expectancy, mortality and survival rates of stroke and cancer have improved in recent years, though these improvements have been slower in Czechia than in other countries. However, life expectancy dropped considerably due to heightened mortality resulting from the COVID-19 pandemic in 2020 and 2021. There remains considerable room for improvement in strengthening disease prevention and health promotion, particularly for dietary habits and health literacy. Various efforts to advance evidence-based interventions in the health system, such as the initiation of health care quality monitoring and health system performance assessment, will assist in further analysing Czechia's health outcomes.

Germany: health system summary, 2022

This Health system summary is based on the Germany: Health System Review published in 2020 in the Health Systems in Transition (HiT) series, and relevant reform updates highlighted by the Health Systems and Policies Monitor (HSPM) (www.hspm.org). For this edition, key data have been updated to those available in July 2022 to keep information as current as possible. Health system summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.

Czechia: health system summary, 2023

This Health system summary is based on the Czechia: Health System Review published in 2023 in the Health Systems in Transition (HiT) series. Health system summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.

A comparison of health system responses to COVID-19 in Bulgaria, Croatia and Romania in 2020.

This article compares the health system responses to COVID-19 in Bulgaria, Croatia and Romania from February 2020 until the end of 2020. It explores similarities and differences between the three countries, building primarily on the methodology and content compiled in the COVID-19 Health System Response Monitor (HSRM). We find that all three countries entered the COVID-19 crisis with common problems, including workforce shortages and underdeveloped and underutilized preventive and primary care. The countries reacted swiftly to the first wave of the COVID-19 pandemic, declaring a state of emergency in March 2020 and setting up new governance mechanisms. The initial response benefited from a centralized approach and high levels of public trust but proved to be only a short-term solution. Over time, governance became dominated by political and economic considerations, communication to the public became contradictory, and levels of public trust declined dramatically. The three countries created additional bed capacity for the treatment of COVID-19 patients in the first wave, but a greater challenge was to ensure a sufficient supply of qualified health workers. New digital and remote tools for the provision of non-COVID-19 health services were introduced or used more widely, with an increase in telephone or online consultations and a simplification of administrative procedures. However, the provision and uptake of non-COVID-19 health services was still affected negatively by the pandemic. Overall, the COVID-19 pandemic has exposed pre-existing health system and governance challenges in the three countries, leading to a large number of preventable deaths.

A reversal of fortune: Comparison of health system responses to COVID-19 in the Visegrad group during the early phases of the pandemic.

This paper analyses the health policy response to the COVID-19 pandemic in the four Visegrad countries - Czechia, Hungary, Poland, and Slovakia - in spring and summer 2020. The four countries implemented harsh transmission prevention measures at the beginning of the pandemic and managed to effectively avoid the first wave of infections during spring. Likewise, all four relaxed most of these measures during the summer and experienced uncontrolled growth of cases since September 2020. Along the way, there has been an erosion of public support for the government measures. This was mainly due to economic considerations taking precedent but also likely due to diminished trust in the government. All four countries have been overly reliant on their relatively high bed capacity, which they managed to further increase at the cost of elective treatments, but this could not always be supported with sufficient health workforce capacity. Finally, none of the four countries developed effective find, test, trace, isolate and support systems over the summer despite having relaxed most of the transmission protection measures since late spring. This left the countries ill-prepared for the rise in the number of COVID-19 infections they have been experiencing since autumn 2020.

Bulgaria: health system summary

This Health System Summary is based on the Bulgaria: Health System Review (HiT) published in 2018 and relevant reform updates highlighted by the Health Systems and Policies Monitor (HSPM) (www.hspm.org). For this edition, key data have been updated to those available in July 2022 to keep information as current as possible. Health System Summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.

Germany: Health System Review.

This analysis of the German health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Germany's health care system is often regarded as one of the best health care systems in the world, offering its population universal health insurance coverage and a comprehensive benefits basket with comparably low cost-sharing requirements. It provides good access to care with free choice of provider and short waiting times, which is partly due to good infrastructure with a dense network of ambulatory care physicians and hospitals, and a quantitatively high level of service provision. With the largest economy in the EU it is not surprising that Germany spends more than other countries on health, with most financing coming from public funds. The country had the highest per capita spending in the EU in 2018. In relation to overall health expenditure and available resources, a very high number of services is provided across sectors, particularly in hospital and ambulatory care. This can be seen as achieving a considerable level of technical efficiency. Given the high volumes, however, there are questions about the oversupply of services, as well as some comparatively moderate health and quality outcomes; from this perspective, there are signs that there is room for improvement in how the system allocates resources. Additional challenges in the German health system may be identified in: (1) the strong separation of ambulatory and inpatient care in terms of organization and payment, which can hinder the coordination and continuity of patient treatment; (2) the coexistence of statutory health insurance (SHI) and substitutive private health insurance (PHI), which weakens the principle of solidarity; and (3) a complex stewardship framework which promotes incrementalism and makes it more difficult to implement reforms.

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 socioeconomic and 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.

An innovative approach to participatory health policy development in Bulgaria: The conception and first achievements of the Partnership for Health.

The Bulgarian Partnership for Health was established in 2015 as a new forum for health policy formulation and discussion. The Partnership presents a new approach of structured and sustained stakeholder involvement to overcome the lack of public participation in health policy development and implementation. Constituted as a permanent consultative body to the Council of Ministers, the Partnership engages a wide variety of stakeholders and professionals to shape and improve health policies. The shared governance of the Partnership between the Minister of Health and a patient organisation supports the elaboration of legislative acts based on the stakeholders' collaboration in priority areas. The governance and organisational structure of the Partnership assures capacity building, fast mobilisation of experts, continuity of stakeholder involvement, and increased responsibility in health policy development and implementation. This type of participatory approach may help reconcile initially opposing positions and foster reforms often impeded by political antagonism. Persisting challenges are a rather slow process of policy development and different perceptions of key concepts among the stakeholders. As policy-making in many countries in Eastern Europe suffers from political distrust, the Partnership's approach of involving experts - and not only politicians - could provide inspiration also to other countries, which have struggled with inconsistency of health policies pursued by different governments.

Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review.

BACKGROUND: In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity. METHODS: A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US. RESULTS: In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2). CONCLUSION: Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.

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.

Non-communicable diseases: mapping research funding organisations, funding mechanisms and research practices in Italy and Germany.

BACKGROUND: Evidence shows that territorial borders continue to have an impact on research collaboration in Europe. Knowledge of national research structural contexts is therefore crucial to the promotion of Europe-wide policies for research funding. Nevertheless, studies assessing and comparing research systems remain scarce. This paper aims to further the knowledge on national research landscapes in Europe, focusing on non-communicable disease (NCD) research in Italy and Germany. METHODS: To capture the architecture of country-specific research funding systems, a three-fold strategy was adopted. First, a literature review was conducted to determine a list of key public, voluntary/private non-profit and commercial research funding organisations (RFOs). Second, an electronic survey was administered qualifying RFOs. Finally, survey results were integrated with semi-structured interviews with key opinion leaders in NCD research. Three major dimensions of interest were investigated - funding mechanisms, funding patterns and expectations regarding outputs. RESULTS: The number of RFOs in Italy is four times larger than that in Germany and the Italian research system has more project funding instruments than the German system. Regarding the funding patterns towards NCD areas, in both countries, respiratory disease research resulted as the lowest funded, whereas cancer research was the target of most funding streams. The most reported expected outputs of funded research activity were scholarly publication of articles and reports. CONCLUSIONS: This cross-country comparison on the Italian and German research funding structures revealed substantial differences between the two systems. The current system is prone to duplicated research efforts, popular funding for some diseases and intransparency of research results. Future research will require addressing the need for better coordination of research funding efforts, even more so if European research efforts are to play a greater role.

Slovakia: Health System Review.

This analysis of the Slovak health system reviews recent developments in organization and governance, health financing, health-care provision, health reforms and health system performance. The health care system in Slovakia is based on universal coverage, compulsory health insurance, a basic benefit package and a competitive insurance model with selective contracting of health care providers. Containment of health spending became a major policy goal after the 2008 financial crisis. Health spending stabilized after 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 acute beds, overprescribing pharmaceuticals, and poor gatekeeping of the system all lead to over-utilization of services and system inefficiency. This suggests substantial room for improvement in delivery of care, especially for primary and long-term care. Additionally, there is inequity in the distribution of health providers, resulting in lengthy travelling distances and waiting times for patients. Given the ageing workforce, this trend is likely to continue. Current strategic documents and reform efforts aim to address the lack of efficiency and accountability. There has been a strong will to tackle these challenges but this has often been hindered by a lack of political consensus over issues such as 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 have taken different positions on these issues since the establishment of the current health system in 2002, and major reforms remain to be implemented.

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.

Czech Republic: health system review.

This analysis of the Czech health system reviews recent developments in organization and governance, health financing, health-care provision, health reforms and health system performance. The Czech health-care system is based on compulsory statutory health insurance providing virtually universal coverage and a broad range of benefits, and doing so at 7.7 % of GDP in 2012 - well below the EU average - of which a comparatively high 85 % was publicly funded. Some important health indicators are better than the EU averages (such as mortality due to respiratory disease) or even among the best in the world (in terms of infant mortality, for example). On the other hand, mortality rates for diseases of the circulatory system and malignant neoplasms are 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. In short, there is substantial potential in the Czech Republic for efficiency gains and to improve health outcomes. Furthermore, the need for reform in order to financially sustain the system became evident again after the global financial crisis, but there is as yet no consensus about how to achieve this.