By Vladimir Sergeevich Gordeev and Dina Balabanova
While the countries of the WHO European region are extremely diverse in many ways, they have developed a shared vision of a ‘European road’ to universal health coverage (UHC) based on equity, financial protection, and a focus on primary care. However, what given the diversity of these 53 countries, their pathways to UHC have already taken very different roads.
This is a pivotal moment for Europe. As Dr Hans Kluge takes up his new role as WHO Regional Director for Europe in 2020 – it presents a great opportunity for him to address the existing disparities across the continent. We call on him to make an explicit commitment to support and invest in social scientists to generate evidence for policies and programs in their context.
A European challenge?
While Europe, overall, has achieved high levels of service coverage on a par with OECD countries, some parts lag far behind. UHC in many of these countries has been established for a number of decades, but it has taken considerable time (e.g. 130 years in Germany and 75 in Luxembourg). And even in countries that have well-performing systems, some groups, such as those working in the informal sector, migrants, displaced persons, refugees, persons with disabilities, and homeless people remain effectively excluded.
The challenges are compounded by the growing numbers fleeing emergencies and disasters, which Europe collectively failed to address effectively, whereby government in several countries restricted even further already limited entitlements of undocumented migrants (i.e. France, UK and Hungary).
Some countries have invested in e-health and e-governance and move towards ‘Health 3.0’ with Estonia being a trailblazer, where individual health accounts will bring together medical and personal health data, others still struggle with a lack of practice and culture of care based on evidence (pdf) and non-conducive legislative environment (i.e. former Soviet Union countries).
Progress towards UHC in the European region has in places been precarious given the adverse political and economic pressures, austerity measures, the rise of populism. A case in point is the expected disastrous consequences for patients and public health services on both sides of the English Channel with no deal or hard Brexit. This suggests a clear need for health systems strengthening in the countries of Europe, taking advantage of the many opportunities for learning from each other.
Closing the evidence-to-policy gap
While their individual needs may differ, HSG’s advocacy Messages and Asks are relevant to all European countries. First, the imperative to generate research and integrate contextualised evidence in the design and implementation of key policies is more important than ever. The question is how this can be achieved. Europe has a strong health policy and systems research (HPSR) community, although it is concentrated in the high-income countries of the region. This needs to be addressed if the whole region is going to achieve UHC.
Measures that can close the evidence-to-policy gap remain central to the health policy debates in the European region. If they are to enhance uptake of policy, countries will need to provide adequate and sustained investment into capacity building for policymakers, researchers, health practitioners and patients, ensuring access to platforms for exchanges and learning. Countries have benefited from close cooperation with the European Regional Office of WHO and other local and international networks and evidence brokers (e.g. UHC2030, European Observatory on Health Systems and Policies, Alliance for Health Policy and Systems Research).
However, a sustainable path towards UHC will require a further emphasis on cross-learning and sharing experience from the implementation of national health strategies (across Europe and globally), with policy dialogues offering an opportunity to drive evidence-informed decision-making. Inclusive dialogues should be held (representing national bodies but also practitioners and the public) so that each voice is heard, and diverse perspectives are taken into account. Achieving this will require fundamental changes: redesigning policy spaces, shifting power towards frontline actors (those who deliver and use services), who often remain less visible.
A balancing act
As such, committed sustained funding for HPSR capacity building that takes account of the specific context and strengths but also targets the gaps is required by all member states, and with even higher urgency in the Eastern European and the former Soviet Union countries. The latter, besides experiencing geographical and financial barriers and gaps in access to high-quality primary care, lack tradition of evidence-based medical practice and have a dearth of legal or administrative mechanisms to support its implementation.
HPSR researchers and implementers from less connected institutions, especially where English is not the main language and HPSR capacity is still weak, need additional support; they frequently lack access to up-to-date international literature or opportunities for continuous medical education, relevant bodies of evidence and peer networks, including local and international knowledge exchange platforms such as the Sixth Global Symposium for Health Systems Research, due to lack of support by governments and international agencies.
Moving towards UHC the European counties should:
- Continue to extend coverage to the hard-to-reach and most vulnerable groups, designing equitable financial and delivery models and social protection provisions, and promoting community involvement in universal health systems;
- Secure enough political will to reinforce the learning capacities of the health system to support UHC through promoting evidence uptake, financial support for continuous and sustainable HPSR capacity building; and regional and global cross-learning;
- Support transition to integrated, people-centred care, as well as innovative digital technologies with a potential to improve the quality of service delivery, ensure resilience and empower healthcare users and provider.
Overall, there is a wealth of good practice and experience in the European region (pdf), but also significant disparities between countries in terms of health systems resources, reach, and capacity to absorb evidence. The European road to UHC by 2030 requires not only shared values but shared evidence on successful strategies, learning from each other, e.g. how to improve coverage, inclusion and financial protection. Acting through partnerships and joint policymaking across sectors is vital. The Asks to the participants of the UN General Assembly – embedding evidence and investing in people to achieve ‘health for all and leave no one behind’ – remain more relevant than ever.
Image credit: Yannis Kolesidis, Freedom House/Flickr. https://flic.kr/p/xs3nwJ