EPH3021 – (Public) Healthcare Systems in the EU
Course Summary
Case 1: The building blocks of a health system: from theory to practice
• Health systems: are essential for delivering equitable and efficient services
• Health system typologies: in the field of health systems research, it is common to
use classifications or typologies to better understand health systems and how they
function
• WHO building blocks: a health systems framework that describes health systems in
terms of several core components or building blocks
Case 2: Beveridge versus Bismarck: Is this the dilemma for health system financing
• Health insurance: a contract between the insurer and insured person to exchange
regular monthly payments for coverage of large losses
• Bismark model versus Beveridge model: the key question is not which model to
apply but how to improve the model that is already implemented
• Efficiency and equity as health system goals: both are important health system
goals but sometimes a trade-off between efficiency and equity should be made
Case 3: Patient involvement in healthcare payments: yes or no?
• OOP payments: efficiency improvement through out-of-pocket payments has not
been empirically confirmed, while their negative equity effects are well established
• Impoverishing and catastrophic effects, and foregoing services
o Equity; socioeconomic inequalities
• Financial protection and UHC: all individuals and communities receive the health
services they need without suffering financial hardship
• Access to healthcare services: affordable health care (i.e. economic access) does not
mean accessible healthcare
Case 4: From volume to value: what is a value-based healthcare system?
• Value in healthcare: value is defined as the health outcomes achieved per dollar
spent. It is not about cost-saving, it is about reducing waste and improving quality
• Value-based health system
• Value-based payment models: Traditional payment models focus on volume with
little or no stimulus to increase value to patients. Value-based payments could
overcome this shortcoming although their implementation is still challenging
Case 5: Integrated Care
• Definitions
• Types of integration: Horizontal & Vertical
• Levels:
o Macro: integration across systems/borders
, o Meso: organisation to organisation
o Micro: within clinics
• Integration paradox: those that most need integration are often the least integrated
Case 6: Digital and e-health
• Dutch and Estonian examples
• Public health goals/challenges that e-health can and should address
• Fourth Industrial Revolution (4IR) and e-health
• EU role and strategy: stewardship (i.e. guiding) of e-health
Case 7: Health system resilience
• What is resilience?
• What are shocks?
• What drives the need for resilience?
• Strategies for building back better (9)
• Fridell et al. interpretation of WHO building blocks
• Importance of communication (against disinformation)
, Lecture 1: Course Introduction (Dr. Matt Commers)
What have you learned thus far in BEPH?
• Year 1: Determinants, diseases, environment, technology
• Year 2: Migration, ageing, lifestyle, work
• SCLs: Statistics, epidemiology, methodology, philosophy/ethics/sociology, policy
advocacy
EPH3021
• It’s time to talk about healthcare
• Prevention versus cure
o Public health is generally more focused on prevention,
while our healthcare systems are generally focused on
treatment (curing)
• Is medicine part of public health, or public health part of medicine?
Types of health systems
• Many attempts to classify health systems
• How do we do this, and why?
• Partly to identify what works best, or least well
• Is there one best practice? Or a few?
Access and equity issues
• Speed, price, quality: they say “you can only choose 2!”
• Public health is about health for all (ethically)
• Is health for all the cheapest as well?
• What are the differences within the EU (and what is common/shared) in terms of
access, equity and financing?
Economics of health systems
• Healthcare bring together multiple parties within a forcefield of incentives
o “Incentives” is a key term in health economics that describes motivating a
particular behaviour
, • Patients, providers, and payors all seek multiple health-related and financial
outcomes
• Policies (which design health systems) determine what these incentives are and
influence the behaviour of these parties
o For example, treatment for a heart attack is universal and covered by all but
fertility treatments are not. Why?
• What is ideal? How do we best do that?
Role of the EU in national health systems
• Member States chose for a hands-off policy on health
systems in 1992
• Yet now we have cross-border care and economic
reform (inc. healthcare)
• What is the past, present and future role of the EU in
national health systems?
Value based care
• As Paul Starr noted: the 3 A’s (Antisepsis [germ theory], anaesthesia [pain control],
and antibiotics) gave medicine a privileged position (1850-1980)
• Then came managed care which has undermined the position of medicine and
physicians
• The powerful position held by physicians had made healthcare very expensive,
particularly with many costs charged to insurers, so value for money became ever
more the focus. But how has that turned out?
Integrated health systems
• Have you ever heard family members talk about getting care for complex
conditions?
• Have you ever navigated a multi-specialty medical trajectory yourself?
• If so, you know at least one reason why a focus has arisen on integrated health
systems!
• (And health economists know of others..)
Health information systems
• Information is the essence of strategy, and public health and
medicine are strategies
• Health systems are exploding with information, much of it
private and sensitive
• Digitisation of health care is arguably the infrastructure for all
other change processes discussed in this course
• What does it mean, and how should we handle it?
Health system resilience
,• How do we make our health systems sustainable in the face of increased stress?
• COVID-19 showed as never before what can happen when health systems are
overwhelmed
• Yet maintaining a health system even under normal conditions is difficult
• What determines how sustainable and resilient a health system is?
• How can we make them stronger? How can we ensure they can handle both acute
and sustained stress?
, Lecture 2: Health Systems Comparisons (Dr. Milena Pavlova)
What is a health system?
• Narrow definition originally: Medical care and other healthcare services
• More recently: Health promotion and protection actions
• With ageing populations: Long-term care services
• Not forgetting the determinants of these health services
Health system definitions include:
• “organisations or policies in place that are designed to plan and provide medical care
for people” (online dictionary)
• “all activities and structures that impact or determine health in its broadest sense
within a given society” (Arah et al. 2006, Int J Qual Health Care 18 Suppl 1: 5-13)
• “all organisations, people and actions whose primary intent is to promote, restore or
maintain health” (WHO, 2017)
Health system boundaries
• Where do we draw the boundaries on healthcare? Does it only refer to medical care,
or does it include all determinants of health (e.g. income, environment, social
welfare, etc)?
