This article is part of our special report Resilient and innovative EU health systems.
SPECIAL REPORT / Poor responses to budget cuts during the crisis have left many national healthcare systems in a bad state but they can still be shock-proofed for the future, according to policymakers who argue that stronger governance is the key to resilience.
The global financial crisis and resulting debt crisis in Europe have taken their toll on the health sector with European governments making deep cuts to healthcare budgets.
Between 2008 and 2011, 17 of the EU's 28 member states slashed public spending on healthcare due to austerity policies.
While countries such as Germany, France, the UK and Luxembourg experienced a decline for one year, Ireland's health budget was slashed for three years.
Speaking during a panel discussion at the European Health Forum in Gastein, Austria, on Thursday (3 October), policymakers emphasised that public health systems in the EU would have to be more "resilient" in the future – meaning they should be able to adapt and respond to unexpected pressures, whether internal or external.
Josep Figueras, director of the European Observatory on Health Systems and Policies, said that resilience had to do with governance and the ability to manage processes.
"Resilience with regards to health systems is not so much about surviving external shocks such as the crisis and austerity. There's also the aging population and obesity epidemic. So the health systems are facing lots of major, important shocks," Figueras said.
Right and wrong responses
For public health systems, the issue is not just about how to survive or adapt, but also how to come back stronger than before.
"Resilience goes beyond the concept of sustainability and performance," Figueras stressed.
The European Observatory on Health Systems has recommended that the responses to the financial crisis should have been a "sensible efficiency response" which could have focused on eHealth, co-ordinated care or streamlining hospital resource management.
Instead, the most widely used responses were cuts in salaries, staff, training and research as well as social benefits. Other strategies included delaying investments or introducing user charges.
"Those countries during the crisis whose ministers and decision-makers had a clear vision of what they wanted, they used the crisis very effectively," Figueras said, adding that many had for a long time wanted to rationalise their systems, but needed the crisis as an excuse to do so.
"We all know what to do, but we don't know how to get re-elected [afterwards]" Figueras commented, quoting Luxembourg Prime Minister Jean-Claude Juncker.
Hans Kluge, director of the Division of Health Systems and Public Health at the World Health Organization's (WHO) Regional Office for Europe said that the most resilient healthcare systems were those that were already performing well before the crisis.
"Usually these systems were working efficiently and tended to have better management capacity and they usually had much better evidence and data systems to make informative decisions in difficult times," he said
Scott Green, professor at the School of Public Health at the University of Michigan, said governance was all about how society takes and implements decisions and whether good ideas succeed or fail.
Green said that there were many aspects crucial to resilience within a system. First of all, decision-making had to be transparent and affected parties needed to be engaged in the process. Accountability was also very important, and those in power had to clearly report to supervisors who could sanction them. Integrity should be ensured through clear jobs and hiring tenure, while policy analysis always needed to be a central concern.
Monika Kosi?ska, secretary-general at the European Public Health Alliance (EPHA), added that civil society also had to get involved in the decision-making as it was a functioning part of a democracy.
"The importance of building civil society and making people active is crucial in a time of social media," Kosi?ska said.
Peter Smith, co-director of the Imperial College in the UK, said:
"We cannot in my view do anything without quality information. This is something we often forget. Incentives are fundamental; we can have intended and unintended ones. And the thing we often really forget when making reforms is the need for the institutional capacities to make these reforms work. That capacity is closely associated with governance."
Dessislava Dimitrova, former Deputy minister at the Ministry of Health in Bulgaria, continued:
"It shocks me that whenever we speak about governance, we speak about it as if it's a one in charge who manages the whole system. Really to me, it's more about the principles that are outlined and applied in processes within the ministry. Because we can't have one governance in charge of the whole system. It's more about each health aspect in the health system. We don't have one resilient system, but we have resilient aspects of the healthcare system."
"We can't have a resilient health system if we don't have resilient people working in it," chief executive at the Professional Standards Authority, Harry Clayton, added.
"I think it's terribly important that we don't talk about system failures in a way that resolves people from responsibility because we are the system. We are the people who make things happen on an organisational level."
The Gastein Health Forum meeting in Austria is Europe's largest gathering of health policymakers.
This year’s conference discusses how to secure the EU's healthcare systems for the future after years of budget cuts due to the financial crisis.
The eurozone debt crisis has forced some governments to drastically cut their public health budgets in an effort to contain deficits.
For example, in Greece, the public healthcare system has come under enormous pressure during the crisis, with hospitals and pharmacies cutting back on medical supplies. Spanish authorities have legally restricted access to care for undocumented migrants.
>> Read our LinksDossier: Austerity: Healthcare in hardship