Include,invest,innovate: health systems for prosperity and solidarity

In 2008 the city of Tallinn, capital of Estonia, welcomed representatives of 53 Member States of the European Region of the World Health Organization to produce an ambitious vision for the future of health systems. The result was the 2008 Tallinn Charter, ¹ in which European governments committed to three sets of mutually reinforcing relationships, each based on a rapidly growing body of evidence. ² Better health fosters economic growth, ³ while increased prosperity makes healthier choices easier. Economic growth provides money for health care, while integration of research with health care fosters innovation and growth. ⁴ Health services improves health, for example by reducing deaths amenable to health care, ⁵ while better health reduces the need for care.

The concept was great, the commitments welcome, but the timing was terrible. A few months later the financial crisis struck, with some countries testing the arguments underpinning the Tallinn Charter by doing the opposite. Austerity measures included disinvestment in health and health care, with those making the deepest cuts suffering the greatest declines in economic performance. ⁶ By doing so they created a number of natural experiments whose results strengthened even further the evidence that had underpinned the discussions in Tallinn.

Ten years later, in 2018, the WHO Member States reconvened in Tallinn. The financial crisis is now largely over, although the consequences, in foregone investment, remain apparent in many countries. Some governments have moved away from years of fiscal consolidation and are renewing investment in health systems. Some are also developing industrial strategies that prioritize the health sector. And the wider societal benefits of better health are increasingly recognized as governments implement measures that, even a few years ago, would have been unimaginable, such as sugar taxes. ⁷

The 2018 Tallinn high-level meeting captured this spirit of renewed optimism. Entitled ‘Health Systems for Prosperity and Solidarity: Leaving no-one behind’ it reiterated the messages from a decade earlier, but with a renewed emphasis on inclusiveness. It recognized that not everyone in Europe’s increasingly diverse societies had benefited to the same extent from the progress that had been made, such as a two-year gain in life expectancy across the region. New evidence demonstrates that European health systems, while in theory providing universal health care, leave many people, and especially the poorest, behind, with many facing large out of pocket payments and, in too many cases, catastrophic expenditure. ⁸ There are also challenges ahead. Some are political, including the unwillingness of some governments to accept and integrate migrant populations. Some are health-related, such as the growing numbers surviving with multimorbidity, a consequence of successes of health care and ageing populations, or antimicrobial resistance. The outcome statement from the conference notes that ‘Some of the attributes we assign to European health systems – solidarity, equity, and universalism – are now at risk’. Yet, at the same time, there are opportunities. All countries present have signed up to the Sustainable Development Goals. Among them are commitments to universal health coverage, to equity, to the building blocks of health systems and to economic growth, all core elements of the Tallinn Charter. The key question is how this can be achieved?

The conference focused on three broad imperatives, Include, Invest and Innovate. Inclusion requires that countries take steps to measure and address inequalities in financial protection and unmet need. This is now happening in the European Union, with recent work showing how such measures can be used for benchmarking and incorporated into health systems performance assessment. ⁹ Access to health care should be extended to the entire population. The public health and economic arguments for doing so are clear and some governments are now reversing recent restrictions. ¹⁰ However, those present also agreed that solutions should take full account of national context, recognizing that the reasons for impaired access and out of pocket spending are often complex.

Investment includes ensuring that money is available to provide inclusive services, and in particular to protect the poorest in society. This has implications not only for how much money is raised but also how it is spent. Health expenditure will inevitably involve redistribution. A universal service should not be paid for primarily by the poor, for example through user charges or regressive indirect taxes. ¹¹ This will require a mature debate between health and finance ministers.

The final element is innovation. Modern health systems require new knowledge, including medicines, technologies and models of care. However, especially for the last of these they must be open to new ways of doing things, something that can be challenging where there are rigid rules and hierarchies.

What does this mean for health services and systems research? First, the research community should promote improved measures to compare health systems performance, so that heads of government see it just as natural to discuss how their health systems are working as they do with respect to their economies. Much progress has been made, for example by the methodological advances incorporated in the Healthcare Access and Quality Index ¹² developed by the Institute for Health Metrics and Evaluation and the work on financial protection described above, ⁸ but more work is needed to develop ways to capture other dimensions of performance.

Second, more can be done to exploit Europe as a natural laboratory, describing, evaluating and comparing the many new models of care, while looking specifically at those contextual factors that facilitate or impede the international exchange of ideas. This can draw on the extensive work undertaken over two decades by the European Observatory on Health Systems and Policies. ¹³

Third, we need a much better understanding of the two-way relationship between innovation and health systems, recognizing that the contribution by government agencies, including those delivering health care, is much greater than is often realized. ¹⁴ We also need to find ways to spread beneficial innovations in health systems rapidly, often in the face of institutional inertia, while ensuring that technological advances narrow rather than widen the health divide.

While the many challenges facing Europe and European health systems are undeniable, the Tallinn meeting concluded with a clear sense of optimism that it had at least produced a direction that will help governments prepare for the challenges ahead. Above all, within the 2030 Sustainable Development Agenda, Europe’s member states re-committed to orient their health systems around the social values of solidarity, equity and participation, the legacy of the Tallinn ¹ and its predecessor, the Ljubljana ¹⁵ Charters. The meeting concluded that for people in Europe to have equal access to health care and public health services, health systems need to be inclusive, benefit from sustained strategic investment and innovate to deliver people centred services.