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.