The Lancet, Editorial, June 23, 2018
Last week, ministers of health, policy makers in health and finance, patient organisations, and academic advisers met in Tallinn, Estonia, to discuss the future of European health systems. Under the stewardship of WHO’s Regional Office for Europe (WHO EURO), and hosted by Estonia’s President, Kersti Kaljulaid, and Minister of Health and Labour, Riina Sikkut, 250 or so representatives of WHO EURO member states celebrated the tenth anniversary of the Tallinn Charter and agreed on principles for building sustainable people-centred health systems.
In 2008, the Tallinn Charter shaped thinking about the importance of health systems and the inter-relatedness of health and wealth. The Charter committed signatory WHO EURO member states to improve health by investing in and strengthening their health systems, and to promote the shared values of solidarity, equity, and participation. Underpinning the Charter were the principles that high-performing health systems contribute to better health and economic development, and that no one should become poor because of ill health.
But later in 2008, the financial crisis hit, leading to hardship and widespread austerity measures in many member states and, in some, to deep cuts to health budgets. Tallinn Charter commitments were derailed, out-of-pocket health expenditure increased, and investment in health systems decreased in many countries. Nevertheless, the past decade has seen some metrics improve, such as life expectancy at birth and tuberculosis case detection. But progress is variable between and within countries, slow in many, and widespread inequalities persist.
Where now for the Tallinn Charter? Last week saw renewed commitment to the fundamental principles of the Charter through adoption of three themes to achieve faster and more equitable health gains. Participants agreed to “include, invest, and innovate” to strengthen their health systems. Ministers of health and policy makers agreed that the health needs of their populations can best be met by improving coverage, access, and financial protection; making the case for investing in health systems; and harnessing innovations in health care.
How to improve inclusion, to ensure universal health coverage, was discussed in the context of financial protection. Health systems play a crucial part in protecting individuals from the financial hardship caused when out-of-pocket payments for health, such as prescription charges or dental care, are greater than a household’s ability to pay. New evidence on financial protection was presented in Tallinn based on analyses across 25 European countries. Even with “universal health coverage”, up to 8% of households in Europe cannot afford to pay for basic needs (food, rent, utility bills) after paying out-of-pocket charges, especially for medicines and dental care. These costs are still causing people to fall into poverty or to do without care; for many in Europe, medicines or dental care, or other health-care costs, are simply not affordable. The risks are greatest where out-of-pocket payments are over 15% of total spending on health, especially if pro-poor policies are absent.
It is still necessary to make the economic case for investing in health systems. Competing demands upon ministries of finance serve to emphasise the need to demonstrate good stewardship of public resources, including measures to reduce health-system inefficiencies and waste, but there is now strong evidence that spending on health contributes to better health outcomes, promotes macroeconomic growth, supports societal wellbeing, and enhances fiscal sustainability of health systems.
It is important to strive for continuous improvement to health systems to benefit populations. Health systems have been slow to innovate in many countries, but key factors that help include supportive leadership, early involvement of clinical staff, dedicated resources including funding, staff, and time, and evaluation of the benefits and costs. Remembering the needs of the public and patient is paramount—innovations that are not needed, wanted, or are too complex will fail.
Inclusion, investment, and innovation are useful themes to build sustainable health systems for the future. The key message from Tallinn 2018 is European solidarity to improve health outcomes, decrease inequalities, and deliver universal health coverage. “Everything we do to improve health outcomes, decrease inequalities, and strengthen health security is fundamentally driven by our European social values of solidarity, equity, and universalism”, Hans Kluge (WHO EURO) told The Lancet. Health systems must be person-centred and flexible to allow change and innovation. Leadership from health ministers, policy makers, academics, and clinicians will be crucial to implementing the recommendations from Tallinn 2018.
By Don McCanne, M.D.
Ten years ago the Tallinn Charter established principles for building sustainable people-centered European health systems. Unfortunately the Great Recession prompted governments to implement austerity measures – a politically difficult time to increase investment of public funds in their health care systems, though Keynesians may not agree.
On the tenth anniversary of the Charter representatives of the WHO EURO member states met again in Tallinn in a renewal of European solidarity to improve health outcomes, decrease inequalities, and deliver universal health coverage. As Hans Kluge from WHO EURO told The Lancet, “Everything we do to improve health outcomes, decrease inequalities, and strengthen health security is fundamentally driven by our European social values of solidarity, equity, and universalism.”
Why should these be foreign concepts to the United States? We are already spending more than enough money to improve health outcomes, decrease inequalities, and deliver universal health coverage. Just think of what the European social values of solidarity, equity, and universalism could do for us.
As we celebrate Independence Day keep in mind that our American exceptionalism does not mean that we should reject solidarity and egalitarianism. Those have served our European friends very well, and at a much lower monetary cost. You would think that there would be considerable support for that.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.