Demographic forecasting of population aging in Greece and Cyprus: one big challenge for the Mediterranean health and social system long-term sustainability.

BACKGROUND: With an increasing aging population and a lower ratio between the active and the dependent population, population aging is considered a global social and health challenge, associated with increased demand in health care needs and social pension. This study projects the Greek and Cypriot population to guide future planning of social and health policies and services. METHODS: The total population by sex and age groups, Total Fertility Rate (TFR), life-expectancies at birth and Potential Support Ratio PSR (persons aged 20-64 years per person 65+ years) are projected probabilistically by the year 2100 using Bayesian hierarchical models and United Nations' population data for Greece and Cyprus from the period of 1950 to 2015. RESULTS: The TFR is projected to be around 1.5 children per woman in 2050 and around 1.75 in 2100 for both countries, with all values of prediction intervals being around or below the Replacement level fertility. PSR is expected to decrease remarkably and be 2.5 in 2050 and 1.6 in 2100 for Cyprus while for Greece it will be around 1.5 for both years 2050 and 2100. Life-expectancy is expected to increase to 84 years for men and 87 years for women in 2050 and 90 years for men and 94 years for women in 2100 for both countries. The share of the population aged 65 years and over is projected to increase in both countries and be the one third of the population by 2100. CONCLUSIONS: Greece and Cyprus will acquire the characteristics of an aging population, putting a significance pressure on the social and health systems of both countries. Both countries should reform their social and health policy agenda to confront population aging and its consequence. They should adopt fertility incentives and family policies to increase fertility and migrants' inclusiveness policies to improve the demographic structure and the economic activity. The national health systems should promote prevention strategies at the primary health sector and promote healthy aging while health research policy should aim to promote research in innovative technologies and digital health to create assistive technology for self-care and greater independence of older people.

Population aging and migration - history and UN forecasts in the EU-28 and its east and south near neighborhood - one century perspective 1950-2050.

BACKGROUND: There is a gap in knowledge on long term pace of population aging acceleration and related net-migration rate changes in WHO European Region and its adjacent MENA countries. We decided to compare European Union (EU-28) region with the EU Near Neighborhood Policy Region East and EU Near Neighborhood Policy Region South in terms of these two essential features of third demographic transition. One century long perspective dating back to both historical data and towards reliable future forecasts was observed. METHODS: United Nation's Department of Economic and Social Affairs estimates on indicators of population aging and migration were observed. Time horizon adopted was 1950-2050. Targeted 44 countries belong to either one of three regions named by EU diplomacy as: European Union or EU-28, EU Near Neighborhood Policy Region East (ENP East) and EU Near Neighborhood Policy Region South (ENP South). RESULTS: European Union region currently experiences most advanced stage of demographic aging. The latter one is the ENP East region dominated by Slavic nations whose fertility decline continues since the USSR Era back in late 1980s. ENP South region dominated by Arab League nations remains rather young compared to their northern counterparts. However, as the Third Demographic Transition is inevitably coming to these societies they remain the spring of youth and positive net emigration rate. Probably the most prominent change will be the extreme fall of total fertility rate (children per woman) in ENP South countries (dominantly Arab League) from 6.72 back in 1950 to medium-scenario forecasted 2.10 in 2050. In the same time net number of migrants in the EU28 (both sexes combined) will grow from - 91,000 in 1950 to + 394,000 in 2050. CONCLUSIONS: Long term migration from Eastern Europe westwards and from MENA region northwards is historically present for many decades dating back deep into the Cold War Era. Contemporary large-scale migrations outsourcing from Arab League nations towards rich European Protestant North is probably the peak of an iceberg in long migration routes history. However, in the decades to come acceleration of aging is likely to question sustainability of such movements of people.

Budgetary Impact of Medicinal Therapies for Rare Diseases in Bulgaria.

BACKGROUND: Rare diseases have been continually outlined as one of the causes for the National Health Insurance Fund's (NHIF) deficit spending in Bulgaria. AIM: To estimate the budgetary impact of rare disease medicinal therapies from NHIF perspective for 2014 and 2016. MATERIALS AND METHODS: Budgetary impact of rare diseases is calculated as a percentage of NHIF total pharmaceutical spending. Total expenditure per ICD-10 code, mean annual number of patients reimbursed and mean annual cost per patient are analysed. RESULTS: Budgetary impact of rare diseases reached a plateau of about 9% of NHIF total pharmaceutical spending for 2014-2016. Mean number of patients reimbursed and mean annual cost per patient increased by median rates of 4.27% and 2.54%, respectively. Glycogen storage disease, neuropathic heredofamilial amyloidosis and C1 esterase inhibitor deficiency stood out, as they had the second, fourth and fifth most expensive medicinal treatment cost. While accounting for only 92 patients in 2016, these three conditions contributed for 22.89% of NHIF total expenditure on rare disease medicinal therapies. For comparison, coagulation defects, with the biggest total cost per indication, had a similar budgetary impact - 24.88%, but for 277 patients reimbursed. CONCLUSIONS: Our study does not support the concerns about uncontrolled growth of expenditures for rare disease medicinal therapies. Nevertheless, there is a need for enhanced post-marketing surveillance and performance-based payment of these treatments. Development, collection and analysis of local real-world data have been increasingly applied as a tool to advance these health policy goals.

Situation, Impacts, and Future Challenges of Tobacco Control Policies for Youth: An Explorative Systematic Policy Review.

Background: Tobacco use in youths is a major public health challenge globally, and approaches to the challenge have not been sufficiently addressed. The existing policies for tobacco control are not well specified by age. Objective: Our study aims to systematically investigate existing tobacco control policies, potential impacts, and national and international challenges to control tobacco use targeting the youth. Data sources: We used the statistics of the Global Youth Tobacco Survey (GYTS), studies, and approaches of tobacco control policies targeting youth. Considering country, continent, age, and significance, PubMed, Health Inter-Network Access to Research Initiative (HINARI), Scopus, the Cochrane Library, Google, and Google Scholar were searched. The related keywords were tobacco control, youth, smoking, smoking reduction policies, prevalence of tobacco use in youth, classification of tobacco control policies, incentives to prevent young people from using tobacco, WHO Framework Convention on Tobacco Control (FTCT), etc. The search strategy was by timeline, specific and popular policies, reliability, significance, and applicability. Results: We found 122 studies related to this topic. There were 25 studies focusing on situation, significance, and theoretical aspects of tobacco control policies associated with youth; 41 studies on national population polices and challenges; and 7 studies for global challenges to overcome the youth tobacco epidemic. All national policies have been guided by WHO-MPOWER strategies. Increases in tobacco tax, warning signs on packaging, restriction of tobacco product advertisements, national law to discourage young people, and peer-based approaches to quit tobacco are popular policies. Smuggling of tobacco products by youth and ignorance of smokeless tobacco control approach are major challenges. Limitation: Our study was flexible for the standard age of youth and we were not able to include all countries in the world and most of the studies focused on smoking control rather than all smokeless tobaccos. Conclusion: The policies of tobacco control adopted by many countries are based on the WHO Framework Convention on Tobacco Control but not necessarily focused on youth. Due to the physical and economic burden of tobacco consumption by youth, this is a high priority that needs to be addressed. Youth-focused creative policies are necessary, and more priority must be given to tobacco prevention in youth. Tobacco control should be a social, public health, and quality-of-life concern rather than a business and trade issue. Implication of key findings: There is limited research on how and in what ways tobacco control policies reach young people and their engagement with these policies from physical, physiological, and psychological aspects. Analysis of these aspects, popular polices practiced in different countries, and creative strategies support the need to review current practices and future ways to discourage youth from tobacco use.

Access to orphan drugs - comparison across Balkan countries.

The aim of this study was to compare orphan drug access in a sample of Balkan countries: five EU Member States (Bulgaria, Croatia, Greece, Romania, Slovenia) and two EU Candidates (Serbia, Montenegro). The comparative analysis was based on a cross-sectional study and included medicinal products with an active orphan designation and market authorisation on January 1, 2017. Access to orphan drugs is an ongoing challenge in these countries. Three clusters of countries were identified in terms of orphan drug access: Greece and Slovenia, making the top tier, Romania, Bulgaria, and Croatia, being in the middle, and EU Candidates, Serbia and Montenegro, forming the bottom tier, where a substantial number of EU market approved orphan drugs was not even registered. Available public health resources and market size are probably among the contributing factors for such inequalities. Sizeable part of EMA market authorised orphan medicinal products is not even priced in the Balkan countries. This is a serious issue, which is putting rare disease patients from this region in a particularly vulnerable situation. There is a need for further improvement in accessibility of orphan drugs in the Balkan countries. Cross-border collaboration in the field of pricing, health technology assessment, and reimbursement negotiation of orphan drugs may help to address these challenges.

Growth of Global Publishing Output of Health Economics in the Twenty-First Century: A Bibliographic Insight.

BACKGROUND: Strong growth of interdisciplinary sciences might find exceptional example in academic health economics. We decided to observe the quantitative output in this science since the beginning of the twenty-first century. METHODS: Electronic search of the published literature was conducted in four different databases: one medical database-MEDLINE/PubMed, two general databases-Scopus/Elsevier and Web of Science (WoS), and one specialized health economic database-NHS Economic Evaluation Database (EED). The applied combination of key words was carefully chosen to cover the most commonly used terms in titles of publications dealing with conceptual areas of health economics. All bibliographic units were taken into account. RESULTS: Within the time horizon from January 1, 2000 to December 31, 2016, without language or limitations on bibliographic unit types, we identified an output ranging approximately from 60,345 to 88,246 records with applied search strategy in MEDLINE/PubMed, Scopus/Elsevier, and WoS. In NHS EED, we detected 14,761 records of economic evaluations of health interventions during the period in which database was maintained and regularly updated. With slightly more than one-third of the identified records, USA clearly dominates in this field. United Kingdom takes a strong second place with about 12% of identified records. Consistently, USA and UK universities are the most frequent among the top 15 affiliations/organizations of the authors of the identified records. Authors from Harvard University contributed to the largest number of the identified records. CONCLUSION: There is a clear evidence of both the upward stream of blossoming in health economics publications and its acceleration. Based on this bibliographic data set, it is difficult to distinguish the actual impact growth of this output provided dominantly by academia with modest contribution by pharmaceutical/medicinal device industry and diverse national government-based agencies. Further insight into the citation track record of these individual publications could provide helpful upgrade and a perspective on ongoing development.

Transposition and implementation of EU rare disease policy in Eastern Europe.

INTRODUCTION: А series of European Union (EU) political decisions have made rare diseases one of the cornerstones of the common European health policy. Adopted in 2009, Council Recommendation on an action in the field of rare diseases aimed to serve as a policy-making guideline. However, the implementation report, which followed it, neither performed detailed cross-country comparison, nor assessed the impact of the policies. Areas covered: A 10-indicator set was elaborated to structure the review and to describe rare disease activities in 14 Eastern European countries. Expert commentary: Taking into account all indicators, EU member states outperform candidate and potential candidate countries in terms of rare disease policy planning and implementation. Hungary is the top performer, followed by Bulgaria and Czech Republic. Non-EU countries form the bottom tier, with Serbia being the best ranked among them. While EU adhesion is a major facilitator for planning and adopting rare disease policies, local stakeholders are the triggering factor for their successful implementation. European reference networks are likely to be the future of rare disease activities in the EU. They need to synchronize and closely collaborate with all important EU projects in the field of rare diseases if they are to achieve their objectives.

Within the triangle of healthcare legacies: comparing the performance of South-Eastern European health systems.

OBJECTIVE: Inter-regional comparison of health-reform outcomes in south-eastern Europe (SEE). METHODS: Macro-indicators were obtained from the WHO Health for All Database. Inter-regional comparison among post-Semashko, former Yugoslavia, and prior-1989-free-market SEE economies was conducted. RESULTS: United Nations Development Program Human Development Index growth was strongest among prior-free-market SEE, followed by former Yugoslavia and post-Semashko. Policy cuts to hospital beds and nursing-staff capacities were highest in post-Semashko. Physician density increased the most in prior-free-market SEE. Length of hospital stay was reduced in most countries; frequency of outpatient visits and inpatient discharges doubled in prior-free-market SEE. Fertility rates fell for one third in Post-Semashko and prior-free-market SEE. Crude death rates slightly decreased in prior-free-market-SEE and post-Semashko, while growing in the former Yugoslavia region. Life expectancy increased by 4 years on average in all regions; prior-free-market SEE achieving the highest longevity. Childhood and maternal mortality rates decreased throughout SEE, while post-Semashko countries recorded the most progress. CONCLUSIONS: Significant differences in healthcare resources and outcomes were observed among three historical health-policy legacies in south-eastern Europe. These different routes towards common goals created a golden opportunity for these economies to learn from each other.

Comparison of historical medical spending patterns among the BRICS and G7.

OBJECTIVE: The past few decades have been marked by a bold increase in national health spending across the globe. Rather successful health reforms in leading emerging markets such as BRICS reveal a reshaping of their medical care-related expenditures. There is a scarcity of evidence explaining differences in long-term medical spending patterns between top ranked G7 traditional welfare economies and the BRICS nations. METHODS: A retrospective observational study was conducted on a longitudinal WHO Global Health Expenditure data-set based on the National Health Accounts (NHA) system. Data were presented in a simple descriptive manner, pointing out health expenditure dynamics and differences between the two country groups (BRICS and G7) and individual nations in a 1995-2013 time horizon. RESULTS: Average total per capita health spending still remains substantially higher among G7 (4747 Purchase Power Parity (PPP) $PPP in 2013) compared to the BRICS (1004 $PPP in 2013) nations. The percentage point share of G7 in global health expenditure (million current PPP international $US) has been falling constantly since 1995 (from 65% in 1995 to 53.2% in 2013), while in BRICS nations it grew (from 10.7% in 1995 to 20.2% in 2013). Chinese national level medical spending exceeded significantly that of all G7 members except the US in terms of current $PPP in 2013. CONCLUSIONS: Within a limited time horizon of only 19 years it appears that the share of global medical spending by the leading emerging markets has been growing steadily. Simultaneously, the world's richest countries' global share has been falling constantly, although it continues to dominate the landscape. If the contemporary global economic mainstream continues, the BRICS per capita will most likely reach or exceed the OECD average in future decades. Rising out-of-pocket expenses threatening affordability of medical care to poor citizens among the BRICS nations and a too low percentage of GDP in India remain the most notable setbacks of these developments.

Health Economics at the Crossroads of Centuries - From the Past to the Future.

Health economics, as an interdisciplinary science, has experienced exceptionally bold evolution through the past eight decades. Generations of committed scholars have built up huge body of knowledge and developed a set of methodological tools to assist health-care authorities with resource allocation process. Following its conception at the US National Bureau of Economic Research and Ivy League US Universities, this science has spread across the Globe. It has adapted to a myriad of local conditions and needs of the national health systems with diverse historical legacies, medical services provision, and financing patterns. Challenge of financial sustainability facing modern day health systems remains primarily attributable to population aging, prosperity diseases, large scale migrations, rapid urbanization, and technological innovation in medicine. Despite promising developments in developing countries with emerging BRICS markets on the lead, rising out-of-pocket health spending continues to threaten affordability of medical care. Universal health coverage extension will likely remain serious challenge even for some of the most advanced OECD nations. These complex circumstances create strong drivers for inevitable further development of health economics. We believe that this interdisciplinary health science shall leave long-lasting blue print to be visible for decades to come.