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Page 1
ESI Funds for health investments
Compilation of topics reflected during national
workshops
Page 2
Topics
I. Introduction of the project and project output
II. Principles of strategic management
III. 2014-2020 PP principles and mechanisms
IV. Health funding potential in 2014-2020 PP
V. ESIF investment critical success factors
VI. Specifics of complex project management
and implementation
VII. Principles of effective project application assessment
and relevant indicators
VIII. Principles of effective coordination
IX. New concepts in health
X. Discussion on specific EC regulations
Page 3
I. Introduction of the project and outputs (i) Project and its context
[Project introduction and disclaimer]
Page 4
Project objectives
► The project is aimed at providing assistance in the area of
healthcare to EU Member States in the programming and
implementation of European Structural and Investment Funds
(ESIF) in the new programming period 2014 - 2020, more
concretely:
► To support the Member States and their efforts to tap into the potential
of ESIF 2014 - 2020 for health investments and to manage ESIF
support for health in a better and more effective way
► To promote effectively implemented actions in the health sector which
will have a major positive impact on the wider population’s access to
quality and sustainable healthcare in EU Member States
► To build knowledge of the implementation of ESIF for health in the new
programming period 2014 - 2020
Page 5
Project background
► The project builds on two key documents:
► Toolbox for effective structural funds investments in health
2014-2020 as developed by Subgroup 2 of the Reflection Process
on modern, responsive and sustainable health systems that was
conducted in the Council of the EU under the auspices of the
Working Party on Public Health at Senior Level
[Electronic version in various languages available at the website of the Council of the European
Union]
► Policy Guide for Health Investments by European Structural
and Investment Funds 2014-2020, developed by the European
Commission (DGs SANCO, REGIO, EMPL)
[Electronic version in English available at the DG REGIO website]
Page 6
Disclaimer
► Please be aware that the workshop (as well as the project itself) are NOT
part of the negotiations between the Commission and the Member
States
► EY has been contracted by DG SANCO, not DGs directly involved into negotiations
► EY provides consultations based on its professional judgment, analysis of documents
and analysis of situation in all Member States
► Information provided in the project outputs and in this presentation should serve as
supportive material for discussion and reflection
► Suggestions presented further do not reflect the Commission's position, but EY’s
professional opinion and good practice examples gathered during this project
The presentation does not reflect the Commission's position and the way
implementation of ESIF will be finally delivered is still being negotiated with
the European Commission
Page 7
II. Introduction:
(ii) Project outputs
[EY outputs introduction]
I. Introduction of the project and outputs (ii) Project outputs
[Project scope]
Page 8
Project outputs
WP 1: Mapping report
Implementation of SF in
health in all EU Member
States
► Overview of 2007 - 2013
period
► Planned implementation
of ESIF for funding health
priorities in 2014 - 2020
based on Partnership
Agreements and OPs
WP 2: Guide
Guidance on effective
health investment from
ESIF
► Recommendations for
Ministries of Health and
managing authorities on
practices that lead to
efficient health investment
funded from ESIF
► Roles of MoH and MA and
ways of their cooperation to
achieve effectiveness
► Lessons learned (Do’s and
Don’ts)
WP 3: Toolkit
Set of technical and
managerial tools to
accompany the Guide
► ESIF instruments and
mechanisms in 2014-2020
► Calls for proposal
management
► Set of indicators
► Sustainable and efficient
models & concepts in HC
► Manual on capital investment
► Investment appraisal methods
► Additional issues raised by
Member States
WP 4: Roll out to Member States: Website, country visits, regional workshops
Page 9
WP1 Mapping report
Mapping report
WP1
►Objective:
► Give a complete picture of health investment under Structural Funds / ESIF in EU Member States for the period
2007 – 2013 and the period 2014 – 2020 (planned actions)
► Provide entry information for the Guide, the Toolkit and the Roll-out phase
►Activities:
►Collect information on health investment under SF made in 2007 – 2013 in individual Member States, including total
allocations of SF for health investment and examples of concrete projects
► Interviews with MAs / Ministries of Health representatives on past investment as well as future priorities
►Analysis of draft Partnership Agreements when available
►Analysis of draft operational programmes when available
►Deliverable:
► Report summarizing areas of health investment under SF / ESIF, identifying main categories of investment
in 2007 – 2013 and main priorities for 2014 – 2020
► Country sheets describing health investment in individual Member States
Page 10
WP2 Guide for effective ESIF investments in health
Guide
►Objective:
► Elaborate a practical Guide for Member States’ authorities that will enhance effectiveness of investment in health
in the programming period 2014-2020
►Activities:
► Analysis of a set of case studies on health investment
► Interviews with managing authorities and Ministries of Health on successful and even unsuccessful projects and
their experience
► Identification of critical success factors
► Summary of lessons learned (Do’s and Don’ts)
► Design of a set of recommendations
►Deliverable:
► Recommendations on practices that lead to efficient setup of actions in health area financed from ESI Funds under
the new programming period 2014 - 2020
WP2
Page 11
Guide for effective ESIF investments in health Structure
Part I:
Theoretical background
► Today’s EU health systems
► Challenges
► Sustainable concepts
► Health funding
in 2014 - 2020 PP
► Funding principles
► Health actions under
thematic objectives
Part II:
ESIF programming
& implementation
► Models of MoH involvement in
the operational programmes
► Intermediate body
► Subject matter expert
► MoH involvement in OP
delivery:
► Calls for proposals
► Projects preparation and
delivery
► Evaluation & monitoring
Part III:
Lessons learned
► Main causes of investment
inefficiency
► Recommendations in areas
considered as critical success
factors based on case studies,
interviews and EY’s experience
► Case studies
WP2
Page 12
WP3 Technical toolkit
Technical toolkit
► Objective:
► Develop a set of tools supporting the national authorities in achieving sustainable and effective investments in
health under ESI Funds, which accompany the Guide
► Deliverable:
► Set of documents providing a technical advice on key issues related to investments in health under ESI Funds
► Technical areas covered by the Toolkit:
► Introduction of 2014 – 2020 instruments & mechanisms and evaluation of their relevance for health area
► Reference checklist on calls for proposals for officials involved in managing 2014 – 2020 funding in health
► Useful indicators for objective evaluation of projects/actions in healthcare
► Compendium of new concepts and models in healthcare
► Capital investment management manual
► Appraisal techniques and evaluation of their relevance for health investment evaluation
► Reflection of additional issues raised by Member States during national visits
WP3
Page 13
WP3 Technical toolkit 1/6 Categorization of instruments and mechanisms for 2014-2020 PP
WP3
Instruments
► Forms of support under ESIF
► Grants and prizes
► Financial instruments
► Specific territorial approaches to
development under ESIF
► Integrated approach to territorial
development
(CLLD, ITI, Integrated Sustainable Urban
Development)
► European Territorial Co-operation
► Community programmes
► Horizon 2020
► Health Programme
Mechanisms
► Funding mechanisms
► Delivering the Europe 2020 strategy
goals
► Synergies, coordination and
complementarities
► Thematic concentration
► Strong result orientation
► Performance reserve based approach
► Cohesion policy principles
► Concentration
► Programming
► Partnership
► Additionality
Page 14
WP3 Technical toolkit 2/6 Reference checklist: Success factors for calls for proposals
WP3
Management of calls for proposals
► Preparation of an indicative timetable
for calls ► OP Performance framework, milestones values
► Absorption capacity
► Synergies and complementarities
► Set-up and public announcement of
individual calls ► Use targeting on specific health themes
► Raise awareness among heath entities about
funding possibilities
► Evaluation of calls ► Reassessment and update of calls timetable
and their focus
Project applications assessment
► Assessment process ► administrative check
► eligibility check
► quality assessment
► Design of quality assessment criteria ► Impact on cost-efficiency and sustainability
► Capacity to reduce inefficiencies in access to
care and health status
► Need for the project (relevance)
► “Value for money”
► Feasibility
► Risk analysis
► Selection of projects for funding
► Award of funding
Page 15
WP3 Technical toolkit 3/6 Set of indicators for final evaluation of action
WP3
Indicators in ESIF context
► Operational Programmes indicators ► Financial indicators
► Output indicators
► Result indicators
► Requirements on Output indicators ► Common output indicators
► Programme specific output indicators
► Requirements on Result indicators ► Responsive to policy
► Normative
► Robust
► Data collection possible in timely manner
Indicators to evaluate ESIF health action
► Indicators per main categories of health
actions eligible for ESI funding* ► eHealth
► Health infrastructure & community based care
► Access to healthcare
► Health workforce
► Prevention, promotion and healthy aging
► Health status
* Indicators based mainly on existing indicators monitored
by:
► Eurostat
► DG Sanco (European Community Health
Indicators - ECHI)
► National statistical offices
Page 16
WP3 Technical toolkit 4/6 Compendium of (new) concepts and models
WP3
Use of information
technologies
Clinical and prescription
guidelines and models
Population-oriented
concepts Other
► eHealth concepts
► Electronic health
records
► ePrescription
► Telehealth
& mHealth
► Networking and
knowledge sharing
► DRG model
► Cost-effective use of
medicines
► Deinstitutionalization
► Cost-effective path
of care
► Community-based
care, personalized
medicine and long-
term care
► Active and healthy
ageing
► Health promotion
and prevention
► Patient
empowerment
► Medical tourism
► Cross border care
Page 17
WP3 Technical toolkit 5/6 Manual on capital investment
WP3
Strategic investment guide
► Capital investment planning ► Strategy identification
► Financial planning
► Project definition
► Risk management
► Capital investment implementation ► Ministry as an Intermediate Body
► Preparing Project Requests and Call for
Proposal
► Reviewing and Prioritizing Project Requests
► Implementation
► Ministry as a beneficiary
► Project request preparation
► Investment implementation
► Capital investment sustainability
Categorization of financial mechanisms
► Other sources of funding apart from
ESIF ► Loans / Guarantees
► Equity / Venture Capital
► Initiatives of EC
► JESSICA
► JEREMIE
► JASPERS
► JASMINE
► Combinations of the instruments
► PPP
Page 18
WP3 Technical toolkit 6/6 Investment appraisal
WP3
General principles of economic appraisal
Key process steps:
1. Problem identification & definition
2. Definition of alternatives for problem solution
3. Assessment of costs and benefits
► List all the costs and benefits
► Quantify/describe all the costs and benefits
► Converse data into value of resources
4. Calculation which will strongly depend on
the type of economic appraisal
5. Decision-making
Investment appraisal techniques
► Quantitative assessment techniques
applicable to health investments
► Cost Benefit Analysis (CBA)
► Option Appraisal (OA)
► Cost Consequence Analysis (CCA)
► Cost Effectiveness Analysis (CEA)
► Qualitative assessment techniques
applicable to health investments
► Cost Utility Analysis (CUA)
► Health Impact Assessment
► Health Technology Assessment (HTA)
Page 19
WP5 Online platform
Online platform (webpage)
►Objective:
► Develop an online platform supporting the roll-out phase by allowing widespread dissemination of the deliverables
and tools developed
►Deliverable:
► A single point providing all the necessary information about funding of health from ESIF in 2014-2020 and the most
up-to-date versions of project outputs
www.
.eu
WP5
Page 20
WP5 Online platform Website content & structure
► News containing information about
workshops / updates or most up-to-date
issues
► Project introduction & background
information
► General introduction of EU Cohesion
Policy 2014-2020 principles & mechanisms
► Indicative list of health actions under
thematic objectives for the 2014-2020
programming period
► Downloadable project outputs:
> Guide
> Toolkit
► Frequently asked questions (FAQs)
► Mapping of implementation of ESIF in
health across EU Member States
► Useful contacts
WP5
I. Website content:
► Existing knowledge and other useful
links
► Information about national and
regional workshops
Page 21
II. Principles of strategic management
[EY understanding]
Page 22
Public strategies development 1/2 Principles
Based on our experience with strategy development we have defined ten principles related to public policies making:
1. Transparency and objectiveness of strategies preparation
► Wide range of stakeholders is involved into the preparation process
2. Responsible decision making
► Government (or approval authority) has to be able to make responsible decisions based on relevant information
3. Specific issues solving
► Strategies are aimed at solving specific and significant problems
4. Coordination of strategic projects
► Particular strategies are not prepared separately, but they are coordinated both horizontally and vertically
5. Standard procedures and project management approach
► Mandatory requirements on strategic documents quality are met and process structure is compliant with standard practice of project management
6. Clear source of financing
► Implementation financing is clearly defined
► Realization of approved strategies is reflected in budgeting on a regular basis
► Seeking the highest feasible level of efficiency; negative unintended effects are minimized
*the list continues on the next page
Page 23
Public strategies development 2/2 Principles
Principles of public strategies development also include:
7. Strategies compliant with real needs
► Strategies development is evidence-based
► Both intended and real impacts of strategies implementation are monitored and evaluated
8. Particular measures and well-defined implementation structure
► Responsibility for objectives accomplishment is clearly defined
► Indicators and metrics of success and process of implementation are specified
9. Defined strategy owner
► Overall responsibility is assigned
10. Regular evaluation
► Effectiveness of implemented measures is evaluated on a regular basis
► Corrective mechanisms are proposed .
► Why is a given strategy being created?
► What is its purpose (which issue will be solved)?
► How will be the issue solved?
► When will be the issue solved?
► Who will solve the issue?
► For how long is the strategy valid?
► How much will a given solution cost?
Key questions to answer within the strategy development process
Page 24
Public strategies development Methodology application scheme
1. Identification of strategy creation need
2. Project set-up
3. Analytics and forecasting phase (on a regular basis)
4. Strategic direction, priorities and variants determination
5. Strategy elaboration
6. Implementation, financing and evaluation set-up
7. Strategy approval
Strategy development (application of public strategies preparation methodology)
Preliminary vision formulation
(final strategic documents, long-term plans and vision, response to external forces etc.)
Strategy implementation
(realization of the strategy, its monitoring and evaluation on a regular basis, final evaluation)
Framework of strategic management
Strategic management in defined areas (public strategy)
Strategic management of public administration
organization (strategy of an office)
Application of public strategies preparation
methodology
Page 25
Public strategies development Strategy development process
► 1. Identification of strategy creation need ► Organization of strategy creation preparation ► Data collection ► Current state analysis and future development
forecast ► Preliminary vision analysis ► Input report preparation and approval
► 2. Project set-up ► Organizational structure staffing ► Project plan of strategy creation preparation ► Plan of cooperation and communication preparation ► Risk management plan for strategy creation
preparation
► 3. Analytics and forecasting phase (on a regular basis) ► Data sources identification and primary analyses
elaboration ► Existing solutions analysis incl. international practice ► Current state analysis ► Future development forecast ► Analytical part of strategic document compilation
► 4. Strategic direction, priorities and variants determination
► Vision verification and options of objectives definition
► Options selection for further elaboration
► 5. Strategy elaboration ► Strategic objectives elaboration ► Set of indicators set-up ► Variant measures identification ► Measures assessment and selection ► Draft strategy finalization
► 6. Implementation financing and evaluation set-up ► Work breakdown structure creation ► Managing structure of strategy implementation set-
up ► Change management plan set-up ► Risk management plan set-up and assumptions
determination for successful strategy implementation ► Monitoring system of objectives attainment set-up ► Strategy evaluation set-up ► Communication plan of strategy implementation
creation ► Strategy implementation budget creation ► Strategy implementation schedule creation
► 7. Strategy approval ► Strategy approval plan revision and finalization ► Internal strategy revising and approval ► External strategy revising and approval ► Project closing
Page 26
Public strategies development Strategy implementation
Essential condition: divisional and functional managers involved as much as possible in strategy-formulation and strategists involved as much as possible in strategy-implementation.
► Managers and employees are motivated more by perceived self-interests than by organizational interests
Basic management issues of strategy implementation:
► Establish annual (or other regular) objectives
► Devise policies
► Allocate resources
► Alter an existing organizational structure
► Restructure and reengineer
► Minimize resistance to change
► Match managers with strategy
► Develop a strategy-supportive culture
► Develop an effective human resources function
Phase of strategy review, evaluation and control:
► Examine the underlying bases of an organization’s strategy
► Compare expected results with actual results
► Take corrective actions to ensure that performance conforms to plans
Regular objectives serve as guidelines for action, and standards of performance
Policies clarify what work is to be done and by whom
Change must be viewed as an opportunity rather than as a threat by managers and employees
Adequate and timely feedback is the cornerstone of effective strategy implementation
Page 27
Public strategies development Barriers and measures
► Absence of unanimous methodology of strategic documents making
► Absence of
► Compact strategic management system and planning
► Unanimous framework of strategy making and implementation
► Hierarchy of strategies
► Absence of strong political assignment
► Budgeting not directly connected to government’s priorities
► Absence of central capacities (departments) for strategic work
► Lack of personal capacities
► Unstable political environment
► Insufficient implementation and monitoring of strategy, unmeasurable objectives
Barriers
Lack of general coordination
Insufficient political support
► Creation and approval of public strategies preparation methodology
► Assembly of public administration workers having adequate knowledge of and experience with strategic work
► Development of strategic management on central level and closer connection of strategic management with budgeting
► Coordination of strategic management on government level
► Setting of prioritization process of strategic objectives on central level of public administration
► Seeking broader political agreement, or at least cooperation, in order to ensure process continuity
► Independence and transparency of strategies preparation
Key measures
Page 28
III. 2014-2020 programming period principles and
mechanisms [Topic covered by the project outputs]
Page 29
2014 – 2020 programming period Cohesion policy principles
ADDITIONALITY
► ESIF do not replace national sources, ESI funding is
complementary to it
► Based on national public health priorities
► Health funding shall be a combination of variety of
financial sources
CONCENTRATION
► Limited number of priorities to be supported
► Targeted on achievement of two underlying objectives:
► Cost-effectiveness and sustainability of health
systems
► Mitigation of inequalities in health status and in
access to health care
PROGRAMMING
► ESIF do not support individual projects
► Multiannual programmes aligned with EU objectives
and priorities
PARTNERSHIP ► Collective process involving partners throughout:
► Programme development
► Implementation
► Monitoring & evaluation
Page 30
2014 – 2020 programming period Principal ESI funding principles
► Delivering the Europe 2020 strategy goals:
► Smart, inclusive and sustainable growth
► Delivery through contribution to thematic objectives
► Synergies, coordination, complementarities:
► Establish mechanisms to ensure coordination and
synergies to avoid overlaps
► Ensure effective coordination in order to increase the
impact
► Combine ESI Funds in a complementary manner
► Ex-ante conditionalities:
► Minimum requirements which need to be fulfilled prior to
the funding is started
► General / thematic – based on the investment priorities
► Existence of a national or regional strategic policy
framework for health with aim to:
► Improve access to quality health services
► Stimulate efficiency in the health sector through effective
innovative technologies
► Introduce monitoring and review system
► Provide cost-effectiveness and concentration of
resources on prioritized needs for health care
► Thematic concentration:
► Targeting of funds at key priorities
► Based on country-specific national, regional and local
context
► Minimum thematic concentration required depending on
the level of development of regions
► Strong result orientation:
► Result oriented approach rather than focus on the
financial means
► For each programme area desired improvement in the
situation should be identified
► Performance reserve based approach:
► Total amount of 6 % of the resources allocated to all ESI
Funds
► In 2018 MSs will submit performance reviews of
accomplished milestones
► Reserve will be allocated to OPs and priorities which
have achieved the milestones
Page 31
2014 – 2020 programming period Funding instruments and financial mechanisms
► Grants & prizes
► Non-repayable public funding
► Main form of ESIF investments in a public
service such as health
► Financial instruments
► Loans, guarantees, equity
► Plan to use them for 10 % of projects
► Possible use to all thematic objectives covered
by OPs
► Clear rules to enable a better combination of
financial instruments with other forms of support
(grants)
Funding instruments Public Private Partnership (PPP)
► The use of PPPs as an alternative source of funding is
a widely discussed topic
► There are two dimensions to the application of PPP
strategies linked with Structural Funds investment
strategy:
► PPP as an integral part of a Structural Funds project;
► PPP as separate but complementing Structural Funds
projects and programmes, where there is no financial
relationship between the two.
► Issues considered as important in relation to PPPs:
► If the resources from ESIF for health might be relatively
restricted, MS might consider PPPs as a viable alternative
of funding for projects that more directly contribute to
economic growth
► Whole hospital PPP projects could be considered where
they form part of a wider Structural Funds strategy
programme [Slovakia]
► In any event Member States would be well advised to begin
to invest in competency training and development
paralleled by the establishment of some form of central /
coordinated expert PPP guidance and advisory service
paying specific attention to the complexity of the health
sector
What is your experience with PPP funding?
Have PPP funding been considered to be used as a complementary source of funding in the new programming period?
Page 32
IV. Health funding potential in 2014-2020 programming
period (i) Health specifics in 2014-2020 programming period
[EY interpretation]
Page 33
2014-2020 health context 1/2 ESIF level
► Health is eligible for funding under 2014 – 2020. However there is
no thematic objective exclusively dedicated to health.
► Health related issues could be identified in most of the 11 thematic
objectives
► Direct investments Investments directly targeted on health care (HC) issues and reforms;
within direct investments MoH is usually formally involved in
implementation.
► Indirect investments Investments not directly targeted on HC, but health care subjects might
apply for funding from them; MoH usually has no formal competencies in
implementation of this group.
Page 34
2014-2020 health context Scheme of 2014-2020 health investment framework
TO 1
National strategic
framework
European strategic
framework
EUROPE 2020
EU policies TO 2 TO 3 … TO 10 TO 11 TO 9
Ministry of Health
Hospitals
General
practitioners
Medical
universities
Providers of
specialized care
Emergency
service
Medical R&D
institutions Medical staff
OP 1 OP2 OP 3 OP 7 OP 8 OP 6
TO 4 TO 5
MoH
Illustrative scheme
Page 35
2014-2020 health context 2/2 ESIF level
The aim of the Ministries of Health (resp. of Ministries of Social affairs
where applicable) shall be to maximize utilization of ESIF
opportunities for health care under legal conditions (EC Guidelines,
3E) and with respect to Europe 2020 as well as national strategic
framework (incl. Partnership Agreement).
Page 36
V. Principles of effective coordination: (i) Role of MoH as a coordinator of health care
[Topic covered by the project outputs]
IV. Health funding potential in 2014-2020 programming
period (ii) Health areas under thematic objectives
[Topic covered by the project outputs]
Page 37
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 1 Strengthening research, technological development and innovation
► Innovation in health
► Research in development of new detection methods and treatments
► Collaborative research in rare diseases
► Support research and related IT infrastructures including support to health information systems
Potential health issues under TO 1?
► Enhancing research and innovation (R&I) infrastructure and capacities to develop R&I excellence, and
promoting centers of competence, in particular those of European interest
► Promoting business investment in R&I, developing links and synergies between enterprises, research and
development centres and the higher education sector, in particular promoting investment in product and
service development, technology transfer, social innovation, eco-innovation, public service applications,
demand stimulation, networking, clusters and open innovation through smart specialisation, and supporting
technological and applied research, pilot lines, early product validation actions, advanced manufacturing
capabilities and first production, in particular in key enabling technologies and diffusion of general purpose
technologies
Investment priorities under given thematic objective:
Page 38
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 2 Enhancing access to and, use and, quality of information and
communication technologies
► Strengthening ICT applications for e-Health (investment priority)
► e-Health solutions compatible with EU standards ensuring (cross-border) interoperability of IT systems
► Use of uniform electronic health care information system
► Creation of legal basis for e-Health
► Improvement of IT Tools for coordination of response to health threats
► Development of ICT based solutions and services for needs of an ageing population
Potential health issues under TO 2?
► Extending broadband deployment and the roll-out of high-speed networks and supporting the adoption of
emerging technologies and networks for the digital economy
► Developing ICT products and services, e-commerce, and enhancing demand for ICT
► Strengthening ICT applications for e-government, e-learning, e-inclusion, e-culture and e-health
Investment priorities under given thematic objective:
Page 39
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 3 Enhancing the competitiveness of SMEs
► Promote awareness among SMEs on “white sector” business opportunities and know-how
► Support SMEs' businesses addressing the needs of old people, or 'age-friendly' businesses (e.g.
providing personalised care, assisting in functional physical or cognitive decline, improving old people's
health literacy), including senior start-ups and entrepreneurship
► Encourage private and public enterprises to play a larger role in public-private partnerships in 'age-
friendly' areas
Potential health issues under TO 3?
► Promoting entrepreneurship, in particular by facilitating the economic exploitation of new ideas and
fostering the creation of new firms, including through business incubators
► Developing and implementing new business models for small and medium-sized enterprises
(SMEs), in particular with regard to internationalisation
► Supporting the creation and the extension of advanced capacities for product and service development
► Supporting the capacity of SMEs to grow in regional, national and international markets, and to
engage in innovation processes
Investment priorities under given thematic objective:
Page 40
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 4 Supporting the shift towards a low-carbon economy in all sectors
► Support energy efficiency of health care facilities
► Assisting low-income communities and the elderly with energy efficiency improvements
► Support actions to help reduce the use of domestic solid fuels (coal and wood) which create indoor
air pollution and negatively effects health
Potential health issues under TO 4?
► Promoting the production and distribution of energy derived from renewable sources
► Promoting energy efficiency and renewable energy use in enterprises
► Supporting energy efficiency, smart energy management and renewable energy use in public
infrastructure, including in public buildings, and in the housing sector
► Developing and implementing smart distribution systems that operate at low and medium voltage
levels
► Promoting low-carbon strategies for all types of territories, in particular for urban areas, including
the promotion of sustainable multimodal urban mobility and mitigation-relevant adaptation measures
► Promoting the use of high-efficiency co-generation of heat and power based on useful heat demand
► Promoting research in, innovation in and adoption of low-carbon technologies
Investment priorities under given thematic objective:
Page 41
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 5 Promoting climate change adaptation, risk prevention and management
► Increase investments in risk prevention and management, including protection, preparedness, response
and recovery that have positive impact on human health
► Creation of early warning systems and health care investments for disasters and climate-related
events and adaptation
► Support water efficiency in health care buildings to reduce water scarcity
► Investments to reduce flooding of health care facilities
Potential health issues under TO 5?
► Supporting investment for adaptation to climate change, including ecosystem-based approaches
► Promoting investment to address specific risks, ensuring disaster resilience and developing disaster
management systems
Investment priorities under given thematic objective
Page 42
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 6 Preserving and protecting the environment and promoting resource
efficiency
► Investing in waste sector management to support protection from dangerous medical waste
► Increase actions that reduce potential health risks of contaminated sites
Potential health issues under TO 6?
► Investing in waste sector to meet the requirements of the Union's environmental acquis and to address needs,
identified by the Member States, for investment that goes beyond those requirements
► Investing in the water sector to meet the requirements of the Union’s environmental acquis and to address needs,
identified by the Member States, for investment that goes beyond those requirements
► Protecting and restoring biodiversity, soil protection and restoration and promoting ecosystem services, including
Natura 2000 and green infrastructures
► Taking actions to improve the urban environment, revitalisation of cities, regeneration and decontamination of
brownfield sites (including conversion areas), reduction of air pollution and promotion of noise-reduction
measures
► Conserving, protecting, promoting and developing natural and cultural heritage
► Promoting innovative technologies to improve environmental protection and resource efficiency in the waste sector,
water sector and with regard to soil, or to reduce air pollution
► Supporting industrial transition towards a resource-efficient economy, promoting green growth, eco-innovation and
environmental performance management in the public and private sectors
Investment priorities under given thematic objective:
Page 43
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 7 Promoting sustainable transport and removing bottlenecks in key
network infrastructures
► Improve connectivity (e.g. through infrastructure) and mobility to enhance access to health services
► Gain health benefits through enhanced safety levels of transport networks
► Support greener infrastructure to reduce obesity and create healthier lifestyles, particularly for the youth
Potential health issues under TO 7?
► Supporting a multimodal Single European Transport Area by investing in the Trans-European Transport
(TEN-T) Network
► Developing and improving environmental-friendly (including low-noise) and low-carbon transport
systems, including inland waterways and maritime transports, ports, multimodal links and airport
infrastructure, in order to promote sustainable regional and local mobility
► Developing and rehabilitating comprehensive, high quality and interoperable railway systems, and
promoting noise-reduction measures
► Enhancing regional mobility by connecting secondary and tertiary nodes to TEN-T infrastructure,
including multimodal nodes
► Improving energy efficiency and security of supply through the development of smart energy distribution,
storage and transmission systems and through the integration of distributed generation from renewable
sources
Investment priorities under given thematic objective
Page 44
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 8 Promoting employment and supporting labour mobility
► Access to employment for job- seekers and inactive people, including the long-term unemployed and people far
from the labour market, also through local employment initiatives and support for labour mobility
► Sustainable integration into the labour market of young people, in particular those not in employment, education
or training, including young people at risk of social exclusion and young people from marginalised communities,
including through the implementation of the Youth Guarantee
► Self-employment, entrepreneurship and business creation including innovative micro, small and medium sized
enterprises
► Equality between men and women in all areas, including in access to employment, career progression, reconciliation
of work and private life and promotion of equal pay for equal work
► Adaptation of workers, enterprises and entrepreneurs to change
► Active and healthy ageing
► Modernisation of labour market institutions, such as public and private employment services, and improving the
matching of labour market needs, including through actions that enhance transnational labour mobility as well as
through mobility schemes and better cooperation between institutions and relevant stakeholders
► Supporting the development of business incubators and investment support for self-employment, micro-enterprises
and business creation
► Supporting employment-friendly growth through the development of endogenous potential as part of a territorial
strategy for specific areas, including the conversion of declining industrial regions and enhancement of accessibility
to, and development of, specific natural and cultural resources
► Supporting local development initiatives and aid for structures providing neighbourhood services to create job
► Investing in infrastructure for employment services
Investment priorities under given thematic objective:
Page 45
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 8 Promoting employment and supporting labour mobility
► Supporting adequate and qualified health workforce in all areas through adaptation and training
and promotion of labour mobility
► Active and healthy ageing measures
► Health and human capital - supporting employment through healthy workers
► Promotion of healthy life style and disease prevention
► Health at the workplace
► Supporting healthy and safe working conditions and prevent work-related injuries
Potential health issues under TO 8?
Page 46
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 9 Promoting social inclusion and combating poverty
► Active inclusion, including with a view to promoting equal opportunities and active participation, and
improving employability
► Socio-economic integration of marginalized communities such as the Roma
► Combating all forms of discrimination and promoting equal opportunities
► Enhancing access to affordable, sustainable and high-quality services, including health care
and social services of general interest
► Promoting social entrepreneurship and vocational integration in social enterprises and the social and
solidarity economy in order to facilitate access to employment
► Community-led local development strategies
► Investing in health and social infrastructure which contributes to national, regional and local
development, reducing inequalities in terms of health status, promoting social inclusion through
improved access to social, cultural and recreational services and the transition from institutional to
community-based services
► Providing support for physical, economic and social regeneration of deprived communities in urban
and rural areas
► Providing support for social enterprises
► Undertaking investment in the context of community-led local development strategies
Investment priorities under given thematic objective:
Page 47
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
► Active inclusion improving employability
► Integration into the labour market of people with disabilities, mental disorders, chronic disease
► Enhancing access to affordable, sustainable and high-quality services, including health care
(reducing inequalities in terms of health status)
► Equitable access to affordable care and medication
► Promote active involvement of patients and their empowerment
► Access to acceptable standards of housing and hygiene
► Investing in health and social infrastructure
► Contributing to cost-effectiveness and sustainability of health systems
► Supporting specialization and concentration of hospital care
► Transition of hospital based care to community based care
► Strengthening of primary and ambulatory care
► Deinstitutionalization of long-term care, after care and mental care / home care strengthening
TO 9 Promoting social inclusion and combating poverty
Potential health issues under TO 9?
Page 48
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 10 Investing in education, skills and lifelong learning
► Reducing and preventing early school-leaving and promoting equal access to good quality early-childhood,
primary and secondary education including formal, non-formal and informal learning pathways for reintegrating
into education and training
► Improving the quality and efficiency of, and access to, tertiary and equivalent education with a view to
increasing participation and attainment levels, especially for disadvantaged groups
► Enhancing equal access to lifelong learning for all age groups in formal, non-formal and informal settings,
upgrading the knowledge, skills and competences of the workforce, and promoting flexible learning
pathways including through career guidance and validation of acquired competences
► Improving the labour market relevance of education and training systems, facilitating the transition from
education to work, and strengthening vocational education and training systems and their quality, including
through mechanisms for skills anticipation, adaptation of curricula and the establishment and development of
work-based learning systems, including dual learning systems and apprenticeship schemes
► Investing in education, training and vocational training for skills and lifelong learning by developing education
and training infrastructure
► Tertiary education delivering workforce sufficient in numbers as well as in qualification, reflecting the
shortages of certain specializations (i.e. General Practitioners)
► Adjustment of education system to deliver sufficient nursing staff (sufficient numbers as well as with
sufficient qualification to provide certain types of care independently)
► Lifelong training to adjust workforce skills – eHealth, new treatment and diagnostic methods
Potential health issues under TO 10?
Investment priorities under given thematic objective
Page 49
Health funding potential under specific thematic objectives in 2014 – 2020 programming period
TO 11 Enhancing institutional capacity and ensuring an efficient public
administration
► Capacity building in health administration: actions to support institutional and management capacities of
health administration
► Actions to increase efficiency of health administration in particular to design and deliver health system
reforms and increase its efficiency, quality and sustainability
► Actions to enhance cross border cooperation of MS in health area
Potential health issues under TO 11?
► Enhancing institutional capacity of public authorities and stakeholders and efficient public
administration through actions to strengthen the institutional capacity and the efficiency of public
administrations and public services related to the implementation of the ERDF, and in support of actions under
the ESF to strengthen the institutional capacity and the efficiency of public administration
► Enhancing institutional capacity of public authorities and stakeholders and efficient public administration
through actions to strengthen the institutional capacity and the efficiency of public administrations and public
services related to the implementation of the Cohesion Fund
► Investment in institutional capacity and in the efficiency of public administrations and public services at
the national, regional and local levels with a view to reforms, better regulation and good governance
► Capacity building for all stakeholders delivering education, lifelong learning, training and employment and
social policies, including through sectoral and territorial pacts to mobilise for reform at the national, regional
and local levels
Investment priorities under given thematic objective
Page 50
[Topic covered by the project outputs]
V. ESIF investment critical success factors (i) ESIF investment effective lifecycle
[Topic covered by the project outputs]
Page 51
ESIF investment effective lifecycle Critical success factors
Critical
success
factors
Strategy
development
Investment
sustainability
Capacity
building
Procurement
management
Financial
planning
Partnership
building
Monitoring
& Evaluation
01 07
02 06
05 03
04
WP2
Page 52
Critical success factors Discussion topics
Q1: Based on introduction of critical areas, where do you think are your:
i. Strong areas, i.e. areas that could be shared with other Member States as a good
practice example.
ii. Weak areas, i.e. areas where would your country appreciate support in a form of a
good practice example from other Member States.
Q2: Would you name any other critical success factor that has not been mentioned here and
is worth mentioning?
Page 53
V. ESIF investment success factors (ii) Practices and recommendations to various investment
life-cycle stages [Topic covered by the project outputs]
Page 54
01. Strategy development
► Lack of real public health strategy
► Absence of clearly defined priorities
► Investments are not focused on achievement of
clear objectives (duplicities and overlapping of
funding)
► Investments do not generate any tangible results
(there are no health gains and no improved cost
efficiency of health sector)
► Unsustainability of the investments
► Lack of project progress or project disruption in
case of changes in political environment
► Lack of coordination in strategy development
► On various levels of public administration
► For different types of health care
(outpatient x hospital care;
primary x specialized care)
► On cross-regional and cross-border level
Problems
Inefficient use of public resources
Obstacles to systemic changes
► Develop an overarching public health strategy
based on evidence and centered around a patient
oriented approach [Ministry of Health]
► Coordinate the strategy-making process with
stakeholders to make the strategy broadly
accepted and relevant [Ministry of Health]
► Identify & involve stakeholders
► Know other existing and developing strategies
► Ensure balanced and complementary approach
to maximize investment effects [Ministry of Health]
► Infrastructure development
► Human resources development
► Prevention and health promotion campaigns
► Identify financial resources and select priorities
to be financed from ESIF [Ministry of Health,
Managing Authorities]
Recommendations
Page 55
Example of insufficient strategy development Hungary, programming period 2007 - 2013
Context
► The implementation of ESIF for health infrastructure in Hungary in PP 2007-2013 was the largest of all
EU Member States (approx. 1,3 bn. EUR allocated over the 7 years, which represents 5,5 % of whole
ESIF allocation)
► Lack of strategic planning in the field of health and coordinative management of resources
► Political instability contributed to insufficient funding coordination
Consequences
► Spending driven approach in preference for project lacking evidence base, rather than a strategic
one taking into account sustainability considerations
► Insufficient attention given to health gains when deciding on where to direct the funding
► Lack of coordinative management function caused inefficiencies in a way that projects addressing
various levels of care provision are not complementary and loose (at least partially) their benefits
► Potential effects limited by insufficient coordination of Structural Funds projects and other
development efforts, on regional level no strategy planning:
► Investments into regional hospitals were not coordinated with investments in outpatient primary
care
► Infrastructure investments in specialized oncological centers were not coordinated with
development of regional hospitals
Page 56
02. Partnership building
► Insufficient involvement of relevant partners in
development of strategies:
► Health care strategy
► Partnership Agreement
► Operational programmes
► Insufficient involvement of all relevant partners
► Public
► Experts
► Foreign partners
► Shortcomings in management of partners in
implementation of strategies, programs and
projects
► Insufficient consultation and information sharing
processes set-up
► Unclear roles and responsibilities
► Inflexible decision-making process
► Gain wide range of relevant partners in
preparation of key strategic documents through
their careful identification and invitation [Ministry of
Health]
► Introduce formalized system for cooperation
among partners, which will be consensually adopted
[Ministry of Health]
► Clearly delimit the roles and responsibilities
of individual partners
► Decide on the decision making process,
favouring flexible forms ensuring at the same
time wide acceptance
► All key decisions and changes consult with partners
and try to find consensus [Ministry of Health]
► Designate a responsible for stakeholder
management [Ministry of Health]
► Learn to understand individual partners’ and group
of stakeholders’ needs [Ministry of Health]
Problems Recommendations
High risk of delay or refusal of a program / project realization
Limitation or blocking of expected outcomes
Page 57
03. Capacity building
► Lack of qualified human resources for efficient
programme implementation at the Ministry of Health,
especially when it plays the role of intermediate body:
► Inadequate knowledge of relevant OP(s)
► Inadequate skills in project and financial
management
► Lack of experience with health strategies
implementation
► High fluctuation rate of employees
► Lack of information and guidance for applicants
and beneficiaries
► Insufficient information about publishing a call
for proposals among potential health sector
applicants
► Insufficient support of applicants in the phase of
project preparation and implementation
► Secure qualified and skilled MoH capacities
capable to support managing authorities in the area
of health expertise [Ministry of Health]
► More extensive use of technical assistance
resources for education [Managing Authority,
Ministry of Health as an Intermediate Body]
► Standard staff education
► Preparation of standard educational plans for
capacities of Ministry of Health, MAs,
intermediate bodies in the field of: Structural
Funds, health policy, project and financial
management
► Exchange of experience and cooperation
with foreign partners
► More active role of MoH in building absorption
capacity among potential beneficiaries [Ministry of
Health]
► Personal contact with beneficiaries and the staff of
intermediate body/managing authority [Ministry of
Health]
Problems Recommendations
Insufficient absorption capacity
Limited quality and value added of funded projects
Possible ineligibility of projects
Page 58
04. Financial planning
► Insufficient detail of a project business case
► Inappropriate use of various techniques for financial
planning and investment appraisal
► Cost-benefit analysis, cost-effectiveness analysis
► Health technology assessment
► Health impact assessment
► Incorrect evaluation of project applications for
funding where even project applications with
insufficient detail and low value added of investments
were accepted for funding
► Project costs overruns which might seriously
threaten project sponsor’s ability even to finish the
project
► Problems with ensuring project sustainability in
case the operational costs during the sustainability
phase were not planned for or identified properly
► Require use of evidence-based approach:
► Put emphasis on detailed and evidence based
needs assessment
► Support benchmarking where possible
► Clearly set the main principles of financial
planning and investment appraisal [MA, possibly
MoH as an Intermediate body]
► Set criteria for project applications evaluation and
selection to ensure only financially realistic,
achievable and cost-efficient projects are
supported [MA, possibly MoH as an Intermediate
body]
► Monitor the financial performance data
periodically to be able to identify any possible
problems in time [MA, possibly MoH as an
Intermediate body]
► Ensure capacities with adequate knowledge and
expertise in the field of financial planning of health
projects and health investment appraisal methods
through the capacity building process [Ministry of
Health]
Problems Recommendations
Failure to achieve expected benefits
Support of unsustainable projects
Page 59
05. Procurement management
► Too complex and frequently changed procurement
laws, disparities across OP
► Erroneous procurement (typically in case of health
instrumentation / technology purchases):
► Discriminatory conditions
► Not enough specific conditions
► Unsuitable scope of the tender
► Too broadly defined contract, combining
unrelated items (excludes specialized suppliers)
► Subdivisions of contract
► Insufficient knowledge and experience with public
procurement of contracting authorities and suppliers
► Insufficient support of beneficiaries – contracting
authorities from the side of administrative capacities
of managing authorities / intermediate bodies
► Define clear, concise and easy-to-follow
programme-specific procurement rules, coordinated
across all country’s Ops [Managing Authority]
► Provide administrative support to beneficiaries
acting as a contracting authority in form of guidebooks,
templates, forms, tutorials and trainings [MA, possibly
MoH as an Intermediate Body]
► Set up sufficient administrative capacity Consider
ex-ante reviews of tender specifications if
sufficient expert capacities are available
► Engage health care experts (as well as IT experts,
engineers etc.) in preparation and/or review of the
technical specifications [MoH as beneficiary,
possibly even as an Intermediate Body, MA]
► Require estimated value in an evidence-based
manner, supported by market research and involve
experts to consider the usual market prices [MoH as
an Intermediate Body]
► Avoid subdivision of related items into separate
tenders, but do not link large contracts with various
components into one tender [MoH as an Intermediate
Body]
Problems Recommendations
Delays in project implementation
Ineligibility of expenses
Disruption of project implementation
Loss of unrecoverable funds
Page 60
Example of consequences of erroneous procurement Slovenia – „eZdravje“ Context of the project
► National eHealth project has been implemented in 2007-2015
► Procurement of technological implementation of eHealth portal funded from ESF
Main problems
► Procurement took significantly longer than expected
► Scope of the tender defined too broadly, which excluded potential smaller and specialized suppliers
► Scope of the tender was not specific enough, or on the contrary too discriminative with focus on a
single technology to deliver services
► Insufficient involvement of IT stakeholders in formulating procurement rules
► Preliminary checks of tender specifications delayed significantly procurement due to insufficient
capacities delayed significantly
► Main tenders were legally challenged
Implementation of the project of major national importance is delayed with increased costs.
Page 61
06. Evaluation and monitoring
► Lack of data or their insufficient quality to monitor
progress made
► Unclear definitions of indicators and resulting
inconsistency in data makes it impossible to
evaluate the real impact of the intervention
► Untargeted support or support of measures, which
do not lead to objective achievements
► Inner inconsistency of supported measures
► Inexistent identification of causes of negative
consequences and of insufficient outcomes of
interventions
► Insufficient information for qualified decision-
making
► Involve Ministry of Health representatives and
other health care expert into the monitoring
committee [Managing Authority]
► Select relevant and unambiguous indicators for
monitoring [Managing Authority with MoH,
possibly MoH as an Intermediate Body]
► Use evaluation not only for OPs, but also for
assessment of:
► Health strategies
► OPs’ priority axes and calls for proposal
relevant for health
► Health programs and projects
[Managing Authority with MoH]
► Improve the quality of evaluators [MA, possibly
MoH as an Intermediate Body]
► Set up the objectives of each evaluation, relevant
timing and methods; evaluation should take place in
all stages of the investment process [Managing
Authority with MoH, possibly MoH as an IB]
► Design measures to take in reaction to the
evaluation results [Ministry of Health]
Problems Recommendations
Lack of information for projects evaluation and for better results achievement of interventions in future.
Page 62
07. Investment sustainability
► Higher operational costs than expected in
investment planning:
► Too high treatment costs for using the new
technologies and equipment
► Insufficient pool of patients requiring
treatment with the new thus more expensive
equipment
► Medical personnel not properly trained to
use new equipment, eHealth and treatment and
diagnostic methods
► Investments do not reflect the current mid-
and long- term trends in health care
► Little attention is given to health promotion
and prevention programs
► Measure and monitor sustainability of health
investment before its implementation [Managing
Authority with MoH]
► Assess future operating costs of
investment actions
► Prioritize investment actions according to their
sustainability - include “sustainability” into
project selection criteria [Managing Authority
with MoH]
► Assess sustainability in terms of availability of
qualified and adequately trained human
resources [Managing Authority, possibly MoH as
an Intermediate Body]
► Promote projects aimed at:
► Monitoring healthcare effectiveness
► Adopting healthcare guidelines and
standards (i.e. for prescriptions)
► Reduction of unnecessary use of
specialists
► Health prevention and promotion
Problems Recommendations
Page 63
Good practice example Sustainable investment in Finland
► Finnish population over 75 years is expected to double by 2030 causing the current health
system financially unsustainable
► With the help of ERDF funding, an innovative and far reaching health reform model has
been developed with following objectives:
► Save at least 10 % in current operating costs of the acute hospital service
► Double the numbers at present of the delivery of a ‘care for elderly’ service with no increase in
operating (staff) costs
► Key components of reform:
► Integrate special / acute and primary care and some social services
► Reorganize service structures within hospitals to improve effectiveness and efficiency
► Rebuilding age care residential accommodation to provide better support and promote healthy
ageing
► Improve rehabilitation services
► Invest in illness prevention wherever possible
Page 64
Critical success factors Q&A
Page 65
VI. Specifics of complex projects management
and implementation [Topic covered by the project outputs]
Page 66
Areas for improvement
Complex projects Introduction
► Complex = integrated, interconnected, interdependent
► Complex projects are those that:
► Are characterized by uncertainty, ambiguity, dynamic
interfaces, and significant political or external influences;
and/or
► Can be defined by effect, but not by solution
Programmes implemented under national strategies
(eHealth, reforms etc.)
Regarding the characteristics of complex projects listed
above, complex projects require different management
approach
Page 67
Areas for improvement
Complex projects management framework 5DPM approach introduction
► Cost = quantifying of the scope in monetary terms ► Project costs estimates
► Risk assessment
► Identification of cost drivers & constraints
► Schedule = time factors that needs to be managed to
deliver a complex project in time
► Time schedule addressing:
► Scope of work and sequence of work
► Project milestones
► Critical path and path of execution
► Risks identified regarding schedule
► Schedule change process
► Key procurement and submittals
► Quality = project overall design and set up ► Scope of work
► Form and composition of the project team
► Contracts & procurement set up
► Technical solution
► Context = identification of all external factors impacting the
project ► Stakehoders
► Other issues such as environmental, legal, global as well as
local
► Financing = identification of financing sources ► Public vs. private sources of funding
► Eligibility for funding under ESIF
Traditional three-dimensional project management
Five-dimensional project management
Schedule Cost
Quality / Technical
Schedule Cost
Quality / Technical
Context Financing
Page 68
Areas for improvement
Implementation of complex projects Main principles
► Strategic context
► Framework for the programme set up and
financing
► Financial planning
► Funding scheme
► Long-term investments VS annual budget
requirements
► Tools such as cost-effectiveness analysis
(CEA), Data envelopment analysis (DEA),
HTA, sustainability analysis
► Proper project definition
► Action plan for each priority
► Introduction of risk management
► Project management framework &
capacities
► Project team selection & maintaining
► Management principles set up ► Project management structure (project
managers, working groups, Steering
committee)
► Coordination of activities ► Overall coordination of project activities
designated to one coordinator
► Relevant indicators for proper monitoring
► EU level indicators
► Specific indicators reflecting national
specifics
► Appropriate timing
► Periodical monitoring of project status
Capital investment planning Capital investment implementation
Page 69
Complex projects implementation Lessons learned from Slovenia
► Research of previous projects
► Lesson learned from them
► Possible use of their components or follow-
up
► Project based on specific documentation
developed prior to its start (nation eHealth
strategy, feasibility study)
► Partnership principle
► Funding agreement as part of a long term
plan of needs put together by the main
stakeholders
► Special project management framework
designed to advance the project
► Project management framework developed to
feature consultation and decision-making
among key stakeholders
► Collaboration between ministries in operating
eHealth network
► Precise time framework
► Procurement process took much more time
than originally planned
► Attract stakeholders from all areas involved
► Lack of a fuller engagement with the IT
industry as a stakeholder
► Set project management priorities
► Create sufficient team
► Prepare realistic tenders not of too large scope,
with clear specification
► Secure qualified staff to manage the project and
subject matter experts
Areas for improvement Successful steps Areas for improvement
Page 70
Complex projects implementation Lessons learned from Hungary
► Critical factor perspective applied
► Evidence based approach used in project
preparation
► Flexibility to improve project efficiency
► Broad scale assessment of projects
► Coordination tools introduced
► Need of a broadly accepted and well-known
health care strategy logged into the political
process
► Do not underrate sustainability studies,
quantitative modelling
► Capacity planning
► Coordination between the projects
addressing the various care provision levels
► Strategic planning should not be vulnerable
to disruptions caused by changes in political
direction
Successful steps Areas for improvement Successful steps Areas for improvement
Page 71
VII. Principles of effective project application
assessment and relevant indicators in health
projects [Topic covered by the project outputs]
Page 72
Project application assessment General background
► Assessment is a process in which submitted
applications are checked and evaluated against a
set of criteria in aim to select projects:
► Eligible for funding under a given call
► With sufficient certainty regarding the ability of
the recipient to implement the project
► Contributing to the OP’s objectives
► Four types of evaluation should be covered by an
assessment process:
► Administrative check (formal requirements)
► Eligibility check (compliance with the goals of
the call)
► Quality assessment (project necessity, cost
appropriateness, effectiveness, sustainability,
management capacities, relevance of indicators)
► Risk assessment (analysis and incorporation of
mitigation actions)
► Two types of assessment model taking into
account the size and type of a project:
► Single step assessment for small and easy-
to-assess projects (e.g. in case of a large
number of similar projects)
► Two- or multi-steps assessment which is
more demanding on time and expertise of
evaluators
► Expertise and quality of evaluators for assessment:
► Administrative and eligibility check to be done
by people skilled in specifics of the OP
(European Funds department of MoH)
► Quality and risk assessment shall be
conducted by experts with relevant
experiences with the field of the project
scope
► Exclusion, eligibility and evaluation criteria
could support evaluators in the whole process
► Selection of projects based on a degree of
fulfillment of each of the criterion. Their
importance should be projected into the weights.
Definition and types Important factors
Page 73
► Put emphasis on properly conducted need
assessment:
► Introduce formalized practices how to prove
necessity of the project
► Require long/term prognoses of key factors to
ensure long-term sustainability of the project
(especially important in health care projects)
► Develop methodology on needs assessment
relevant for the field of investments (call) and
develop guideline for project applicants
► Assign relevant weight to this criterion in overall
scale
► Require detailed feasibility study proving
sustainability of the solution
► Expert assessment of quality of the study shall be
essential
► Assess competencies of nominated project team
► Project management, financial management, expert
knowledge etc.
► Sufficient knowledge and experience in relevant
areas
► Require risk analysis and assess detail of the
analysis conducted and mitigation actions suggested
by the analysis
► Improve evaluation of project sustainability:
► Especially in case of large and important
investments, consult experts from practice
► Formalize approach to project sustainability
assessment by developing methodology for
proving and assessing project sustainability
► Consider sustainability also from long term
point of view [five years horizon is not sufficient
especially in strategic health projects]
► Assign relevant weight to project
sustainability, so that it reflects importance of
this criterion
► Support applicants in the process of project
(application) development:
► Provide consultations to potential beneficiaries
► Review applications before submitting especially
procurement set up and financial adequacy
[applicable especially on large and strategic
projects]
Project application assessment Recommendations
Page 74
► Fund-specific indicators
► Financial indicators relating to expenditure
allocated
► Output indicators relating to the operations
supported (per priority axes).
► Result indicators relating to the priority concerned
► Programme-specific indicators
► Should the fund-specific indicators be insufficient to
measure supported actions they can be completed
with programme-specific output indicators
► Common specific indicator for ERDF actions
specifically defined for health:
► Population covered by improved health services
[persons, no multiple counting]
► Specific indicators to monitor health care
actions to evaluate health investments in a more
focused way. They list can be developed based on:
► ECHI – European Core Health Indicators
(indicators aiming to create a comparable
health information and knowledge system to
monitor health at EU level)
► Eurostat database
► WP 3 (3): Set of indicators useful for final
evaluation of actions
Relevant indicators in health projects Types of indicators
► Output indicators
► Limited set of indicators defined at fund level
► A list of common output indicators is defined for
both ERDF and ESF, and the indicators used in
OPs are to be chosen primarily from this list
► Programme-specific indicators designed by the
Member States and Managing Authorities
► Result indicators
► Result indicators express the change sought by
a specific objective
► For each specific objective, one or a few result
indicators are defined
Indicators to monitor health care
actions
Page 75
Indicators per main categories of health actions Access to healthcare
Category / Indicator Measurement unit
Hospital care
Proportion of people (all population) with self-declared unmet needs for healthcare services
due to either financial barriers, waiting times or travelling distances
% of population
Proportion of people whose highest level of education is ISCED 0, 1, or 2 with self-declared
unmet needs for healthcare services due to either financial barriers, waiting times or travelling
distances
% of population with highest level of
education is ISCED 0, 1, or 2
Proportion of people in the first quintile of equalized income (20 % lowest income group) with
self-declared unmet needs for healthcare services due to either financial barriers, waiting times
or travelling distances
% of population in the first quintile of
equalized income
Proportion of people (all population) with self-declared unmet needs for dental care services
due to either financial barriers, waiting times or travelling distances
% of population
% of women aged 50 - 69, whose highest level of education is ISCED class 0, 1 or 2 (lower
secondary), reporting a mammography in the past two years
% of women with highest level of education
is ISCED class 0, 1 or 2
Percentage of persons (aged 50-74), whose highest level of education is ISCED class 0, 1 or 2
(lower secondary), reporting a colorectal cancer screening in the past two years
% of population with highest level of
education is ISCED 0, 1, or 2
Waiting time for certain types of surgeries
Cancer treatment delay
Access to primary care Number of inhabitants per one general practitioner, by region Number of inhabitants
Number of women per one gynecologist, by region Number of women
Number of inhabitant per one dentist, by region Number of inhabitants
Page 76
Indicators per main categories of health actions Health infrastructure & community based care
Category / Indicator Measurement unit
Hospital care
Standardized rate of hospitalization Number of hospital admissions per 100 000 inhabitants
In-patient average length of stay in days, all diagnosis Average duration in days of a single episode of
hospitalization in a hospital per discharged in-patient
In-patient average length of stay in days, for individual diagnosis groups Average duration in days of a single episode of
hospitalization in a hospital per discharged in-patient
Hospital care capacities
Hospital beds per 100 000 inhabitants Number of beds
Long-term hospital beds per 100 000 inhabitants Number of beds
Psychiatric hospital beds per 100 000 inhabitants Number of beds
Acute care hospital beds per 100 000 inhabitants Number of beds
Transition to community-based care, development of long-term care and after care
Persons, to whom care has been provided in a community / at home / in a nursing
house* Number of persons
Percentage of persons discharged from hospital who are readmitted within 30 days Percentage of discharged persons
Primary and ambulatory care
Percentage of ambulatory physicians on total number of physicians % of physicians
Percentage of general practitioners in outpatient care % of physicians
Percentage of ambulatory specialists in outpatient care % of physicians
Percentage of illness cases where the first point of contact is a general practitioner % of illness cases
* To monitoring of transition or change, also indicators expressing change in demand could be used.
Page 77
Indicators per main categories of health actions Health workforce
Indicator Measurement unit
Practicing physicians Number per 100 000 inhabitants
Practicing nurses Number per 100 000 inhabitants
Percentage of physicians aged 35 years and younger % of physicians, all specializations
Percentage of physicians aged 55 years and older % of physicians, all specializations
Percentage of nurses aged 35 years and older % of nurses
Percentage of nurses aged 55 years and older % of nurses
Average age of general practitioners Average age in years
Number of jobs created in health care sector Equivalent of full time jobs
Number of jobs created in health care sector for qualified workforce holding post-
secondary degree
Equivalent of full time jobs
Shortage of physicians (nationwide, regional) Vacancy rate
Percentage of care not covered
Shortage of dentists Vacancy rate
Percentage of care not covered
Page 78
Indicators per main categories of health actions Health status
Indicator Description / measurement unit
Life expectancy at birth
(total population, men / women) Average number of years of life remaining at birth
Life expectancy at 65 years of age
(total population, men / women) Average number of years of life remaining at the age of 65
Healthy life years Expected remaining number of years, lived from a particular age without long-term activity limitation
Infant mortality rate Ratio of the number of death of infants per 1000 live births
Diabetes incidence % of persons with diabetes diagnosed in the past 12 months
Cancer incidence Incidence per 100 000 inhabitants
Acute myocardial infarction incidence Incidence per 100 000 inhabitants
Depression incidence Proportion of people reporting diagnosed chronic depression in the past 12 months
General musculoskeletal pain Proportion of people reporting to experience general musculoskeletal pain
Long-term activity limitations Proportion of people reporting to have long term restrictions in daily activities
Self-perceived health Proportion of people who assess their health to be good or very good
Page 79
Indicators per main categories of health actions eHealth
Category / Indicator Measurement unit
ICT infrastructure
Physicians using a computer % of physicians
Physicians using a computer during consultation (to display a patient's file, to get supporting information when
making treatment or medication decisions) % of physicians
Physicians with broadband connection with speed above
50 MBps % of physicians
Physicians having a website % of physicians
Physician using email to communicate with patients % of physicians
Use of eHealth applications
Physicians with an electronic appointment booking system % of physicians
Physicians using electronic storage of patient’s data % of patients
Use of electronic networks for transfer and exchange of patient medical data (i.e. exchange of clinical information,
laboratory results, medication information etc.) % of physicians / % of patients
Use of electronic networks for transfer and exchange of patient administrative data (i.e. for reimbursement
purposes between care providers and health insurance companies) % of physicians / % of patients
Physician with integrated system to send electronic discharge letters % of physicians
Physicians with an integrated system for tele-medicine (tele-radiology, tele-homecare/tele-monitoring services to
outpatients) % of physicians
Physicians monitoring patients remotely at their home % of physicians
Physicians using electronic networks to transfer prescriptions electronically to dispensing pharmacist
(ePrescribing) % of physicians
Data security
% of physicians using coded data to store and exchange information % of physicians
% of physicians using e-signatures % of physicians
Page 80
Indicators per main categories of health actions Prevention, promotion and healthy aging 1/2
Category / indicator Description / measurement unit
Prevention
Brest cancer screening % of women aged 50 - 69 reporting a mammography in the past two years
Cervix cancer screening % of women aged 50 - 69 reporting a cervix cancer screening in the past two years
Colorectal cancer screening % of persons (aged 50-74) reporting a colorectal cancer screening in the past two years
Influenza vaccination in elderly Proportion of persons aged 65 and over reporting to have received one shot of influenza (flu) vaccine
during the last 12 months
Vaccination coverage in children
Percentage of infants reaching their first birthday in the given calendar year who have been fully
vaccinated against diphtheria, tetanus, pertussis, poliomyelitis, haemophilius influenza type b or
Hepatitis B and those reaching their second birthday in the given calendar year who have been fully
vaccinated against measles, mumps and rubella
Preventive health determinants
Regular smokers Proportion of persons aged 15+ reporting to smoke cigarettes daily
Alcohol abuse Liters of pure alcohol consumer per persons aged 15+ per year
Physical activity Proportion of persons aged 15+ reporting practice of daily physical activity
Obesity: Body mass index Proportion of adult persons who are obese, i.e. their body mass index is equal or bigger than 30.
Blood pressure Proportion of persons reporting diagnosed high blood pressure (hypertension) in the last 12 months
Occupational health
Work injuries Standardized incidence rate of accidents at work per 100 000 workers
Work-related health problems
Percentage of workers reporting work-related health problems in the past 12 months
Workers off work at least 1 month due to accidents at work and work-related health problems in the
past 12 months
Sick leave Number of sick leave cases per 100 000 workers
Average length of 1 episode sick leave in days
Work safety Number of employed persons who would stay longer at work if their workplace was healthier and/or
safer
Page 81
Indicators per main categories of health actions Prevention, promotion and healthy aging 2/2
Category / indicator Description / measurement unit
Active and healthy ageing
Employment rate of workers aged 55-64 Proportion of people aged 55-64 in employment.
Population with health-related restrictions Proportion of people reporting to have long-term restrictions in daily-activities
Physical activity Proportion of persons aged 55+ reporting practice of daily physical activity
Dementia / Alzheimer incidence Incidence per 100 000 inhabitants
Influenza vaccination in elderly Proportion of persons aged 65 and over reporting to have received one shot of influenza
(flu) vaccine during the last 12 months
Promotion programmes*
Policies of healthy nutrition N/A, under development
Policies and practices on health lifestyles N/A, under development
Integrated programmes in workplace, schools, hospitals N/A, under development
* Indicators under this category are currently being developed as a part of the ECHI initiative
Page 82
VIII. Principles of effective coordination (i) Role of MoH as a coordinator of health care
[Topic covered by the project outputs]
Page 83
Roles of the MoH in health investments funding from ESIF
Ministry of Health in implementation structure of operational programmes
in 2014 - 2020 in three possible roles:
► Intermediate body (Delegated Act)
► Ministry of Health in the role of an intermediate body (responsible body) has a direct influence on the designing
and delivery of the OP (or more specifically its priority axis relevant for health) and funding of selected strategic
health priorities
► Being a responsible body is a complex task and impose a commitment on MoH to ensure/build sufficient
administrative capacities to be able to efficiently manage implementation of ESI Funds
► Subject matter expert (Memorandum of Understanding)
► Role of a subject matter expert is in place at areas that are not specifically devoted to health, but where health
entities could implement ESIF to contribute to achieving strategic health priorities
► Ministry of Health in the role of a subject matter expert could support MAs or relevant IBs during the whole
programming life-cycle
► Beneficiary of important strategic projects (Grant Agreement)
► In case of a large projects of a strategic importance, MoH might get in a position of a beneficiary from OPs not
managed by MoH
► Being a beneficiary responsible for implementation of important strategic projects impose a commitment on MoH
to ensure/build sufficient management capacities to be able to efficiently manage the investment
Page 84
Possible roles of the Ministry of Health in 2014 - 2020
1. Subject matter expert in ESIF implementation structure
To ensure health care will utilize ESIF funding opportunities
2. Coordinator of strategic health investments in regions
To ensure equal access to appropriate health care services across
all regions
3. Intermediate body
To ensure proper performance of activities delegated by MAs
4. Beneficiary
To perform health care projects of a strategic importance
I. Coordination of health care system development
II. Coordination across implementation structure
Page 85
Possible roles of the Ministry of Health in 2014 - 2020 Schematic overview
National health strategy
SP 1 SP 2 SP 3
Capacity building Energy efficiency eHealth
MoH as possible
Intermediate
Body
MoH as
possible
Beneficiary
OP Administrative
reform
Medical staff
development
Regional OP 1 Regional OP 2
Improve access to
health care Development of
specialized centers
SP 4 SP 5 SP 6
OPs
Strategic
priorities
Funding
areas
Implementation of strategic health priorities
Co
ord
inati
on
wit
h O
P M
As
Coordination with OP MAs
OP LLL & HRD OP technical
assistance
MoH as a subject matter
expert supporting
implementation
Illustrative scheme
OP Environment
Page 86
I. Coordination of health care system development MoH as a subject matter expert
► Elaboration of health care strategy / strategies (ex ante conditionality)
► Identification of what investments in health are eligible under thematic objectives
and investment priorities supported under set Ops
► Cooperation on the Partnership Agreement / OPs design
► Open discussion with managing authorities of OPs with identified direct and
indirect health investment possibilities on possible involvement of MoH in
implementation of the OPs (IB / expert support etc.; shall be formalized in e.g.
delegation agreement, memorandum)
Phase Possible roles & responsibilities of MoH as a subject matter expert
Programming
phase
► Ensure health institutions are not excluded from relevant calls
► Help with absorption capacity building via mobilizing relevant health care institutions
► Possibly support applicants in preparation of project applications
► Possibly provide expertise during project applications assessment
► Provide an expertise during monitoring of projects performed by health care
institutions (administrative control, on the spot control)
► Provide an independent expertize in evaluations
Implementation
phase
► Evaluate development in health care system as a whole
► Lessons learned Winding up
Page 87
I. Coordination of health care system development Coordinator of strategic health investments in regions
► This role reflects implementation structure with many independent regional entities
► Initiate and set up coordination platform and involve regional authorities
► Familiarize regional representatives with health care priorities and their impact on
regional level
► Discuss regional development needs/priorities and find mutual agreement on
future development in each region
► Identify regional priorities to be funded under PAs managed by MoH [support
health care system reform] and priorities to be funded by ROPs [mitigating
regional disparities]
Phase Possible roles & responsibilities of MoH as a coordinator
Programming
phase
► Keep active involvement of regions in coordination structures
► Moderate sharing of experience and support cooperation of regions
► Gather information about projects realized in the regions and monitor developments
in each region/in the system as a whole
Implementation
phase
► Evaluate development in health care system as a whole
► Lessons learned Winding up
Page 88
Case study #1 Coordination of health care system development
Mental care specialized
centers
Mental care community
centers
Mother / child care ► Two levels of coordination:
► Thematic
► Regional Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Specialized neurological
centers
Region 8
► Two welcome opposing tendencies:
► Specialized care distribution across the country requires proper coordination to avoid concentration of similarly focused centers in one region while omitting the other areas. Coordinator should take into account geography and probability of particular disease emergence, while
► Community-based care or primary care should be developed in all regions. Coordinators should monitor that all the regions are covered by primary care centers.
Illustrative scheme
Page 89
Case study #2 Development of specialized neurological centers
► Three illustrative regions are developing specialized neurological care centers without coordination
► Each of the regions builds its own specialized neurological center, buys expensive equipment, attracts specialized medical staff
SITUATION::
RESULT::
► Three specialized centers in relatively small area compete with each other
► Small area cannot fulfill the number of patients required so as the specialized centers are sustainable
► High risk of ineligibility of expenses if funded from ESIF
Legend:
Location of specialized neurological center
Illustrative scheme
Page 90
Case study #2 Development of specialized neurological centers
► Three illustrative regions are developing specialized neurological care centers without coordination
► Each of the regions builds its own specialized neurological center, buys expensive equipment, attracts specialized medical staff
SITUATION::
RESULT::
► Three specialized centers in relatively small area compete with each other
► Small area cannot fulfill the number of patients required so as the specialized centers are sustainable
► High risk of ineligibility of expenses if funded from ESIF
Legend:
Optimal location for specialized neurological center
SOLUTION::
► One highly specialized center for three neighboring regions in the area easily accessible for inhabitants of other two regions
► Complex approach counting on geographic location, existence of similar specialized centers in nearby location and probability of particular disease emergence
Illustrative scheme
Page 91
II. Implementation structure of respective OPs MoH as an Intermediate body
► Identification of which priorities from the national public health strategy are in line
with the thematic objectives and investment priorities supported under set
Operational Programmes
► Active negotiations with the relevant Managing Authorities on investing in health
and competencies of MoH as an IB (shall be formalized in delegation agreement)
Phase Possible roles & responsibilities of MoH as an intermediate body
Programming
phase
► Preparation of calls for proposals and indicators
► Assessment of project applications and selection of projects
► Preparing and signing Grant Agreements with beneficiaries
► Project implementation monitoring
► Verification of application for payments
► Procurement control
► Conducting/participating on the on-spot controls of projects
► Other activities based on delegation of duties set by the respective MA
Implementation
phase
► Closing of Operational Programmes Winding up
Page 92
II. Implementation structure of respective OPs MoH as a beneficiary
► Mapping of health investment possibilities under thematic objectives and within
national OPs
► Preliminary negotiations with Managing Authorities of OPs from which MoH
expects to apply for money
Phase Roles & responsibilities of MoH as a beneficiary
Programming
phase
► Development of evidence-based project, proper financial planning and consideration
of project sustainability
► Preparation of project applications that comply with all requirements
► Proper project team set up
► Main responsibility lays in proper project implementation (public procurement,
change management, fulfillment of indicators etc.)
► Securing of continuity of project implementation and continuity of human resources
► Ensuring the coherence of individual project with national strategic frameworks
► Possible coordination with other departments in MoH (other institutions)
Implementation
phase
► Sustainability of projects Winding up
Page 93
VIII. Principles of effective coordination (ii) Effective involvement of MoH in various stages of
OP lifecycle [EY’s professional opinion]
Page 94
Organizational set up Good practices identified
1. Coordinator of health care system development
i. Specialized department at MoH dealing with horizontal and vertical coordination of
investments in health = hereinafter indicated as a department for coordination of
health strategy implementation
ii. External coordination platform bringing together the above mentioned department
with representatives of regions to ensure horizontal cooperation = hereinafter
indicated as a coordination committee
2. Implementation structure of respective OPs
i. Function of Intermediate Body in responsibility of department solely focused on EU
Funds implementation and management = hereinafter indicated as a department for
EU Funds
ii. Implementation of projects financed from ESIF (beneficiary) in responsibility of
relevant departments or eventually Project management office (PMO)
The above mentioned roles should be institutionally detached and shall not overlap
Page 95
Coordinator of health care system development i. Department for coordination of health strategy implementation
► Coordination body in the structures of the MoH
► Should be a part of strategic department or be closely linked to this
department
► Main competencies & responsibilities:
► Development of health care strategy/individual action plans
► Mapping of health issues covered by other OPs
► Coordination with other MAs in the areas resulting from initial mapping
► Negotiation about involvement of MoH in implementation of OPs in
2014 - 2020 programming period
► Ongoing coordination of activities among other MAs and especially
with regions
[formally in the Coordination committee, informally on an ongoing basis]
Political support and mandate given to this department is very important factor to be able to
effectively fulfil the role of a coordinator of the whole health care system development.
Page 96
Coordinator of health care system development ii. Coordination committee
► Composition of the Coordination committee:
► Chaired by representatives of MoH [Department for coordination of health strategy
implementation]
► Representatives of regions [Bodies responsible for HC in the regions, ROP MAs]
► Main competencies & responsibilities:
► Agrees on health priorities and specific form of implementation of health priorities
on regional level
► Reviews investments to be supported in each region regarding the priorities
agreed and categorize investments:
► Strategic investments of national importance [to be further reviewed and approved by the
Committee; sources of funding needs to be further coordinated]
► Investments of regional importance [remains in competency of regions; funding solely from
ROPs]
► Coordinates implementation of projects of national importance
► Evaluates and monitors progress towards agreed strategic objectives
Body coordinating overall quality and efficiency of implementation of health care development
needs and improvement of health care system across all the regions.
Page 97
Implementation structure of respective OPs i. Department for EU Funds (Intermediate Body)
► Intermediate body responsible for implementation of activities delegated
on it by a respective MA (based on Delegation Agreement)
► This department should be independent on other departments
► Competencies & responsibilities*:
► Consultations to applicants
► Managing of calls for proposal
► Assessment of project applications and selection of projects
► Absorption capacity building
► Cooperation with beneficiaries
► Monitoring of projects (incl. administrative and on the spot controls)
► Coordination with MA on other related activities (evaluations, reporting etc.)
Department responsible for performance of activities delegated by MA (related to health care
direct investments). Specific competencies always depend on negotiations with Managing
Authority.
* Specific competencies of the IB always depend on negotiations with Managing Authority in each country.
Page 98
Implementation structure of respective OPs ii. Beneficiary
► Two possible approaches based on complexity and number of
projects managed
i. Single projects could efficiently been managed by relevant departments
ii. In case of complex projects/higher number of projects PMO could
support effective implementation
Project Management Office ► Supports implementation and application of centralized management standards
► If involved also in projects implementation, it could bring cost and time savings
thanks to concentration of management and administrative capacities in one
department
► Simplifies coordination and monitoring of investments and projects in health
Relevant project management capacities are critical factor
regardless the form of organizational set up
Page 99
Example of possible organizational platform
Develops healthcare strategy and coordinates
strategy implementation on a day-to-day basis
Strategic coordination department at MoH
EU funds
departme
nt (IB)
Ministry of Health
Specialized
departments
/ PMO
(Beneficiarie
s)
Legend:
Key departments in the structure
Participants of Coordination Committee
Ongoing coordination & cooperation
Illustrative scheme
Vertical cooperation
Stakeholders
Coordination Committee
MAs of national
OPs Regional
HC
institutions
National HC
institutions
ROP manag.
authorities
Page 100
IX. New concepts in health
[Topic covered by the project outputs]
Page 101
Health in the EU strategic context
► Health sector as one of the most important in public spending… ► 15 % of all government expenditure in the EU
► 8 % of the total European workforce
► 10 % of the EU’s GDP*
► …is a part of the Europe 2020 policy framework and has three main
branches:
INVESTING IN
SUSTAINABLE HEALTH
SYSTEM
► Health expenditure
is recognized as
growth-friendly
expenditure
► Potential for
efficiency gains in
the health care
sector
INVESTING IN
PEOPLE’S HEALTH
► Precondition for
economic prosperity
► Influences
economic
outcomes:
► Productivity
► Labour supply
► Human capital
► Public spending
INVESTING IN
REDUCING HEALTH
INEQUALITIES
► Contributes to
social cohesion
► Allows improvement
of average levels of
health
* Source: Commission Staff Working Document - Social Investment Package: Investing in health, February 2013
Page 102
Use of information technologies in health care 1/3
► Cost- and time-effective means of health care
provision through integration of all relevant
patient information and medical processes
► Stands for electronic storage, exchange of
patient data and the provision of health care by
electronic means
► Allows interaction between:
► Patient and health care provider
► Medical facilities (including pharmacies)
► Patients
► Health care professionals
► Supported measures based on the degree of
development:
► IT infrastructure development
► Development of systems, moduls and
applications
► Implementation of eHealth into praxis
► Information about individuals’ lifetime health
status that can be found in one place and can
be shared across different medical facilities
► Creates a more efficient, convenient and more
cost-effective delivery of care:
► Saves time of physicians, other medical
personnel as well as patients
► Improves management, coordination and
administrative efficiency
► Enhances the quality of the provided care
through evidence-based tools which help to make
decisions about treatment
► Enables faster sharing of patient information with
other health care providers across institutions
Areas for improvement eHealth concepts 1/3
(i) Electronic health records
Page 103
Use of information technologies in health care 2/3
► Consists of two tightly connected processes:
► ePrescribing – prescribing using electronic
software
► eDispensing – act of electronic reception of the
prescription by the pharmacy and dispensing it to
the patient
► Has a high impact on effectiveness, quality and
sustainability of medical care through:
► Patient safety as it allows easier access to
medication history reduces the risk of negative
drug interactions
► Efficient prescription reducing the number of
duplicate prescriptions
► Management efficiency allowing overview and
easier monitoring
Areas for improvement (ii) ePrescription
► Reduces hospitalization and general
practitioner or specialist visits
► Reduces travel time
► Improves access to health care particularly for
elderly or disabled people
► Telemedicine:
► Refers to health care services at a distance,
where interaction between the health care
provider and the patient is needed
► Video consultations with specialist
► Remote medical evaluation and diagnosis
► Digital transmission of medical images
► Telecare:
► Based on patient monitoring using telephones,
computers, videophones, alarms and other
portable or wearable systems
► Remote physiological monitoring of a patient
► Pill dispensers and reminders
► Environment monitoring (floods, fire)
(iii) Telehealth
Page 104
Use of information technologies in health care 3/3
► Medical and public health practice supported by
mobile devices such as:
► Mobile phones
► Patient monitoring devices
► Personal digital assistants (PDA)
► Allows collection of medical, physiological,
lifestyle, daily activity and environmental data
► Potential to serve as a basis for evidence-
driven care practice
► Enables more accurate diagnosis and treatment
► Saves time of health care professionals spent
on accessing and analyzing information
► Allows patients to do more medical and care
interventions remotely by themselves, guided
by monitoring and reporting systems, reducing
hospitalization
Areas for improvement (iv) mHealth
► Allows effective and sustainable knowledge and
information sharing
► Includes:
► Health information system for citizens in order to
increase health literacy
► Health knowledge management systems for
professionals and students
► Virtual health care teams which consist of health
care professionals who cooperate and share
information on illnesses and patients through
digital equipment
(v) Networking and knowledge sharing
Page 105
Cost-effectiveness of care
► Worldwide problem of ineffective use of
medicines:
► Prescription of overpriced medicines
► Use of an excessive number of sometimes
unnecessary medications (polypharmacy)
► Inappropriate self-medication
► Use of less expensive equivalent (generic)
drugs
► Set of prescription guidelines to prevent misuse
and unnecessary use of medicines (e.g.
antibiotics)
► Awareness about medicines and better literacy
will allow patients to better manage their
medication
► Transfer of information between the health care
units participating in the care of the patient will
help to lower the number of unnecessarily
prescribed medicines
Areas for improvement Cost-effective use of medicines
► Patient classification system which assumes
that the treatment of patients with the same
diagnosis will require a similar or identical
diagnostic and therapeutic algorithm
► Financial benefits:
► Using DRG funding as a fixed payment per case
in a specific DRG
► Budget set up based on the measurement of
production by DRG
► Management benefits:
► Access to provided care through clinically and
economically comparable units
► Tool for measuring the outputs
► Tool for measuring the quality of the provided
health care
► DRG allows professionals with a different focus
to better communicate (e.g. communication
between economists and doctors)
► DRG allows comparison of different HC
providers on their performance activity
DRG: Diagnosis-related group
Page 106
Transformation of care delivery 1/2
► Process of gradual reduction in specialized
institutional care for patients
► Potential contribution to elimination of the
increasing costs caused by the ageing
population
► Patient-centered care solutions and
personalized care for chronic and long-term
care needs
► Deinstitutionalization consists of two main
areas:
► Cost-effective path of care which
strengthens the primary care
► Community based care
Areas for improvement Deinstitutionalization
► Cost-effective path of care should always lead
from primary care (advanced practice nurses,
general practitioners, family doctors) to
secondary care (specialists, hospitals and
emergency care) and then, where appropriate,
to tertiary care (highly specialized consultative
health care)
► Benefits:
► Increases the accessibility to primary health care
and reduces inequalities
► Reduces the unnecessary use of specialist care
► Reduces inpatient hospital care
► Takes care of patient’s disease prevention
► Ensures patient follow-up care after secondary
care
► Links patients to social care
► Requires to make primary care more attractive
to both patients and practitioners
Strengthening of primary care
Page 107
Transformation of care delivery 2/2
► Community-based care is especially
contributive to:
► Seniors dependent on long-term care
► People with disabilities
► People with mental health problems
► Lower costs of ambulatory care and care
provided to patients home compared to costly
hospital / medical institution care
► Provides better outcomes in terms of quality of
life in contrast to institutional care causing long-
term social exclusion and segregation of the
patients
► Community-based services include:
► Personal assistance
► Respite care
► Family-based care
► Hospital at home
► Independent living
Areas for improvement Community-based care
Page 108
Investing in people’s health 1/2
► Stands for the process of optimizing
opportunities for health, participation and
security in order to enhance quality of life as
people age
► Elderly people will account for 29,5 % of the EU
28’s population by 2060 (17,5 % in 2011)
► The health status of individuals strongly
influences their labour market participation
► Health sustaining activities prevent costly
health care and lower dependency burdens
► Activities improving the employability of older
people also enable people to work longer and
retire more gradually
► Stands for the process of enabling people to
increase control over, and to improve their
health
► Potential for cost savings for subsequent
(secondary or tertiary) care and cure and the
improvement of the individuals’ health allowing
them to live a more active and independent life
► Primary prevention aims to avoid occurrence
of disease through:
► Eliminating disease agents
► Increasing resistance to disease
► Secondary prevention aims to detect and treat
a disease early on and attempts to prevent
asymptomatic disease from progressing to
symptomatic disease
► Tertiary prevention attempts to reduce the
damage caused by symptomatic disease by
focusing on mental, physical, and social
rehabilitation
Areas for improvement Active and healthy ageing Health prevention
► Stands for the process of enabling people to
increase control over, and to improve their
health
► Raises awareness of health risks and how to
prevent them
Health promotion
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Investing in people’s health 2/2
► The concept aims to enable and encourage
patients to take control of their health needs
through their own health decisions and self-
selected changes to their lifestyle
► An empowered patient:
► Understands his health conditions
► Feels able to participate in decision making with
his health care professional and to make
informed choices about treatment
► Understands the need to make necessary
changes to his lifestyle
► Takes responsibility for his health and actively
seeks care only when necessary
► The concept requires patients to take
responsibility for their own health through e.g.:
► Attending regular preventive checks
► Leading a healthy lifestyle
Areas for improvement Patient empowerment
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Investing in reducing health inequalities
Areas for improvement ► Investing in reducing health inequalities breaks
the vicious spiral of poor health contributing to,
and resulting from, poverty and exclusion
► Health inequalities represent:
► Waste of human potential
► Huge potential economic loss
► Reasons:
► Barriers in access to health care
► Social status / mental state
► Barriers in access to health care can be
removed through e.g.:
► Use of ICT in health such as telehealth or
mhealth
► Improved health care territorial cover
► Cross border care
► Inequalities caused by social status / mental
care can be removed through contribution
towards reaching Europe 2020 poverty and
social exclusion target
► Specific activities addressing health
inequalities:
► Ensure physical activity possibilities in
poorer regions / areas
► Address risk factors that are particularly
prevalent in disadvantaged population
groups (e.g. tobacco consumption)
► Set up, improve or expand local health
care basic services (including
infrastructure) for the rural population
► Support to better living and housing
conditions for vulnerable groups:
► Access to acceptable standards of housing
and indoor temperature
► Access to sanitation and water which meets
EU standards
► Bring innovations to the care system to
improve patients’ health literacy
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X. Discussion about specific EC regulation (i) Performance reserve and monitoring
[Analysis of EU regulation]
Page 112
Performance framework One of the pillars towards the result orientation of ESIF
1. Clear articulation of the objectives of OPs with a
strong intervention logic
2. Definition of ex-ante conditionalities to ensure that
the necessary prerequisites are in place for the
effective implementation of ESIF
3. Establishment of clear and measurable milestones
and targets to ensure progress is made as planned
(performance framework)
► Regular monitoring by the EC and the monitoring
committee for each programme:
► MA provides information on progress in the
Annual Implementation Report (AIR), beginning
for the reports submitted in 2017
► Annual review meeting for all OPs convened
every year from 2016 until 2023
► Monitoring committee reviews implementation of
the OP and progress towards achieving its
objectives
► Two formal reviews scheduled for 2019 and the
closure of the programming period
Areas for improvement Three pillars of the result orientation of ESIF Time framework
Milestones and targets in form of:
► Financial indicators
► One indicator per priority in form of the total amount
of eligible expenditure
► Output indicators
► Selected by Member States from among the
indicators already chosen for the programme
► Result indicators
► Key implementation steps
► Used to set a milestone when no measurable
output is expected by the end of 2018
Building blocks of performance framework
2014 2018 2019 2023 2025
► Milestones (intermediate targets) to be achieved by 31
December 2018
► Performance review in 2019
► Targets set to be achieved by 31 December 2023
► Final assessment and the closure of the programming
period in 2025
Monitoring performance
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Performance reserve 6% of the allocation for successful priorities
Areas for improvement Performance reserve
► Total amount of the performance reserve allocated by ESI
Fund and category of region shall be 6%
► Constitutes between 5 and 7% of the allocation to each
priority within a programme
► Corresponding amounts shall be set out in the OPs broken
down by priority and, where appropriate, by ESI Fund and
by category of region
► Will be allocated to OPs and priorities which have
achieved their milestones
Performance review
► Carried out in 2019 on the basis of the information and the
assessment presented in the annual implementation report
(AIR)
► EC adopts a decision to determine for each MS and ESI
Fund, the OPs and priorities which have attained their
milestones and will get the performance reserve
► Where priorities have not achieved their milestones,
the MS shall propose the reallocation of the
corresponding amount to “successful” priorities
► The number of output indicators selected for a priority
should be as low as possible – increases in their number
raises the risk of failing the milestone set
► Appropriate ex-ante assessment of each programme
should address the suitability of milestones and targets
selected. The assessment should analyze:
► Relevance of the milestones
► Whether the milestones are realistically achievable
► Ensure that are not unrealistically low or high
► The key question is: “What should be achieved by the end
of 2018?”
► Monitoring committee may also make observations to
the MAs regarding implementation and should then
monitor actions taken as a result of its observations to
ensure achievement of the milestones
► MS should not fail to submit information on progress
against the milestones in the AIR as the reserve will not be
allocated for the priorities or programmes not supported by
progress report
Steps towards successful achievement of performance reserve
Useful sources:
Guidance fiche: Performance Framework Review and Reserve in 2014-2020; Version 3 – 19 July 2013 available at http://ec.europa.eu/fisheries/reform/emff/guidance-performance-framework-review_en.pdf
Page 114
Reporting system Annual implementation report
► The Annual Implementation Report (AIR) consists of the
AIR itself and the corresponding set of Indicators
► The AIR contains details of both the physical and
financial progress that has occurred in the year
► Including the contribution of the ESIFs to changes in
the value of result indicators
► The AIR should include the following information:
► Key information on implementation of the programme and
its priorities by reference to the financial data
► Common and programme-specific indicators and
quantified target values*
► The data transmitted shall relate to values for
indicators for fully implemented operations and also
where possible for selected operations
► A synthesis of the findings of all evaluations of the
programme that have become available during the
previous financial year
► Actions taken to fulfil the ex ante conditionalities (only in
the report to be submitted in 2016)
► Any issues affecting the performance of the
programme, and the corrective measures taken
► A citizen's summary of the content of the AIRs that
shall be made public
► In addition, the AIR submitted in 2017 shall:
► Set out and assess the previous information and the
progress towards achieving the objectives of the
programme
► Set out the actions taken to fulfil the ex-ante
conditionalities not fulfilled at the time of adoption of
programmes
► Assess the implementation of actions to take into account
the principles of promotion of men and women equality
and non-discrimination, sustainable development,
and the role of the partners**
► Report on support used for climate change targets
► The AIR for the financial years of 2014-2022 has to be
submitted to the European Commission by 31 May
from 2016 until and including 2023***
► Following this, the Commission may make observations
to the MA concerning issues affecting implementation of
the programme
► Each programme’s performance is also the subject of
the annual review meeting attended by the
representatives of the Commission and the Member State
* And beginning from the report submitted in 2017 the milestones defined in the performance framework
** Referred to in Article 5 in the implementation of the programme
*** The last AIR covering the financial year of 2023 is to be submitted by 15 February 2025
Useful sources:
Guidance fiche No 5: Annual Implementation Report, Version 3 – 7 March 2014 available at http://ec.europa.eu/fisheries/reform/emff/doc/04-annual-implementation-report_en.pdf
SFC2007: System for Fund management in the European Community 2007-2013 - The Annual Implementation Report FAQ available at http://ec.europa.eu/employment_social/sfc2007/quick-guides/sfc2007_ms_air_faq.pdf
Page 115
X. Discussion about specific EC regulation (ii) State aid
[Analysis of EU regulation]
Page 116
State Aid EU State Aid policy framework 1/3
► Article 107(1) of the EC Treaty on the Functioning of the European Union
(hereinafter “the Treaty”) prohibits Member States from distorting competition on
the Common Market by giving state aid to undertakings*
“Save as otherwise provided in the Treaties, any aid granted by a Member State or through State
resources in any form whatsoever which distorts or threatens to distort competition by favouring certain
undertakings or the production of certain goods shall, in so far as it affects trade between Member
States, be incompatible with the internal market.”
► To determine whether an intervention/investment represents state aid or not,
Article 107 (1) of the Treaty refers to four test criteria:
► Is the measure (i.e. form of support) being provided by the State or state resources?
► Does the measure favor particular undertakings or the production of certain goods?
► Does the measure affect tradable activity between Member States?
► Will the measure distort competition, or does it have potential to distort competition?
! The fair chance exits that interventions of Member States in health care markets
may meet all criteria and fall under the Community regime of State Aid
* every entity engaged in economic activities is an undertaking within the meaning of EC competition law
Page 117
State Aid EU State Aid policy framework 2/3
EXCEPTIONS
► Categories acknowledged by the Commission as compatible with the
common market*, e.g. ► regional aid, allocated according to the map for regional aid in the period 2007-2013
► aid for the creation of small enterprises by women; aid in favor of SMEs, to allow them to benefit from
consultancy services and participation in fairs;
► aid for research, development and innovation, in particular concerning cooperation between research
organizations and enterprises, intellectual property rights costs for SMEs etc.
! Health care is not addressed among the exempted categories
► The Commission has also the power to approve national state aid measures
on the basis of:
► Article 107 (3) of the Treaty
► e.g. according to sub para (c) of this Treaty “aid to facilitate the development of certain economic
activities or of certain economic areas, where such aid does not adversely affect trading conditions to an
extent contrary to the common interest” may be allowed
► Article 106 (2) of the Treaty
► deals with Services of General Economic Interest (SGEI) and provides an exemption from the prohibition
laid down in Article 107 (1) EC
* Commission Regulation (EU) N°651/2014 of 17 June 2014 declaring certain categories of aid compatible with the internal market in application of Articles 107 and 108 of the Treaty
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State Aid EU State Aid policy framework 3/3
EXCEPTIONS
► State Aid under conditions of De minimis rules* are exempted from the
notification requirement
Main conditions set by the regulation:
► De minimis aid can not exceed EUR 200 000 (EUR 100 000 in case of road freight transport)
granted over a period of three years. In case of the SGEI, the interventions can not exceed EUR
500 000 over any period of three fiscal years to meet the SGEI de minimis Regulation rules.
► De minimis aid may be granted to an undertaking that has received other State aid as long as the
de minimis aid is not used to top up that other aid beyond the allowable ceiling for the same
attributable costs [= the treshold of EUR 200 000 is per Member State].
► Member State must check before providing it that a new grant will not breach the limit of EUR
200,000 per undertaking.
► Only transparent de minimis aid, i.e. aid where the amount can be calculated precisely in advance
without needing to carry out a risk assessment, could be applied.
* Regulation (EU) No 1407/2013 on the application of Articles 107 and 108 of the Treaty on the Functioning of the European Union to de minimis aid
Page 119
State Aid The concept of undertaking in health care (analysis of case law)
“Every entity engaged in economic activities is an undertaking within the meaning of EC competition law”
► In application of the definition of undertakings to health care cases the European Court of
Justice (ECJ) and the Court of First Instance (CFI) distinct between bodies managing
health care schemes and health care providers*
► Managing bodies
► It depends on the national design of health
care schemes whether managing bodies
fall within the ambit of EC competition law
► The main argument is related to the
principle of solidarity and universal
coverage.
In state oriented HC systems in which the
principle of solidarity is predominant,
benefits granted by public authorities to
managing bodies of these schemes do not
fall within ambit of Article 107 (1) of the
Treaty
► Health care providers
► In cases where health care providers, like
doctors and hospitals are concerned, ECJ
simply departs from the assumption that
health care is (usually) provided for
economic consideration
► Concerns of universal coverage do not
play a role in the ECJ’s case law on the
concept of undertaking and to health care
providers
Doctors and other health care providers
are in general concerned to be engaged in
economic activities and thus fall within
ambit of Article 107 (1) of the Treaty
* Analysis of EU law approach towards health care with respect to EC competition law; THE COMPETITION LAW REVIEW, Volume 6 Issue 1 pp 5-29; Financing Health Care in EU Law: Do the European State Aid Rules Write Out an Effective Prescription for Integrating Competition Law with Health Care?
Page 120
State Aid Concept of SGEI and it application in health care
► SGEIs represent economic activities that public authorities identify as being of particular
importance to citizens and that would not be supplied if there were no public intervention.
► The state aid for SGEI is regulated by Commission Decision of 20 December 2011 on the
application of Article 106.2 of the Treaty in the form of public service compensation
granted to certain undertakings entrusted with the operation of services of general
economic interest.
► Issues of general interest built upon the concept of SGEI do not constitute state aid,
provided that the following conditions are met [Altmark case]:
(1) the beneficiary must have public service obligations to discharge, and the obligations must be clearly
assigned;
(2) the parameters for calculating the compensation must be established in advance in an objective and
transparent manner;
(3) the compensation cannot exceed the relevant costs and a reasonable profit (no overcompensation);
(4) the provider is either chosen through a public procurement procedure or the level of compensation is
determined based on an analysis of the costs of an average "well-run“ undertaking in the sector concerned -
EFFICIENCY criterion.
! Concept of the SGEI and its exemption from the state aid rules might be applicable in many
situations in health care.
Page 121
State Aid Concept of SGEI and its application in health care (analysis of case law)
► Some useful conclusions from the jurisdiction in relation to SGEI*:
► Bodies managing a health care scheme based on both competition and solidarity
elements may benefit from the jurisdictional approach of Altmark
► The jurisdictional decisions reflect opinion that SGEI missions may be derived from
general obligations. A consequence an open group of operators may be entrusted with
a SGEI mission.
This is an important conclusion for the health care sector, as in this sector an open group of operators is
supposed to realize objectives of general interest.
► On the other hand, it has still not been enlightened, whether SGEI mission still need to
be derived from explicit official acts or whether general obligations related to public
interest issues suffice.
However, based on CFI‘s judgment in a case concerning state aid granted in Italy, it can be concluded that
merely claiming that the public interest is involved without putting forward any substantiated evidence will not
help Member States to escape from the European state aid rules.
Some countries have therefore clearly defined which tasks and services are considered of general economic
interest [e.g. in Slovakia, providing healthcare in the outpatient care and inpatient care is legally defined as a
service of general economic interest].
* THE COMPETITION LAW REVIEW, Volume 6 Issue 1 pp 5-29; Financing Health Care in EU Law: Do the European State Aid Rules Write Out an Effective Prescription for Integrating Competition Law with Health Care?
Page 122
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