deliverables for working conference ‘strengthening …...working conference ‘strengthening the...

Working conference ‘Strengthening the European dimension of HSR’, grant agreement 20114304, EAHC. June 2013.

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Deliverables for working conference ‘Strengthening the European dimension of HSR’, grant agreement 20114304 for the EAHC Author: Johan Hansen, NIVEL ([email protected]), June 2013 Deliverable 4 – Conference Contents 1 Conference programme including list of participants p. 2 2 Extracts from Conference Programme European Public Health

Conference p. 10 3 Slides of all presentations during the conference p. 13


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1 Copy of Conference programme including list of participants


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2) Extracts from Conference Programme European Public Health Conference: reference to the working conference on page 25 and reference to a lunch session to discuss the main conference results with participants of the EPH Conference on page 74


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3 Slides of all presentations during the conference Contents: Plenary opening session Peter Groenewegen ‘Strengthening the European dimension in Health Services Research’ Parallel theme 1: Improving service delivery for noncommunicable diseases Ellen Nolte ‘Approaches to managing chronic conditions in Europe’ Jack Hutten ‘Tackling the burden of chronic diseases’ Parallel theme 2: Better using international evidence at national level Josep Figueras ‘Learning from International Health Systems Evidence’ Nick Fahy ‘Improving health systems using (international) evidence’ Parallel theme 3 – Evaluating health care reforms and health care financing options Josep Figueras ‘Privatization of funding: A response to the crisis in the EU? Assessing the Evidence’ Vladimir Lazarevik ‘Health Reforms and Crisis: What have we learned?’ Parallel theme 4 Finetuning national and European research agendas Nancy Edwards ‘The Fine-Tuning of National and European Research Agendas’ Edvard Beem ‘Reflections on the use of research agendas from ZonMw - The Netherlands’

Strengthening the European dimension in Health Services

Research

Peter GroenewegenNIVEL, Netherlands Institute for Health Services Research

The Past

FP-7 Funded Support Action in Pillar 3 ‘Optimising the delivery of health care’(From March 2009 until Feb 2011)

General aim: to identify, evaluate and improve the contribution of Health Services Research (HSR) to the health policy process at national and European level, and thus help optimize the delivery of health care services to European citizens

Objectives:a) To identify the state-of-the-art of European HSR.b) To identify current and upcoming HSR priorities.c) To assess infrastructures for the translation of HSR into the policy and

practice.d) To contribute to agenda setting on HSR at European and Member States’ level.e) To offer a forum at which studies in the field of HSR can be presented,

discussed and evaluated.

HSREPPHealth Services Research into European Policy & Practice

Health services research in 5 main domains:

• Health care systems

• Health care organisations and service delivery

• Health Technology Assessment

• Benchmarking & performance indicators

• Linkage and exchange between research & policy

HSREPP (continued)

Priority setting projects

Working ConferenceFirst HSR Working ConferenceThe Hague, 8-9 April 2010

• Emphasis on discussion• Both researchers and policy makers• No ‘ten minute paper presentations’

Result: inventory of research priorities

Where did it bring us?

Outcomes and use of the project

• Establishment of an HSR-network

• Final report, special issue JHSR&P and Policy Brief• At EC level inputs were used in the

FP-7 call of 2012– On integrated care, patient

involvement, workforce, HTA & knowledge transfer

– But not on e.g. financing/privatisation,reform evaluation & benchmarking

• At national level?


Success factors:

• Timing of draft versions• Transparent process• Synergy with FUTURAGE, roadmap project on ageing• Personal commitments from EC officers• And a bit of luck


FP-7 projects that received funding

Under the call of ‘improving the organisation of health service delivery:• OPTIBIRTH: Improving the organisation of maternal

health service delivery, and optimising childbirth, by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care (led by Trinity College Dublin)

• PROJECT INTEGRATE: Benchmarking Integrated Care for better Management of Chronic and Age-related Conditions in Europe (led by Universidad de Navarra)

• MUNROS: Health Care Reform: the iMpact on practice, oUtcomes and costs of New roles for health pROfeSsionals (led by University of Aberdeen)

Under the call of ‘New methodologies of HTA’• ADHOPHTA: Adopting Hospital Based Health Technology

Assessment in EU (led by Fundació Clínic Barcelona)


The Present

Goals:• International comparative HSR: added

value for national and European policy

• Using evidence from international comparisons to inform decision making

• Discussing inputs for Horizon 2020

• Capacity building at the research and policy side

Background to today’s meeting

• Common challenges• Interconnectedness of (European) policies

Troika Portugal and Greece: health system reform

• Don’t make the same mistakes• Better use of proven interventions

Why is international comparative research so important?

Variation• (health) outcomes• Processes of care• Organisational and system

structure

Multilevel• Countries• Federal states, regions• Organisations

Designs• Longitudinal• Repeated surveys• Comparative system info

Data• Quantitative• Qualitative• Patient records

Europe: HSR research laboratory

Variation• (health) outcomes• Processes of care• Organisational and system

structure

Multilevel• Countries• Federal states, regions• Organisations

Designs• Longitudinal• Repeated surveys• Comparative system info

Data• Quantitative• Qualitative• Patient records

Europe: HSR research laboratory

Two thematic areas:• Improving service delivery for non-communicable diseases

• Evaluating health care reforms and financing options

Two strategic areas:

• Better using international evidence at national level

• Fine-tuning national and European research agendas

Focus on four areas

• Addressing two topics:– Use of international evidence in national decision making– Creation of national research agendas

• Among:– Working conference participants– mailing list of HSR Europe – mailing list of EUPHA Section on HSR (response so far 63 responders)

• And among:– Members of European Medical Research Councils – Ministries of Health (response so far 3 responders)

First results online survey

Topic area 1:

Use of international evidence in national decision making


First results online surveyWhere does one find information (e.g. research outcomes or expert opinions) from other countries

First results online surveyWhich type of information does one find most important when reviewing the usefulness of the evidence from other countries

First results online surveyAre you aware of health policy measures in your country in which evidence from other countries was used, and if so, from which countries

Topic area 2:

Creation of national research agendas


First results online surveyDoes a country have a national health research agenda or is such an agenda currently being developed?

Yes No Unclear

Germany (2 x) Israel (1 x) Belgium (3 x don't know)Norway (2 x) Macedonia (1 x) Denmark (1 x yes, 1 x no)Australia (1 x) Sweden (1 x) Mexico (1 x don’t know)Canada (1 x) Switzerland (1 x, but also 2 x don't Bulgaria (1 x don’t know)

Finland (1 x) know)Kosovo (1 x)Luxembourg (1 x)Malta (1 x)Spain (1 x)Netherlands (5 x, but also 2 x no, 1 x don’t know)Italy (3 x, but also 1 x no, 5 x don't know)Uk (2 x, but also 1 x no)Ireland (2 x, but also 1 x no, 1 x don't know)

First results online surveyCan one personally influence the national health research agenda?

Linkage to European agendas

How to get HSR priorities into the EU agenda?

The Future

Centred around 6 main societal challenges:

• Health, demographic change and well-being• Food security, sustainable agriculture, marine and maritime

research and the bioeconomy• Secure, clean and efficient energy• Smart, green and integrated transport• Climate action, resource efficiency and raw materials• Inclusive, innovative and secure societies

Horizon 2020

• Larger programmes• Integration of DG Research and DG Sanco priorities• Synergy with national programmes, other forms of

support• Growing importance of public-private partnerships

with industry, SMEs• More emphasis on biomedical research• Valorisation (patents, economic spinoff)

What’s different under Horizon 2020

• Larger programmes• Integration of DG Research and DG SANCO priorities• Synergy with national programmes, other forms of

support• Small research areas don’t have a big influence on

national priorities• Find a common voice within Europe and with related

networks• Building and maintaining a relationship with DG

Research and DG Sanco

And how can we respond?

• Growing importance of public-private partnerships with industry, SMEs

• More emphasis on biomedical research• Valorisation (patents, economic spinoff)

• What are relevant private partners and SME’s for HSR?

• Importance of how treatments are delivered and how services are organised

• Social valorisation, policy impacts of research

And how can we respond?

How to get into a call?

From 30/11: Parliament and Council negotiations on the basis of the Commission proposalsOngoing: Parliament and Council negotiations on EU budget 2014-20 (including overall budget for Horizon 2020)Mid 2012: Final calls under 7th Framework Programme for Research to bridge gap towards Horizon 2020By end 2013: Adoption of legislative acts by Parliament and Council on Horizon 20201/1/2014: Horizon 2020 starts; launch of first callsHorizon 2020 will be adopted using the "ordinary legislative procedure" (formerly known as "co-decision"). The diagram below illustrates this.

Time-line of Horizon 2020

Back To The Present

• Policy brief: Contribution of HSR in tackling European challengesPriorities for HSR

• Plenary closing session

• Collect ideas during parallel sessions

Ground rule for the discussions: Chatham House Rule: “When a meeting, or part thereof, is held under the Chatham House Rule, participants are free to use the information received, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed”

The rule allows participants to speak as individuals, and to express views that may not be those of their organizations, and therefore it encourages free discussion and sharing of information.

Some pointers for the rest of the day

Approaches to managing chronic conditions in Europe

Strengthening the European dimension of Health Services ResearchWorking Conference

Parallel Session ‘Improving the service delivery for NCDs’

Malta, 7 November 2012

The nature of chronic conditions requires a different approach to service delivery

Acute disease Chronic illnessOnset Abrupt Generally gradual and often subtle

Duration Limited Lengthy and indefinite

Cause Usually single Usually multiple and changes over time

Diagnosis and prognosis

Usually accurate Usually uncertain

Technological intervention

Usually effective Often indecisive, adverse effects common

Outcome Cure possible No cureUncertainty Minimal Pervasive

Knowledge Professionals knowledgeable, patients inexperienced

Professionals and patients have complementary knowledge and experiences

Source: Holman & Lorig (2000)

Requirements for chronic illness care

Goals enhance functional status, minimise distressing

symptoms, prolong life through secondary prevention and enhance quality of life

Requirements complex response over extended period of time co-ordinated inputs from a wide range of professionals access to essential medicines and monitoring systems promotion of active patient engagement

Evidence points to improved outcomes of components of care coordination

Main focus of intervention (number of studies)

Proportion (%) of studies with positive outcome for

Health Service user satisfaction

Cost saving

Changed relationships between service providerse.g. case management, multi-disciplinary teams (33)

65.5%(19/29)

66.7%(8/12)

16.7%(2/12)

Coordination of clinical activitiese.g. joint consultations, shared assessments (37)

61.3%(19/31)

33.3%(4/12)

20%(3/15)

Improving communication between service providerse.g. case conferences (56)

55.3%(26/47)

54.5%(12/22)

14.3%(2/21)

Support for clinicianse.g. supervision for clinicians, reminder systems (33)

57.1%(16/28)

57.1%(8/14)

8.3%(1/12)

Information systems to support co-ordinatione.g. care plans; decision support; register (47)

60.5%(23/38)

36.8%(7/19)

15.4%(2/13)

Support for health/social care service userse.g. education, reminders; assistance (19)

35.3%(6/17)

50.0%(3/6)

14.3%(1/7)

All studies 55.4%(36/65)

45.2%(14/31)

17.9%(5/28)

Source: Powell Davies et al. 2008

Improvements are typically associated with practice redesign

Source: Coleman et al . 2009

Measured outcomes improved(number of trials)

All Some None Total (n)

Substantial attempt to redesign practice

4 3 0 7

Some attempt to redesign practice

8 9 0 17

Minimal attempt to redesign practice

1 6 1 8

No attempt to redesign practice

2 7 1 10

Total 15 25 2 42

Patients with chronic disease report deficiencies in care coordination

Source: Schoen et al. 2011

Support for patient engagement and self-management remains sub-optimal

Source: Schoen et al. 2011

What does this mean for health systems?

An effective response to the rising burden of chronic disease requires a health system environment that allows for the development and implementation of structured approaches to chronic disease management Countries are developing new models of healthcare delivery

to achieve better coordination of services across the entire continuum of care Review of approaches and models in place in 13 countries

across Europe Austria, Estonia, France, Germany, Hungary, Lithuania,

Netherlands, Switzerland Denmark, England, Italy, Latvia, Spain

The majority of approaches tend to focus on populations with defined conditions

Most frequently targeted conditions: diabetes type 2, asthma/COPD, cardiovascular disease (chronic heart failure, IHD, stroke), cancer, mental health problemsApproaches with generalist focus tend to be organised

around older people Frequently available in selected regions only and/or operated

as pilot studiesTypes of approaches vary across and within countries Care coordination (GP acts as principal coordinator) Multidisciplinary team working (frequently led by GP) Nurse-led approaches including managed discharge and case

management

Source: DISMEVAL 2012

Strengthening coordination through structured disease management

‘Disease management programmes’ Austria: ‘Therapie aktiv’ (diabetes) (national); regional projects Denmark: DMPs (various) (national through regions) France: Sophia (diabetes) (national) Germany: DMPs (various) (national) Hungary: DMP (asthma) (national); diabetes (national) Italy: IGEA (diabetes) (national through regions) Netherlands: Care groups (various) (national)

wide variation in extent to which non-medical staff is involved in care delivery (eg Netherlands, Hungary, Italy)GP/family physician tends to remain principal provider/’care

coordinator’ (eg Austria, Germany, France)


Strengthening the role of nurses in care delivery and coordination

Common in systems with tradition in multidisciplinary team working Nurse-led clinics; nurse-led case management (England, Italy,

Netherlands, Spain)Challenging in systems where primary care traditionally

provided by doctors in solo-practice and few support staff Enhanced functions in care coordination or case management

under development/piloted (eg Denmark, France; Lithuania) Enhanced functions in patient self-management support

and/or selected medical tasks but under supervision of GP/physician (Austria, France, Germany)


Reducing barriers between sectors

Managing the primary/secondary care and/or secondary care/rehabilitation interface Provider networks (France) Integrated care contracting (Germany) Care Coordination Pilot (Hungary) ‘SIKS’ project (Copenhagen, Denmark) ‘From On-demand to Proactive Primary Care’ (Tuscany, Italy) (some) Reform pool projects (Austria) Stroke service Delft (Netherlands)

Managing the health and social care interface (some) Integrated Care Pilots (England) Partnership for Older People Project (England) Multifunctional community centres (Hungary) Improving intersectoral collaboration (pilot) (Lithuania)


The majority of approaches are funded from ‘usual’ sources

Start-up funding Supporting payers (municipalities, Denmark; integrated care

pilots, England; integrated care contracts, Germany) Supporting providers (provider networks, France)

Financial incentives Incentivise payers (municipalities, Denmark; DMPs, Germany) Incentivise providers (DMPs, Austria; GPs (diabetes care),

Denmark; provider networks, France; DMPs, Germany; some regional projects, Italy; care groups, Netherlands; Quality & Outcomes Framework, UK) Incentivise patients (provider networks, France; DMPs,

Germany; care groups, Netherlands)


Levels of patient and clinician support vary

Patient access is typically granted in line with access to usual careMany approaches are being implemented in selected

geographical regions so potentially limiting access to defined population groupsThe majority provide some form of patient self-management

support, although the level and scope of support offered variesThe use of clinical information systems for chronic disease

management tends to be the least developed strategy in most approaches


Are these new approaches making a difference?Improvements reported mainly on process measures (eg eye

examinations)Evidence of improvement of outcomes less certain Evidence of improved survival of patients in German diabetes

DMP => selection? Some evidence of effect of improved clinical outcomes in

Austrian diabetes DMP


… however, findings differ by evaluation design

Source: Flamm et al. 2011




Austrian diabetes DMP Evidence of effect in subgroup of patients in Dutch diabetes care

groups


Small average changes but clinically relevant improvements in patients with poor control

Source: Elissen et al. 2012




Austrian diabetes DMP Evidence of effect in subgroup of patients in Dutch diabetes care

groups English Integrated Care Pilot programme: increase in re-

admissions (but fewer planned admissions); some worsening in patient experience (Roland et al. 2012)


Challenges remain

Need to better understand differential impacts of new approaches and ‘what works for whom’Need to better understand how specific local conditions

influence the outcomes of a given programmeMuch of existing research evidence has focused on the

management of a few specific diseases Need to shift focus on individuals with coexisting conditions or

multiple health problems

… with a particular need to understand the epidemiology of multimorbity

Source: Barnett et al. 2012

Tackling the burden of chronic diseases

Dr. Jack B.F. HuttenPublic Health Department

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The Netherlands• Small country (38.000 km2)• 16.7 million inhabitants, high population density• GDP/capita: €36.200 (2011)• Open economy (traders) economic incentives• European history social principles• Mix of influences (religion, culture) pragmatic• Coalition Government consensus

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Recent trends in health and chronic illnesses

Trends•People live longer

- life expectancy males: 78,3 years- life expectancy females: 83,3 years

•But they become chronically ill earlier in life - males at age 48- females at age 42

How many people with a chronic condition?- now 4,5 million - 1,3 million have multiple conditions

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The ChallengeAn expected increase of people

with chronic diseases (2005-2025)

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The Causes

• Demographic developments

• New medical technology

• Life style- food (too fat/salty, too much)- smoking- alcohol abuse- too little physical activity

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Four Ambitions of the Ministry of Health (2008)1. Reduce the increase number of people with a chronic condition2. Delay the age at which chronic conditions firstly manifest3. Prevent or delay the onset of complications4. Enable patients to cope with their condition in order to improve

quality of life

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7

HEALTHY PEOPLEHIGH RISK

GROUPSPATIENTS

How to reach these ambitions?

Dutch health policy has whole population as target

WHOLE HEALTHY POPULATION

HIGH RISK GROUPS

Ambition 1 & 2

Universal prevention

Selectiveprevention

Public Health

IncludesHealth protectionDisease preventionHealth promotion

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10

Too much preaching!

Thou shall be healthy!

Listen, you foolish other sectors, act in the name of health!

Health as a self-selling argument

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Government hesitant to interfere in personal choices

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Trust in healthprotection

Health and sport

in the neigbourhood

Prevention and primarycare closeby and

accessible

Safe sport and physicalactivity in the neighbourhood

Elder people: a long, healthy and

independent life

Lifestyle is a personal issue

Basic life skills

Youth as the startingpoint

Healthy choice,

easy choice

Reliable and accessibleinformation

Policy paper: Health close to people

HIGH RISK

INDIVIDUALPATIENTS

Care related

prevention

Ambition 3 & 4

Indicatedprevention

A programmatic approachPatient-focused

Tailor made personal care plansCentral coordinator/patient’s point-of-contactLife time coaching /self management

Integrated health care encompassing early recognition, prevention, self-management and adequate health and social care

Multi-disciplinary approach (‘health care team’)

Transparent and cost-efficientQuality indicatorsGood information systems (ICT)

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PRESENT SITUATION:

Home care Primary Care

Hospital care Tertiary care

Patient’s Health Issue still packed in Silo’s

Ways to stimulate the programmatic approach?Norms and regulation

Integrated health care standardsBasic health insurance package (compulsory)

TransparencyQuality indicatorsBenchmarking

Financial incentivesPatient: own payments/own riskCare providers: integrated financing (functional)Health insurers: risk compensation

Integrated Health Care Standard…

is based on consensus, developed by all stakeholders- patients, all care providers involved (GPs, specialists, nurses, etc)

patient version is available- patient knows what he may expect- what he can do himself to improve outcomes

describes in general terms- what encompasses good health care- the care process and organization

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The health care standard

Three health care standards are now available: diabetes cardiovasculair risk management COPD

Four health care standards are in development: depression (mental disorder) obesity heartfailure cancer

Health care standard: basis for contracts between care providers and health insurance

companies

Integrated financing of chronic health care

• Starting point are health care needs

• Not ‘who’ but ‘what’ should be financed

• One contractor, one price for the whole integrated package of care needed

• Healthcare standard-based funding started in 2010 for three chronic conditions

- on voluntary and experimental basis- evaluation commission: conditions?

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First results

PatientsActive patient associations: involvement in the development of health care standards

Care providersIncrease of ‘primary care groups’ for chronic careMore than 100 groups (70% of the GPs)

Health InsurersMost insurers have started contracting care groups for diabetes care. Some insurance companies contract cardio vascular risk management

Future challengesRisk of double paymentsCo-/multi-morbidityReduction of choices of patientsUnclear responsibilitiesInequality in the marketConnection with long term care

and social support act

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Results of programmatic approach so far very promissing….

But still a long way to go!

Learning from International Health Systems Evidence

Learning to transfer - across country bordersLearning to translate - the evidence /policy gap

www.healthobservatory.euwww.healthobservatory.eu 1

Malta, 7Malta, 7thth November 2012November 2012Josep Josep FiguerasFigueras

Strengthening the European Dimension Strengthening the European Dimension of Health Services Researchof Health Services Research

Learning from International Health Systems Evidence

Learning to transfer - across country bordersLearning to translate - the evidence /policy gap


Malta, 7Malta, 7thth November 2012November 2012Josep Josep FiguerasFigueras


OutlineOutline

1. Transferring evidence in Europe, is it possible? If so.... How to? What we know and don’t know?

2. Translating evidence into practice, is it possible? If so.... How to? What we know and don’t know?


3. Assessing the impact of the policy settings4. Understanding decision makers5. Strengthening knowledge brokers: actors & organizations6. Developing knowledge transfer/translation strategies7. A possible agenda for research and discussion

• Policy transfer (Dolowitz and Marsh, 1996, 2000)• Policy convergence (Bennett, 1991)• Policy diffusion (Eyestone, 1977, Walker 1969)• Policy learning / lessons drawing (Rose 1993)

What do we mean by policy transferWhat do we mean by policy transfer


• Policy learning / lessons drawing (Rose, 1993)

• Diffusion of innovations (Rogers, 1962, …, 2003) • Knowledge utilization

• Policy migration• Cross fertilisation

What do we mean by policy transferWhat do we mean by policy transfer

“The process by which knowledge about policies, administrative arrangements, institutions and ideas in one political system (past or present) is used in the development of policies administrative


the development of policies, administrative arrangements, institutions and ideas in another political system”

Dolowitz and Marsh, 2000 and 1996

“ Under what circumstances and to what extent can a program that is effective in one place transfer to another?”

Rose, 1993 on policy learning

2. Learning to translate 2. Learning to translate

Surveys indicate that Surveys indicate that researchers continue to spend researchers continue to spend time identifying questions, time identifying questions, conducting evaluations and conducting evaluations and refining methodologies ratherrefining methodologies rather


refining methodologies rather refining methodologies rather than communicating with than communicating with decision makersdecision makers. [e.g. Stryer et al]

From From the academic ‘ivory tower’ to the academic ‘ivory tower’ to thethe ‘day to day’ of reactive ‘day to day’ of reactive politicspolitics

Key elements Key elements for for policy policy transfer & translationtransfer & translation

3. From where to where? • Policy settings / contextual factors

4. Who are the clients (decision makers)


5. Who (or what) transfers / translates evidence? • Actors (knowledge brokers) & organizations

6. What is transferred? • Strategies to transfer / translate evidence• Source and quality of evidence

3. Policy 3. Policy settings / contextual factorssettings / contextual factors

• For both: exporters & importers (lenders & borrowers) • Culture (Weltanschauung, Checkland, 1991)• Political structures and administrative arrangements• Political cycle (‘window of opportunity’)• Problem severity e g financial crisis as opportunity?


Problem severity e.g. financial crisis as opportunity?• Ideology (relative to policy / evidence proposed)• Resource availability (political, financial, technical,..)• Role of internal policy entrepreneur• Geographic / cultural proximity

4. Understanding policy makers4. Understanding policy makers‘‘MindlinesMindlines’’

Evidence based guidelines or collectively constructed “mindlines”? Gabbay & le May

www.healthobservatory.euwww.healthobservatory.eu

5. Actors 5. Actors and and OrganizationsOrganizations

• Official (bureaucrats and politicians) • Multilateral organizations (WHO, WB, OBS, OECD)

– Role of the EU • Government / bilateral org. (DfID, USAID, SIDA,..)

P f i l d i i i / NGO


• Professional, consumer and patient associations / NGOs• Advocacy groups

• International consultancies• Individual product champions / policy entrepreneurs

– academics, politicians, ….

• How is it governed? Representation (e.g policy makers) in its govern; transparency; independence

• How is it managed staffed? Accountability for its KB mandate; size, mix and capacity of staff for KB

5. Actors and Organizations5. Actors and OrganizationsOrganizational ModelsOrganizational Models

Matching design to functionMatching design to function


KB mandate; size, mix and capacity of staff for KB• How its resources are managed and allocated?

Explicit priorities, appropriate funding for KB• How it collaborates? Networks, linkages with

policy making, stakeholder organizationsLavis J, et al BRIDGE Summary 3, European Observatory, 2012





Key role of interpersonal networks“…. most individuals do not evaluate an innovation on the basis of scientific studies of its consequences





the basis of scientific studies of its consequences… instead, most people depend mainly upon a subjective evaluation of an innovation that is conveyed to them from other individuals like themselves who have previously adopted the innovation. (…) So diffusion is a very social process.”

Rogers, 2003, Diffusion of Innovations





Key role of interpersonal networks“…. most individuals do not evaluate an innovation on the basis of scientific studies of its consequences





the basis of scientific studies of its consequences… instead, most people depend mainly upon a subjective evaluation of an innovation that is conveyed to them from other individuals like themselves who have previously adopted the innovation. (…) So diffusion is a very social process.”

Rogers, 2003, Diffusion of Innovations

6. Developing Strategies for Knowledge 6. Developing Strategies for Knowledge Transfer & Translation Transfer & Translation Transferability Transferability of policiesof policies

– Timing (windows of opportunity)– Accordance: evidence & policy maker thinking• i.e. higher impact of research when

confirms political self interest


f p f– Compatibility (consistent with existing values/context)– Perceived success elsewhere– Communicability (ease of communicating to others)– Promoted policies (e.g professional associations)– Coerced or induced policies (e.g. EU, Troika)

Communicating clearly Communicating clearly InformationInformation--packaging (IP) mechanismspackaging (IP) mechanisms

• What it covers? Relevant policy issue and its multiple features: problem, options, implementation,…

• What it includes? Draws on synthesized (global) research, incorporates tacit knowledge

• For whom it’s targeted? Policy makers & stakeholders,


For whom it s targeted? Policy makers & stakeholders, also involved in the review.

• How it’s packaged? Decision relevant, understandable language, grade entry.

• How its use is supported? Brought to target audiences

Lavis J, et al BRIDGE Summary , European Observatory, 2012

• Focus to policy makers needs • Address practical (key) policy questions• Targeted and opportunistic• Implementation considerations

HEN/Observatory Policy Briefs HEN/Observatory Policy Briefs


• Not normative / lessons on policy options• 1 /3 / 25 structure • Timing• E.g. Briefs for EU presidencies

Learning from one another Learning from one another Interactive knowledgeInteractive knowledge--sharing (IKS) mechanismssharing (IKS) mechanisms

• What it covers? Relevant policy issue and its multiple features: problem, options, implementation,…

• What it includes? Draws on systematic information, incorporates tacit knowledge, views and experiences

• For whom it’s targeted? Policy makers & stakeholders,


For whom it s targeted? Policy makers & stakeholders, explicitly related to a policy process.

• How it’s organized? Proactive identification of participants, equal contribution, pre-circulation of info

• How its use is supported? Captures insights, brought to target audiences

Lavis J, et al BRIDGE Summary , European Observatory, 2012

• Key strategic questions / policy windows• ‘Rapid reaction triggers’

• Demand driven / supply induced• Co-organised with policy makers

OBS Policy Dialogues OBS Policy Dialogues


• Target small group of senior policy makers • Evidence on alternative options• Emphasis on implementation• Evidence as a neutral platform for

consensus

7. A possible Agenda for HS Research 7. A possible Agenda for HS Research 1. Policy settings / contexts: role and interplay with evidence

transfer, assessing context impact & differences 2. Decision makers

• Behavioural research• Problem focused, rather than discipline focused


3. Organizations / Actors (knowledge brokers)• Analysis and comparison of organizational models• Skills & incentives for brokers

4. Strategies to transfer knowledge• Rigorous evaluation, developing innovations• Interactive sharing/packaging mechanisms• Link to key policy priorities

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Privatization of funding:Privatization of funding:A response to the crisis in the EU?A response to the crisis in the EU?

Assessing the Evidence Assessing the Evidence


Malta, 7Malta, 7thth November 2012November 2012Josep FiguerasJosep Figueras


9

10

11

12

Austria

Belgium

Czech Republic

Denmark

Estonia

Finland

France

Germany

Greece

Hungary

Health Expenditure as % GDP (1975-2011)

An ever increasing curve...An ever increasing curve...

4

5

6

7

8

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Iceland

Ireland

Italy

Luxembourg

Netherlands

Norway

Poland

Portugal

Slovak Republic

Slovenia

Spain

Sweden

Switzerland

United Kingdom

Source OECD HEALTH DATA 2011, October

Outline Outline

1. Disentangling the research question• What is meant by financial sustainability?• Crisis of values, economic paradigm, governance?• What role amidst the response menu?

2 Rationing health services coverage2. Rationing health services coverage 3. Increasing user charges4. Fostering voluntary health insurance

What is meant by Sustainability?What is meant by Sustainability?

• Fiscal sustainability?• Not just an accounting problem• Not just an accounting problem• Single focus on fiscal balance may ignore

efficiency problems and/or other goals • The absence of deficit efficiency• Cost containment (savings) efficiency

What is meant by Sustainability?What is meant by Sustainability?

• Fiscal sustainability?• Not just an accounting problem• Not just an accounting problem• Single focus on fiscal balance may ignore

efficiency problems and/or other goals • The absence of deficit efficiency• Cost containment (savings) efficiency

Crisis of ... European Crisis of ... European ValuesValues? ?

Crisis of… Crisis of… thethe WelfareWelfare StateState??

Crisis of Crisis of ParadigmParadigm??ByeBye--byebye KeynesKeynes?? Welcome Austerity?Welcome Austerity?

Crisis of … (Crisis of … (oror a new) a new) GovernanceGovernance??

What role amidst the responses menu? What role amidst the responses menu?

Protect the health budgetHealth for economic productivityHealth systems as an economic sector

Raise (additional) statutory & earmarked resourcesSt ti i & hifti t tStep up rationing & shifting costs to consumersImprove performance (squeeze efficiency)Act on health determinants (Health in All Policies)

What role amidst the responses menu? What role amidst the responses menu?

Protect the health budgetHealth for economic productivityHealth systems as an economic sector

Raise (additional) statutory & earmarked resourcesSt ti i i hifti t tStep up rationing i.e. shifting costs to consumersImprove performance (squeeze efficiency)Act on health determinants (Health in All Policies)

Reforming Funding Sources Reforming Funding Sources What is the right Public/Private mix? What is the right Public/Private mix?

60%

70%

80%

90%

100%

Sou

rce:

WH

O 2

010

0%

10%

20%

30%

40%

50%

CY

BG

CH LV EL

SK PT

HU PL SI

ES LT BE FI AT DE IT MT

EE

FR RO IE SE NL

UK

NO CZ

DK LU

Public PHI OOP Other private

2. Rationing Health Services2. Rationing Health ServicesCoverage dimensionsCoverage dimensions

13R. Busse

30

40

50

60

1998 2008

OutOut--ofof--pocket as % of total health spendingpocket as % of total health spending

Countries in which OOPs have increased as % of TEH since 1998

Source: WHO 2009

0

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20

Cyp

rus

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nia

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vaki

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ryP

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gal

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alta

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gium Ita

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ceN

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rland

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xem

bour

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Source: WHO GHO 2011 Thomson S. et al Forthcoming 2013

3. Increasing user charges (depth)?3. Increasing user charges (depth)?• Increasing user charges in 13 countries• New charges for some health services

e.g. Estonia, France, Ireland, Italy, Latvia, Netherlands, Portugal and Romania and Slovenia

• Increased rate of existing user chargesh bli k i l de.g. Czech republic, Denmark, Finland, France, Greece,

Ireland and Portugal• Services affected

– Pharmaceuticals (8 countries)– Hospital sector (5 countreies)– Ambulatory sector (3 countries– Emergency departments (2 countries)– Specific services (10 countries)

Mladovsky P. Thomson S. Evetovits T. Cylus J. Karanikolos M. McKee M. Figueras J. 2012

Efficiency arguments for user charges Efficiency arguments for user charges

• Contain costs• Reduce ‘unnecessary’ use• Raise revenue (user pays principle)• Direct people to more cost effective use• Direct people to more cost-effective use

• User charges may enhance efficiency– If no negative effect on health AND– No increased use of other health resources

User charges impact on health & costs User charges impact on health & costs

• Reduce both appropriate & inappropriate care – Blunt tool of limited selective effect

• Disproportionate effect on poor & ill– 10 % population account 70% expenditure

• Increased in unwanted (more expensive) effects• No evidence of long term cost control

– Squeezed balloon effect– User charges little impact on prices, intensity,

technology, excess capacity• It may not increase but undermine efficiency

Thomson S. et al Forthcoming 2013

Where the cost of seeking care is lower, the reduction of utilization is also lower

Source: Lusardi et al. The economic crisis and medical care usage 2010. Harvard Business School

“ Reductions in routine care today might lead to undetected illness tomorrow and reduced individual health and well-being in the more distant future.”

User charge capsUser charge capsPrimary care annual

capOP prescription annual

capInpatient annual cap (daily

charge)AT €10 (poor free) 2% 28 days (10%)BE €450-1,800 depending on incomeCH €580DE 2% (1% for chronically ill)DK FREE €480 (chronic only) FREEDK FREE €480 (chronic only) FREEFI €630 (minors free) x 7 days (minors only) (€32)FR x (chronic free, minors free primary care) 31 days (€18 + 20%)IE x (poor free) €120-€1,440 (chronic free,

low for poor)€750 (poor free) (€75)

NL FREE €220NO €250SE €105 €205 x (€10)UK FREE €130 FREE

Source: Thomson and Reed (2012)

4. Efficiency arguments for 4. Efficiency arguments for Voluntary Health Insurance?Voluntary Health Insurance?

• Contain costs?• Relieve fiscal pressure on public budgets?• Address health coverage gaps?

• Population (breadth)p ( )• Services / benefits (scope)• Costs (depth)

• Will those who need have access to it?• Does it undermine value in public spending health?• Strengthen health systems performance through

purchasing?

3540455055

VHI does not do well in VHI does not do well in filling gaps in coveragefilling gaps in coverage

VHI = > 25% of private spending on health, EU 2009

05

1015202530

Fra

nce

Slo

ven

iaG

erm

any

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land

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rus

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Source: Thomson 2012 forthcoming

VHI impact on health and costsVHI impact on health and costs

• May exacerbate fiscal pressures (substitutive)• Concerns for financial protection and equity• Undermine value in public spending if public resources

subsidise private access• Risk segmentation, tax subsidies, distortion of public

priorities: the larger the market ..... • Efficiency concerns (complementary / user charges)• No evidence of superior efficiency of VHI purchasers

Source: Thomson 2012 forthcoming

Access regulation in the EUAccess regulation in the EU

Regulation CountriesOpen enrolment, lifetime cover

Belgium, Ireland, Slovenia, Germany (basicsubstitutive policy only)

Prohibition of age limits NoneCommunity-ratedpremiums

Non-profits only: Belgium, Estonia, HungaryAll: Ireland Sloveniapremiums All: Ireland, Slovenia

Risk equalisation Ireland, SloveniaPremium caps Germany (basic substitutive policy only)Cover of pre-existing conditions

Non-profits only: BelgiumAll: Ireland

Minimum benefits Ireland, Germany (basic policy only)

User charges cap Germany (basic policy only)

Source: Chollet and Lewis 1997

Health Reforms and Crisis What have we learned?

Vladimir Lazarevik MPHInstitute of Social Medicine

Skopje, [email protected]

www.healthgrouper.com

www.healthgrouper.comMladovsky at al. 2012

Health expenditure in Macedonia

• 1 Health Insurance Fund = 354 million Euro Budget

• Decreased in Contribution rates (from 9.2 to 7.3%)

• Universal coverage (government program)

• OUP around 36% of Total Health Expenditure


Trend of the HIF budget in MKD

4

-4%

-2%

0%

2%

4%

6%

8%

10%

12%

14%

0

5.000

10.000

15.000

20.000

25.000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Пор

аст на

буџет

во

%

Мил

иони

денари

Year

Budget of the Health Insurance Fund 2002-2012

Буџет на ФЗОМ Пораст


Graph 1: Government health spending as % of GDP

50

60

70

80

90

2000 2005 2010 2015

BulgariaCroatiaIsraelSerbiaTFYR Macedonia

Public sector health expenditure as % of total health expenditure, WHO estimates

Policy tools

• Increased Transfers from budget (from 0.2 of GDP in 2008, to 0.9 of GDP in 2011)

• Increased investments in medical equipment, renovation of health facilities

• Regulation of the price of pharmaceuticals (capped, equal and references prices)

• Increased number of contracts with private providers (from 1894 to 3533 individual contracts)

• Increased regulation, medical map • Considering to regulate price of services in private

hospitals


Transfers from the central budget

8

0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

4.500

5.000

2005 2006 2007 2008 2009 2010 2011 2012

Transfers from the central budgets

In miliondenars

Reforms in financing providers

• Capitation to all GP’s (targets) (2001/2007)

• DRG’s to 55 hospitals in the country (2008)

• Pay for Performance (reporting) for doctors (2012)


Survey results among 300 doctors: Do you think P4P project is fair?


Survey results among 300 doctors: How does it reflect over the team work at your department?


Effect on health system goals

• Key health indicators slowly improving, there is no direct connection with the reforms;

• Increased Out of Pocket expenditure;• Patient satisfaction – lower in public, higher in

private health sector; • Physician satisfaction – low job satisfaction,

migration of personnel to private hospitals; • Poor availability of data and use of research;• No clear Health System Targets;


Discussion points • What is priority for health policy

makers/politicians in times of crisis?

• How to use more international experience in policy research?

• What have we learned?

• How to support countries to develop national health policy agendas?


The Fine-Tuning of National and European Research Agendas

EUPHA ConferenceNovember, 2012Nancy Edwards, RN, PhD, FCAHS

Scientific Director,Institute of Population and Public Health,Canadian Institutes of Health Research

Professor, School of Nursing and Department of Epidemiology and

Community Medicine,University of Ottawa

Presentation at a Glance• Canadian health care system and

research context

• CIHR mandate, structure and strategic priorities and relationship to Provincial priorities

• Discussion questions

Key Discussion Questions• What are the drivers (e.g. funding mechanisms and

requirements) that foster buy-in for cross-jurisdictional research?

• What are the multi-layered structures essential for relevant knowledge generation and uptake?

• What metrics should be used to assess relevance and to support contextualization of research findings?

• What are the respective roles of funders, researchers and local institutions vis-à-vis the generation of research questions with high policy-relevance?

Canadian health care system and research system context

Canadian Health Care System Brief Synopsis

• Constitutionally, health is a provincial/territorial mandate with a few exceptions

• Canada’s Health Act designed to ensure all residents have reasonable access to medically necessary hospital and physician services on a prepaid basis

• 13 interlocking provincial and territorial health insurance plans with common features and basic standards of coverage

• Ratio of private:public funding for health care in Canada is approximately 30:70

• Federal government makes transfer payments for health care to provinces and territories

Public Health• Primarily under authority of provinces• Exceptions (examples):

– First Nations and Inuit Health– Quarantine Act

• Public Health Agency of Canada (response to SARS)– National Collaborating Public Health Centres

• 3 provinces with Public Health Institutes• Public Health Network Council (Chief Medical Officers

of Health – all provinces and territories)• Statistics Canada (Canadian Health Measures survey)• Canadian Population Health Initiative (administrative

data)

Research Funding Context• 3 federal tri-councils

– Canadian Institutes of Health (Annual budget approximately1 Billion)

– Social Sciences and Humanities Research Council– Natural and Engineering Sciences Council

• Provincial funding organizations– Existence, priorities and funding level vary

considerably• Federal and Provincial Health Charities

(numerous)– Canadian Heart and Stroke Foundation– National Partnership Against Cancer

CIHR mandate, structure and strategic priorities

About CIHROur Mandate:

“To excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health-care system.” (Bill C-13, April 13, 2000)

Our Vision:

To position Canada as a world leader in the creation and use of knowledge through health research that benefits Canadians and the global community.

Research Pillars of CIHR• Biomedical

• Clinical

• Health systems and services

• Health of populations, societal and cultural dimensions of health, and environmental influences on health

CIHR Approach: 13 “Virtual” InstitutesAnnual budget per Institute: $8.5 M

Aboriginal Peoples’ Health

Health Servicesand PolicyResearch

Genetics

Infectionand Immunity

Cancer Research

Aging

Musculoskeletal Health and Arthritis

Circulatory andRespiratory Health

HumanDevelopment,

Child and Youth Health

Population and Public Health

Gender and Health

Nutrition, Metabolism and Diabetes

Neurosciences, Mental Health and Addiction

http://www.cihr-irsc.gc.ca/e/9466.html

12

Comparative funding of the four research themes(70% open (investigator driven), 30% strategic)

Strategic funds can leverage $ from external partners

0

1000

2000

3000

4000

5000

6000

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2000

01

2001

02

2002

03

2003

04

2004

05

2005

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Biomedical Clinical Health systems/services Social/Cultural/Environmental/PopulationHealth

Fiscal Years (and CIHR Themes)

Num

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(Gra

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Tr

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Sal

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Aw

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)

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Open

12

CIHR’s Strategic Plan (2009-2014)

A Health Research RoadmapCreating innovative research for better health

and health care

13

CIHR Health and Health System Research Priorities

1. Enhance patient-oriented care by targeting science and using new technologies (SPOR)

2. Support a high-quality, accessible, and sustainable health care system

3. Ameliorate the effects of health inequities of Aboriginal peoples and other vulnerable populations

4. Prepare for and respond to existing and emerging global threats to health

5. Promote health and reduce the burden of chronic disease and mental illness

14

Enhance Patient-Oriented Care and Improve Clinical Results

through Scientific and Technological Innovations

Support a High-Quality, Accessible and Sustainable

Health-Care System

Reduce Health Inequities of Aboriginal Peoples and other

Vulnerable Populations

Prepare For and Respond To Existing and Emerging Threats

to Health

Promote Health and Reduce the Burden of Chronic Disease

and Mental Illness

• Epigenetics , Environment and Health Research Consortium (CEEHRC)

• Community Based Primary Health Care

• Personalized Medicine

• Pathways to Health Equity for Aboriginal Peoples

• Inflammation in Chronic Disease

• Patient-Oriented Research Networks and Support Units

• International Collaborative Research Strategy for Alzheimer’s Disease

• Evidence-Informed Health Care

15

CIHR Roadmap Signature Initiativeshttp://www.cihr-irsc.gc.ca/e/43567.html

Funding Mechanisms Tailored to Provincial Needs

• Regional partnership program• Partnerships in health systems improvement• Evidence-informed health care renewal• Strategy for patient-oriented research

– National steering committee– Provincial support units– National networks (mental health, community-

based primary health care)• Population health intervention research

(natural experiments, rapidly unfolding interventions (policy, program, resource redistribution)

Federal/Provincial/Territorial Strategy

• Range of possible interventions to be researched:– Built environment policies

– Active and safe transportation to and from school

– Strategies to reduce availability, accessibility and marketing of foods and beverages high in fat, sugar and/or sodium to children

17

RFA Approaches Targeted to Provincial Needs

• Cross-jurisdictional comparisons• Assessment of scale-up potential• Demonstrated involvement of decision-

makers and policy-makers on teams• Selection of promising models (policy,

programs, resource distribution approaches)

• Provincial-led knowledge translation (e.g. Best Brains exchange)

Evidence-informed Health Care Renewal - Priority research areas

• Healthcare financing and funding models– E.g., Models for funding and remunerating health care

services across the continuum of care and within specific sectors and their impacts on incentivizing behaviour change and improving health and health system outcomes

• Health system sustainability– E.g., Frameworks, tools and models that advance existing

approaches to resource allocation decision-making, both within and across sectors.

• Governance and accountability– E.g., Frameworks and models for improving the appropriate

engagement and participation of the public, patients, and/or service users in health care decision-making.

Key Discussion Questions• What are the drivers (e.g. funding mechanisms and

requirements) that foster buy-in for cross-jurisdictional research?

• What are the multi-layered structures essential for relevant knowledge generation and uptake?

• What metrics should be used to assess relevance and to support contextualization of research findings?

• What are the respective roles of funders, researchers and local institutions vis-à-vis the generation of research questions with high policy-relevance?

The Netherlands organisation for health research and development

Edvard Beem, co-director

ZonMw’s simple formulae

Innovation = knowledge x implementation

Evidence-based practice #

Practice-based evidence

HSR in Europe policy brief 2011

Challenges• Increasing demand on health care

• Connecting (health and social) sectors

• Towards patient-centered care

• Towards better quality of care

• Maintaining sufficient health care workers

• Decreasing country-to-country variations

Research priorities (macro, meso, micro)

HSR in Europe policy brief 2011

The resulting list of priorities for future health services research aims • to provide guidance and inspiration for setting

research priorities at a national and European level

• and to inform the next EC Framework Programme.

How to do this?

Timing is favourable

• Changing health concept

• Changing national policies

• Changing EU policies

Changing health concept

Health being the…

• (<1948) …absence of disease and disability

• (>1948) …state of complete physical, mental and social wellbeing

• (>2011) …ability to cope, adapt and self-manage

Changing health concept

Health improvement can not be solved by the medical sector alone, a collective

response including the social and behavioural sciences, technology sector

incuding ICT and e-health, and foodsector is needed

Changing health research & innovation policies

EU and MS Triple ambition• To improve health and quality of life during

life career

• To provide a major boost to the economy through market growth for B/M enterprises

• To maintain a sustainable, accessible, efficient and affordable health care system

EC: changing and ready for input

• From research themes towards grand societal challenges

• Partnerschip, partnership and partnership

• Innovation, innovation and innovation

EC: partnerships and innovation

EC driven (15%)• Horizon 2020

• Excellent science, Industrial leadership, Societal challenges

• EIP (PPP on Active and Healthy Ageing)

MS driven (85%)• Joint Programming Initiatives (JPI)

• Towards common strategic research agenda

• Shared Research Infrastructures (ESFRI)• Towards common business plans for distributed RI’s

SERVICE and MARKET pull

DISCOVERY of new insights

DESIGNtranslation into

evidence-based practices

DEPLOYof innovative healthcare

solutions

JointResearch

&InnovationPartnership

KNOWLEDGE push

Statement

• HSR is cross-cutting and imperative for European health research and

innovation

• Need for a HSR infrastructure to improve HSR impact on health policy

making

Bridging the gap between HSR and policy, national and international

• Funding• Priority setting and strategic planning• Level of funding• Co-ordination of funding

• Capacity building• Building capacity of researchers and users• Collaboration and comparison• Developing multidisciplinary research agenda

• Linkage and exchange• Enhancing presentation• Building relationships• Timelinesss of research

Questions• In order to feed this in (inter)national programming

and partner with others, is there scope for a robust alliance or infrastructure with a good governance ensuring a single voice?

• Might a “Knowledge hub-and-spoke model” to establish governance, organising meetings, mutual learning, scientific missions, training schools, communication, dissemination and publications?

deliverables for working conference ‘strengthening …...working conference ‘strengthening the...

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