Europe Health Profile

The WHO European Region includes 53 Member States and nearly 900 million people living in diverse cultural, economic, social and political circumstances. Although the Region has the highest average score on the Human Development Index of any WHO region, significant inequity remains within and between countries or population groups, especially in health ; inequity in health is the avoidable and unjust systematic differences in health status between groups in a given society. How well do Member States in the Region fulfil their aim of promoting health and reducing inequity, given the demographic, epidemiological, technological, environmental, socioeconomic and fiscal challenges that they face? The European health report 2009 reviews and assesses public health indicators and trends during the past four years. Since 2005,

European governments have taken a health systems approach towards combating ill health, promoting healthy lifestyles and reducing inequality in health. This report reflects the fact that the European Region is experiencing great change, internally through reforms of health systems and externally due to global crises, causing great uncertainty in both health systems and outcomes. Although several global trends affect health, the global economic recession and the new pandemic (H1N1) 2009 influenza are the most acute. First, the severe economic crisis will have many implications and long-term consequences: economic growth seems unlikely to recover soon, and debt may constrain public finances for years to come. Slowing economic activity and rapidly rising unemployment seriously threaten or already affect the living conditions of millions of individuals and families in the European Region and the revenue base of health and social protection schemes. Experience from previous economic recessions suggests the vital importance of ensuring a high degree of solidarity and social security, maintaining public expenditure and basic health services and scaling up disease prevention and health promotion activities.

The health status of the population in the WHO European Region has improved in the past decades, as indicated by longer life expectancy at birth. Nevertheless, important and growing inequality in longevity is associated with gender and social and economic factors. Gains in life expectancy have been attributed to overall decreasing mortality, mainly from declining communicable diseases in early childhood and delays in premature death among adults due to improved health care. In addition, changes in lifestyles and behaviour have led to further changes in the patterns of mortality and the burden of disease, with chronic noncommunicable conditions, injuries and violence affecting health more strongly. Groups of European countries vary substantially. The Commonwealth of Independent States (CIS), including the central Asian republics and Kazakhstan (CARK), in general have higher mortality and disease rates, which have been linked to demographic, social and economic transitions. The 15 countries in the European Union (EU) before 1 May 2004 (EU15) and the 12 countries joining the EU since 1 May 2004 (EU12) in general have lower mortality and disease rates. As health systems require further delineation of country situations and needs, to adjust and respond accordingly, this section describes mortality and the burden of disease and their recent trends in the Region.

Life expectancy

Life expectancy roughly but comprehensively measures overall population health, as it summarizes, in a standardized format, current information on the health situation of all age and sex groups of populations. As such, it reliably indicates overall health performance in a society at a specific time. This broad indicator reflects societies’ performance in improving health and not solely the performance of health systems. This distinction is key, as it links to public health’s greatest idea: that human health and disease embody the successes and failures of society as a whole. The highest life expectancy at birth in the European Region was 82.0 years in Switzerland (2006) and the lowest, 66.4 years in Kazakhstan (2007).

Life expectancy for the Region as a whole increased from 73.1 years in 1990 to 75.6 years in 2006. Life expectancy has increased steadily and considerably in the EU countries.. Remarkably, the averages for EU15 and EU12 countries have both improved by 5% from already high levels. This reflects a consistent reduction in mortality rates at all ages, due to such factors as higher living standards and educational levels, healthier lifestyles and improved access to and quality of health services.

Unfortunately, the CIS countries have not been able quickly to recover from the rising mortality in the early 1990s. The average life expectancy for these countries deteriorated sharply between 1991 and 1994 and then recovered only partly. Since the late 1990s, the CIS average has essentially stagnated. The Russian Federation’s large population strongly influences average life expectancy in the CIS. Many researchers have focused on the unfavourable trends in the country, finding clear associations between life expectancy and socioeconomic trends. For example, the increases in mortality in 1991–1994 and in 1998–2003 paralleled the critical socioeconomic situation in those periods, and the relative declines in mortality in 1994–1998 and 2003–2006 were associated with relative economic improvement. Moreover, excessive alcohol intake by much of the population caused much of the premature mortality, particularly among men, although many alcohol-related deaths were wrongly attributed to diseases of the circulatory system .

Nevertheless, several CIS countries (such as Armenia, Azerbaijan, Tajikistan and Uzbekistan) have performed relatively well and been able to improve life expectancy slightly from their 1990 levels. This indicates that, despite converging trends in the past, more recent national policies have made a difference. Comparative analysis is needed to identify the specific policies that have played a role in these countries, but research evidence from a broad range of other countries suggests that the policies affecting the socioeconomic circumstances in which people live and work usually have more influence than policies related solely to health care.

The increasing trends in life expectancy in the European Region are similar for people younger and older than 65 years. The reduction or loss of life expectancy from death before 65 years of age is a very useful measure of premature mortality.

In recent years, therefore, governments have changed the tools they use to regulate the delivery of services and the extent to which political, managerial and fiscal functions are decentralized or recentralized from the central to the regional levels (105) to achieve broad health system goals. There are, however, some challenges in implementing health in all policies:

1. success in implementation is limited by the extent to which health policies or intersectoral action of selected sectors on their own can improve the determinants of health;
2. the costs of the strategies are important decision-making points, and any health policy measures that negatively influence the cost structure of another public policy area will encounter difficulty;
3. the promotion of local health agendas and measures will have limited effects if the determinants of other policies are set at the national, regional and global levels; and
4. the health effects of specific policy changes are not necessarily direct and immediate but may only become evident much later.

Tackling these challenges requires building the capacity for intersectoral action and basing decisions on an increasing evidence base and reliable information and data. One of the six WHO global priorities in stewardship is to support Member States in building coalitions across government ministries, with the private sector and with communities to act on key determinants of health and to ensure that the health needs of the most vulnerable people are properly addressed. Achieving this objective requires not only episodic action but also the building of robust social institutions capable of exerting continued influence on society. Health system stewards must therefore strike a balance between the medium-term outcomes necessary to respect the pace of political life and the long-term actions required to promote better health through healthy public policies.

Assessing health system performance for accountability

Improving the performance of countries’ health systems is a priority issue across the European Region, especially in the current economic climate in which obtaining the greatest value from existing resources is paramount. In this regard, health system performance assessment is a recognized approach among the countries in the WHO European Region. It has been given renewed recognition and impetus by the Tallinn Charter, through which Member States committed themselves to transparency and being accountable for health system performance to achieve measurable results.

Accountability for better health outcomes and health system stewardship Assessing a health system’s performance involves measuring and analysing how well it is meeting its ultimate goals, such as better health status and better financial protection for the population, and increased responsiveness or efficiency for the health system (75,106) and how its performance against intermediary objectives – such as access, coverage, quality and safety of health services – contributes to reaching these goals. A fully developed approach to assessing health system performance has the following
attributes.

• It is regular, systematic and transparent. Reporting mechanisms are defined beforehand and cover the whole assessment. It is not bound in time by a reform agenda or national health plan end-point, although it might be revised at regular intervals better to reflect emerging priorities and to revise targets with the aim of achieving them.
• It is comprehensive and balanced in scope, covers the whole health system and is not limited to specific programmes, objectives or levels of care. The performance of the system as a whole is more than the sum of the performance of each of its constituents.
• It is analytical and uses complementary sources of information to assess performance. Performance indicators are supported in their interpretation by policy analysis, complementary information (qualitative assessments) and reference points: trends over time, local, regional or international comparisons or comparisons to standards, targets or benchmarks.
• In meeting these criteria, health system performance assessment needs to be transparent and promote the accountability of the health system steward. These two elements are mutually reinforcing, and this section focuses on examining how countries can use health system performance assessment to drive performance and ensure accountability.

Accountability has two main characteristics: rendering an account (providing information) and then holding accountable (imposing sanctions or rewards for the accountable party). Health system performance assessment corresponds to a performance accountability approach grounded in management science, which aims to demonstrate and account for performance based on agreed targets and, as such, differs from accountability for compliance with procedures and rules (also known as hierarchical control). It holds stakeholders to account for both the performance of their national, regional and local health systems and for their action to improve performance.A commitment to accountability is not only an answer to external audiences but also a constructive tool for organizational development, enhancement of management practices, self-evaluation and strategic planning (110). More specifically, building coherence between strategy, performance management and accountability by measuring performance can lead to improved performance and increased value for health systems .
In addition, the release of publicly available report cards has enhanced accountability for health system performance to the public by documenting the relative performance of national health systems, often with related international rankings. Such scorecards have raised awareness and interest in health systems’ performance at all levels. Moreover, by creating a focused platform for bringing public and mass-media attention to differences between health systems, international comparisons have become a powerful tool for alerting national policymakers to deficiencies and prompting remedial action. Such comparisons may also force health system stewards to explain publicly the reasons for variation and their own system’s potentially lower scores in given areas. Although many methodological challenges related to comparable data and aggregation of indicators in league tables remain , the responses to such reports as The world health report 2000 (75) or the OECD Health at a glance 2007 (116) indicate the power of such comparisons. Although mass-media and consumer reports have so far focused primarily on the quality of health care providers, through scoring, they are now stepping into the wider sphere of international health system comparisons with, for instance, the development of the Euro health consumer index (117).
Assessing health system performance can also improve performance more directly. Embedding strategic performance information into decision-making processes supports policy-makers in assessing and readjusting strategies, plans, policies and related targets to move towards achieving health system goals. Health system performance assessment, linked to accountability and strategy, thus supports stewardship by ensuring that: health systems are strategically oriented towards improving health outcomes for the population, policy decisions are informed by appropriate intelligence related to health problems and determinants of health, all government policies contribute to better health and healthy public policies are promoted across all areas of government. This is consistent with the core responsibilities of health system stewards: ensuring that a strategic policy direction is formulated, ensuring good regulation and appropriate tools for implementing it and fostering the intelligence on health system performance needed to ensure accountability and transparency (107).
Assessing health system performance in European countries Most countries in the WHO European Region have incorporated elements of health system performance assessment into their oversight arrangements. Very few, however, have developed systems that have formalized and integrated all of its attributes with the potential substantially to improve performance.

Table 3.4 presents an overview of the implementation of health system performance assessment in selected European countries. Consistent with the approach presented above, it reviews the characteristics of health system performance assessment and identifies strengths and weaknesses in implementation. For example, a “–” score under “Regular, systematic and transparent” means that the assessment is not released regularly or that the results are not shared broadly and transparently with health system stakeholders and the public at large. Conversely, a “+” score on the “Link to health system performance management” column means that performance information is clearly linked to strategy and that processes are in place to ensure that it is used systematically at different stages of the decision-making process, for policy development, resource allocation or accountability decisions. A “–/+” score indicates that the situation is still unclear.

The Netherlands: regular, systematic and transparent assessment of health system performance In the Netherlands, the Ministry of Health, Welfare and Sport commissioned the National Institute for Public Health and the Environment (RIVM) to develop and release performance assessment reports for the health care system in the Netherlands in 2007 and 2008. The reports are published annually on the RIVM web site (118). The framework for assessing health system performance focuses on the technical quality of health care while keeping a broader perspective on health and its other determinants. It measures performance through 110 indicators. The selected system goals and indicator domains are in accordance with the policy of the Ministry of Health, Welfare and Sport.

England: comprehensive assessment of health system performance Since 1999, England has developed three different systems of performance assessment for the NHS. The NHS performance assessment framework (119) is based on six areas of performance: health improvement, fair access, effective delivery of appropriate health care, efficiency, patient care experience, and health outcomes of NHS care. The annual star rating system, which ran from 2001 to 2005, gave different types of organization a rating from zero (failing) to three stars (high performing) based on assessment against a set of key targets and a balanced scorecard of three domains (which varied by type of organization). Failing key targets put an organization at risk of being zero-rated, while attaining three stars required
good performance on key targets and the balanced scorecard. Since 2006, organizations have been assessed through an annual health check, which has two components: financial management and quality care.
The framework is used: to assess the NHS’ performance, covering quality and efficiency, to encourage benchmarking between similar NHS organizations and to underpin national and local performance and accountability arrangements.

Kyrgyzstan: health system performance assessment supported by in-depth analysis addressing performance drivers In Kyrgyzstan, the Department of Strategic Planning and Reform Implementation of the Ministry of Health regularly assesses core health system performance. The Republic Centre for Health System Development and Information Technologies supports the Ministry. The Centre is an autonomous public entity responsible for supporting policy development and implementation by generating knowledge, in-depth analysis of performance and training. Health system performance and the impact of reforms have been monitored and published regularly since 2004. The 2008 report, assessing the impact of the implementation of the health system reform programme, showed that, halfway through the programme, key performance indicators demonstrate strong and sustained progress towards meeting targets on financial protection, access, efficiency and transparency, and mixed results in terms of health and quality of care indicators.

Portugal: linking health system performance assessment and accountability structures and processes In Portugal, the National Health Plan 2004–2010 targets performance improvement objectives for the health system and monitors progress on targets related to the plan. The set of performance indicators is available on the Internet and monitored and released regularly.
The National Health Plan has many characteristics of a framework for health system performance assessment through its scope and regular reporting mechanisms. To ensure the implementation of the plan, structures (such as the Office of the High Commissioner for Health) and processes (coordination mechanisms through an interministerial committee) were established to clarify roles and responsibilities, coordinate implementation and ensure accountability across the government and health system for achieving health system targets.

Sweden: linking performance assessment and management of health system performance In Sweden, the National Board of Health and Welfare monitors and evaluates health services to determine whether the services delivered are aligned with the goals set out by the national government. If the scope of the assessment is related to health services, the link to the national goals is important from a health system perspective. With the Swedish Association of Local Authorities and Regions, the Board published a report on health care quality and efficiency in 21 county councils and health care regions in Sweden that serves two purposes. The first is to inform the public and to stimulate the debate on health care quality and efficiency. Second, the results are used to support local and regional efforts to improve health care services in terms of clinical quality, health outcomes, patient experience and efficient resource use.

The implementation of health system performance assessment varies widely across the WHO European Region. Data and quantitative indicators are produced and to some extent made public in all countries, but analysis is very often fragmented and not linked to regular and systematic accountability and performance management processes. Rather than building additional parallel systems, developing full frameworks for health system performance assessment in many countries
would mean bringing isolated initiatives together, complementing them and making sense of the data already available to assess performance from a health system standpoint and inform strategic priorities.
The impetus generated by the Tallinn Charter has created high awareness of the essential role of health system performance assessment in successful stewardship of the health system. This commitment was further reinforced in the context of the economic recession during the first Tallinn Charter follow-up meeting in February 2009, when European Member States agreed on plans to take the Tallinn Charter forward. In addition, they requested support and facilitation at the international level to develop a common framework for health system performance assessment, to select minimum and tailored sets of performance indicators and to develop processes for cross-country learning and benchmarking . Some of the challenges and ways forward in implementing full performance assessments across the Region are described below.
Many issues around information systems and data quality or the selection of indicators are used to explain why health system performance assessment is still underdeveloped. The lack of standardization in methods and data often results in inconsistency, which might prevent performance information from being used for comparison over time, across organizations, cross health care settings or across regions. Nevertheless, even if limitations still exist, major advances have been achieved in recent years with the support of international organizations such as WHO, OECD and the European Commission. A consensus is increasingly being built on data standardization and a focus on a limited number of health system performance indicators (108,127). Advances at the international level are likely to benefit the national level, with more coherence in information systems to adapt to international reporting requirements and build on international best practices. The fragmentation of performance measurement and monitoring systems often creates major bottlenecks, reflecting a lack of coordination and communication within different levels of government and the health system, especially as each stakeholder monitors processes and outcomes on specific programmes.

The challenge lies in aligning performance assessment and accountability based on strategy, by cascading performance indicators at the macro, meso and micro levels while recognizing and adapting to the different levels of responsibility. The intention is to reach greater clarity in the roles and responsibilities of health system actors to achieve health outcomes, which should translate into clearer performance expectations and better performance management approaches driving improvement. A better alignment of information systems, indicator selection and accountability structures and processes (both nationally and internationally) would probably benefit many countries in the European Region.

Effective communication and wide dissemination are required to create platforms to introduce important changes in health systems. From this perspective, information on performance should be interpreted in ways that are simple and clear to policy-makers (128) and can be communicated effectively to the public. Further, health system performance assessment has to be built into integrated performance management systems, through which important indicators are used systematically in decision-making processes across government. These processes relate to strategy and policy development, target setting, performance measurement, resource allocation and improving accountability and performance. Member States in the Region vary widely in terms of the availability and quality of data, accountability structures and processes, citizens’ participation, transparency, and the maturity of their culture of performance measurement and continuous quality improvement. If accountability relationships are to function properly, no system of performance information should be viewed in isolation from the broader design within which the measurement is
embedded. National ownership and fostering of a culture of measurement, transparency and continuous performance improvement are crucial to improve health system performance based on research evidence and performance information. This culture grows as data are used, information systems improve and policy-makers are equipped to translate performance information into evidence-informed decision-making. The WHO Regional Office for Europe supports health ministries and governments in using better performance information to steer complex reforms in environments of growing financial constraints and rising expectations. Future priorities for action, as indicated by Member States, will be:

• developing a common framework for assessing health system performance;
• based on the experience of other international organizations, selecting a core and a
tailored set of performance indicators to enable both international comparisons and indepth
assessment of health system performance at the national level; and
• developing mechanisms for cross-country learning and benchmarking.