What are health systems for?
It is easy to forget that one of the primary purposes of a health system should be to improve health (McKee, 1999). For decades, debates on health systems have been dominated by discussions of how much they cost to run (typically questioning whether they are affordable, as if there was an alternative in a civilized society) or how many resources they require (typically expressed in an arbitrary fashion as people, usually doctors and nurses but not managers or physiotherapists, or facilities and items of furniture, usually hospitals but not primary-care clinics or beds, but not examination couches). The nature of this discourse has meant that health systems have tended to be regarded as a cost to society from which there is little return, instead of as an investment whereby appropriately directed expenditure leads to better health. Indeed, some studies even suggested that more resources were associated with higher mortality, possibly as a consequence of higher rates of discretionary surgery (Cochrane et al., 1978), a finding supported by the observation that death rates fell when doctors went on strike (Roemer, 1981).
This chapter is based on a very different vision, in which health, health systems and economic growth can exist together, in a mutually supportive virtuous circle. Drawing on work undertaken for a ministerial conference organized by the European Region of the World Health Organization in Tallinn, Estonia, in 2008, it builds on what is now a substantial body of research on these three sets of mutual inter-relationships (Figure 5.1).
In November 2005, a young French woman received the world's first ever face transplant. The operation was carried out in Amiens, France, by a team that was mainly French but contained one Belgian. This case exemplified very visibly the benefits that free movement of health professionals can bring to the delivery of the increasingly complex health care being provided in Europe. The benefits of professional mobility extend far beyond the very specialized care involved in that exceptional case. Within Europe, there are both surpluses and shortages of health professionals. The opening of borders offers a means to ensure that appropriate health professionals and potential patients are brought together, whether through movement of patients or, as is discussed in this chapter, movement of professionals. In addition, there are particular issues that arise in border areas, where patients may live closer to a hospital across the border than to one in their home state. Especially where these areas are sparsely populated, it is simply good management of resources to ensure that health professionals can also move across borders, working in the most appropriate facilities, wherever they are situated.
Yet there are also dangers. The large economic differences between Member States, which have grown substantially with the two most recent enlargements to the European Union, pose a challenge for the poorer countries. A plentiful supply of health professionals, coupled with formidable physical barriers to migration, meant that, during the communist era, wages were very low in comparison with other occupations.
This chapter considers how the European Union (EU) has discharged its obligations to develop and implement public health policy, obligations that arise primarily from its competences granted by Article 152 EC and Article 95 EC on the creation of the EU's internal market.
In doing so, the EU confronts four important tensions. The first concerns the relationship between those matters that are national and those that are international. Throughout history, threats to public health have transcended national borders, initially in the form of infectious diseases and more recently in the form of trade in dangerous goods, such as tobacco. Yet, reflecting the absence of an appropriate international architecture, responses have largely been developed and implemented at a national level. This only began to change in the latter part of the nineteenth century, when a series of international sanitary conferences began a process that would, in time, lead to the creation of the World Health Organization. However, even now, international public health remains a state-based model, involving interactions among state-defined actors, albeit through institutions established in international law.
The nub of this tension is that the EU is neither an international public health organization nor a state. The EU lacks the public health expertise, resources and experience of international bodies such as the World Health Organization, the World Bank or UNICEF. It also lacks the capacity – in particular, the financial and human resources – of a state, which would enable it to deliver public health policies.
This chapter examines the challenges inherent in assessing how health systems perform in response to chronic diseases. These are diseases that persist over an extended time and require a complex response involving coordinated inputs from a wide range of health professionals, access to essential medicines and (where appropriate) monitoring equipment. Ideally this is embedded within a system that promotes patient empowerment. There are many chronic diseases but in this chapter we draw extensively on experience with diabetes. The reasons for this are three-fold. First, diabetes was the first example of an acute disease that was transformed into a chronic disorder by the introduction of effective treatment. Second, it exemplifies the complex nature of chronic disease as its complications affect many different bodily systems and call upon the expertise of a wide range of specialists. Third, it provides a lens through which to view the performance of the overall health system.
Health system performance is the focus of the chapter and this volume. However, before looking specifically at performance it is necessary to understand the specificities of chronic diseases, many of which pose substantial challenges for performance measurement. It may also be helpful to reflect on the rapidly increasing contribution of chronic diseases to the overall burden of disease, a development that has important consequences for the assessment of health system performance more generally.
Health systems have three goals: (i) to improve the health of the populations they serve; (ii) to respond to the reasonable expectations of those populations; and (iii) to collect the funds to do so in a way that is fair (WHO 2000). The first of these has traditionally been captured using broad measures of mortality such as total mortality, life expectancy, premature mortality or years of life lost. More recently these have been supplemented by measures of the time lived in poor health, exemplified by the use of disability-adjusted life years (DALYs).
These measures are being employed increasingly as a means of assessing health system performance in comparisons between and within countries. Their main advantage is that the data are generally available. The most important drawback is the inability to distinguish between the component of the overall burden of disease that is attributable to health systems and that which is attributable to actions initiated elsewhere. The world health report 2000 sought to overcome this problem by adopting a very broad definition of a health system as “all the activities whose primary purpose is to promote, restore or maintain health” (WHO 2000) (Box 2.1.1). A somewhat circular logic makes it possible to use this to justify the use of DALYs as a measure of performance. However, in many cases policy-makers will wish to examine a rather more narrow question – how is a particular health system performing in the delivery of health care?
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