EU instruments for practical support to health system reforms

1. EU instruments for practical support to health system reforms Dr Loukianos Gatzoulis Unit "Performance of national health systems" Directorate-General for Health and Food Safety European Commission

2. What is available? • Guidance material • Good Practices • Tools • Technical assistance • Financing instruments

3. Guidance material HSPA group report – Integrated care I. Introduction II. What do we mean by integrated care: theory, concepts and definitions III. Building blocks, design principles and system levers for integrated care IV. Measuring the performance of integrated care V. Conclusions https://ec.europa.eu/health/sites/health/files/systems_performance_assessment/docs/2017_blocks_en_0.pdf

4. HSPA group report – Integrated care Analysis of >60 experiences, from >30 regions, with description of:Intervention and target groupsSuccess factorsTransferable elements Example:

5. Guidance material HSPA group report – Integrated care III. Building blocks, design principles and system levers for integrated care • For each building block: • Tips and suggestions • Pointing to real examples

6. Guidance material HSPA group report – Integrated care IV. Measuring the performance of integrated care Severalproposals of frameworks, domains, and indicators to assessintegrated care, with experiences from USA New Zealand WHO

7. Good practices • From the EIP AHA • Repository of practices: https://ec.europa.eu/eip/ageing/repository_en • "How To" Guide of the Reference Sites: https://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/how_to.pdf • Action Group B3 on Integrated Care: https://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/gp_b3.pdf • Case studies on integrated care: http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS3cases.html • In the HSPA integrated care report (Annex 1 + links) • From the Joint Action CHRODIS: http://platform.chrodis.eu/ • DG SANTE – MS Steering Group on “Health Promotion, Disease Prevention and Management of Non-Communicable Diseases” for implementation of good practices

8. Tools Tool for Integrated care assessment • A contract under the Third Health Programme • Timeline: January 2017 – March 2018 • Contractor: Optimity Advisors • Main deliverables: • Mapping of strategies and models of IC across the EU health systems • Proposal of assessment framework for integrated care (tool)

9. Tools The Maturity Model (from the EIP AHA Action Group B3 onIntegrated Care) • Assessing Readiness/Maturity to adopt Integrated Care • Assessing Maturity Requirements of Good Practices • Supporting Twinning and Coaching to transfer good practices

10. Tools Using the B3 Maturity Model

11. Tools Comparing "readiness" and "requirements" for a good practice

12. Technical Assistance Knowledge transfer • Seminars How to design and implement integrated care: • Lessons from early adopters in Europe • @ ICIC17, 8-10 May, Dublin • Each seminar focused on a successful example of integrated care in a European region • Northern Ireland, Northern Netherlands, Catalonia, Scotland, the Basque Country, Norrbotten

13. Technical Assistance Twinning “Twinning” for good practice transfer • Started within the EIP AHA context • Small financial support to regions to kick-off bilateral actions for transfer of knowledge and (elements of) good practices • Example: Basque Country Riskstratification • Three twinnings as originator Region: • New Aquitaine • Scotland • Liguria Region • One twinning as adopter Region : • Scotland Patientempowerment

14. Technical Assistance Twinning First lessons: Twinning plan

15. Technical Assistance Twinning First lessons: requisites for adopters

16. SRSS/SRSP Technical Assistance Structural Reform Support Service • A service of the European Commission with a mandate to: • Support the preparation, design and implementation of growth-enhancing reforms • Direct provision of support and coordination of the support provided by the Commission • Special assignments: Support for the management of migration in Greece and support for Cyprus settlement • Focus on implementation and support on the ground - covering all reform stages and challenges • Focus on country-specific perspective; tailor-made support

17. SRSS Technical support to Member States • Support provided upon request from the MS • European Semester • Union Law • EU policy priorities • Better use of EU funds Economic governance processes • Conditionalities Adjustment programmes MS reforms at their own initiative • Other growth-enhancing reforms to achieve sustainable investment, growth and job creation • Ownership of the reforms remains with MS

18. Structural Reform Support Service (SRSS) • The Structural Reform Support Service, SRSS, is a service of the European Commission with a mandate to: • Support Member States with the preparation, design and implementation of reforms in the health sector, and many other policy areas • Focus on tailor-made support, on the ground • Steer and coordinate technical support provided by the Commission • With a proposed budget of EUR 142.8mn (2017-2020), the SRSP will be a significant factor for future SRSS engagements with Member States. • SRSS Facts • Created in July 2015; • Offices in Brussels, Athens and Nicosia; • 130+ staff. Introducing the Structural Reform Support Service How it Works Types and Providers of Technical Support At the request of a Member State, SRSS: Engages in a dialogue to discuss technical support needs; Puts in place a specific technical support plan together with the Member State; and SRSS provides financing for the technical support and coordinates the necessary expertise. SRSS works with TA providers, such as Experts from Member States administrations; International organisations; Private firms, including consultancy firms; and Individual experts. Together with in-house Commission expertise, these providers ensure the right assistance is delivered where it is needed.

19. SRSP budget Financial envelope: twolayers SRSP "dedicated" envelope: EUR 142.8 million (to be split by annual allocations) "Additional" budget: voluntary contribution from MS – transfer of resources under Article 25 ESIF • extended to all MS (programme countries or not) • follows ESIF rules (both procedure and eligibility) NOTA BENE: NO CO-FINANCING BY MS (COM DIRECT MGMT)

20. SRSP process Request for support (this year two budget cycles: 30 April for 2017; and 31 October for 2018) • One request encompassing all MS support needs • Template + instructions for MS (guidance) • Purpose: to enable MS to prioritise and to provide information relevant for the assessment by COM of the request for support COM decisional process • General principles:transparency, equal treatment, sound financial management • Criteria for analysis: urgency, breadth and depth of problems identified, support needs in relevant policy areas, socio economic indicators, general administrative capacity of MS Contacts: SRSS Labour Market, Health and Social Services Unit: GéraldineMahieu, Head of Unit, Geraldine.MAHIEU@ec.europa.eu, Tel: +32 2 29 63796 / Christoph Schwierz, Deputy Head of unit, christoph.SCHWIERZ@ec.europa.eu, Tel: +32-2-296.07.52

21. Financing Instruments EU Health Programme 2014-2020 • financial instrument for policy coordination in the area of health • supporting collaborative actions between • 28 EU Member States • Iceland, Norway • Serbia & Moldova • to find solutions to commonhealthconcerns

22. Health Programme 2014-2020 The objectives

23. Health Programme Examples of outputs Joint Action CHRODIS http://www.chrodis.eu/ Repository of Good practices

24. Health Programme Examples of outputs Project ACT http://www.act-programme.eu/ Guidance material

25. Health Programme Examples of outputs Project SCIROCCO http://www.scirocco-project.eu/ Maturity Model Tool

26. Research and Innovation Climate change adaptation, risk prevention Employment and mobility, incl. AHA ICT, incl.e-health Environmental protection and resource efficiency Social Inclusion, incl.access to healthcare Competitiveness of SMEs Sustainable transport Education, training and LLL Low carbon economy Better public administration Structural Funds ESIF Thematic Objectives

27. Commission guide on healthinvestmentsthrough ESIF One of the guiding principles: Moderating the use of hospital care in favour of primary and out-patient care, operating a transition from institutional- to community-based services Investment possibilities in primary care: • As part of the transition from hospital-based to more community-based care, support reorientation of specialist to general practitioners, to strengthen healthcare in primary care settings; • Increase pool of primary care human resources within education and training programmes; • Strengthen and support primary and secondary prevention to reduce the development and onset of major preventable chronic diseases; • Promote innovative integration of care, based on improved communication and coordination, across the levels of health care (incl. primary); • Strengthen ambulatory services and primary care, via prevention and monitoring, including telemedicine and telecare solutions. Available at: http://ec.europa.eu/health/health_structural_funds/docs/esif_guide_en.pdf

28. "Effective use of European Structural and Investment Funds for health investments in the programming period 2014-2020" http://esifforhealth.eu/Mapping_report.htm

29. ESIF Mapping Report • What information you will find: • Overall assessment – summary of the mapping results • Main health-related areas of investment (direct and indirect) per MS and OP, for programming periods 2007-13 and 2014-20 • ESIF health-related specific objectives in all MS • Source of funding (the list of all OPs) • Financial allocations as regards some types of health-related investments (4 "categories of intervention") • Contact data for relevant national/regional Authorities

30. Overview of the Mappingresults Scope of investments 2014-2020: • Deinstitutionalisation and community-based care • Active and Healthy Ageing • Improving access & quality of health care services • Health promotion and disease prevention • Education of medical staff • E-health • Medical R&D • Public administration and health services • Workplace health & safety • Health tourism • Risk prevention and disaster preparedness Scope of investments 2007-2013: • Health infrastructure • Health promotion and disease prevention • Education of medical staff • E-health • Medical R&D • Public administration and health services • Workplace health & safety • Health tourism

33. Examples of actionsidentifiedwithin the "Mappingexercise"

34. ESIF Investments in primary careexamples • (Estonia) Improving access to primary health care • Investments in modern, regionally accessible and optimal primary health care and acute care networks offering high quality and sustainable health care services • Development of competency centres (pathology, psychiatry, children's clinic, ear clinic), • Early detection of alcohol abuse, counselling, alcohol addiction treatment and internet-based counselling will be provided to alcohol abusers and their relatives. • (Greece) E-health investments - To support operation of the Primary Health Care Information System, development of Electronic Patient File

35. ESIF Investments in primary careexamples • (Croatia) Improving access to primary and emergency health care - Investments in primary health care infrastructure and equipment, improving emergency health care services, with focus on isolated and deprived areas - Acquiring the medical equipment and vehicles necessary to provide primary health care. • (Hungary) Improving health services - Modernization of local government’s primary health care services - Education and training programmes aimed at providing the health sector with qualified professionals including primary and specialized care workers, family doctors and physicians

36. ESIF Investments in primary careexamples • (Latvia) Improving access to primary health care • Development of infrastructure; Development of planning, including access to health services and infrastructures, patient flow planning, health promotion planning, health care level selection criteria and guidelines for clinical health care • (Malta) Primary care strengthening - Investment in infrastructure for primary health care services - Optimisation of capacity in the provision of health services and establishment of a more sustainable primary health care system - Development and / or modernisation of primary health care infrastructure, improvement of the regional health facilities in Gozo (aimed at providing services to ageing population)

37. Conclusions from the Mapping • Health is a relevant issue both for ERDF and ESF (though no health-OP) • While all MS invest in health through ESIF, such investments prevail in the "new" Member States • Less investment in health infrastructure in 2014-2020 as compared to 2007-13, but more focus on community-based care, access to care, active and healthy ageing. • Overall combined investment 2014-2020 in health infrastructure, eHealth, access to health and social services, AHA: more than ~9 billion EUR • Figures for investment in other areas that include investment in health (health R&I, health SMEs, health workforce training, institutional capacity building for health authorities, etc.) cannot be given at this stage (for later evaluations)

38. http://s3platform.jrc.ec.europa.eu/ Mapping ICT investments in Operational Programmes

39. http://s3platform.jrc.ec.europa.eu/ Mapping ICT investments in Operational Programmes

40. Where to find information about concrete project possibilities? Contact authorities responsible for a given OP implementation Contact details under the link: http://ec.europa.eu/regional_policy/en/atlas/managing-authorities/ Or in the Mapping: http://esifforhealth.eu/pdf/Mapping_Report_Final.pdf

41. NEXT STEP: DG SANTE (B1) tender project: ESIF support in the area of health: building knowledge and capacities for monitoring and implementation, supporting innovation and effectiveness "Thematic blocks": Improving access to healthcare (with emphasis on primary and preventive care, especially for vulnerable groups); Support to reform processes towards effective and resilient health systems: 2a) Deinstitutionalisation measures for people with disabilities, mental health problems, older people and children deprived of parental care; 2b) transition from hospital to community-based care i.e. primary/integrated care; 2c) investments in healthcare facilities efficiency and sustainability, in particular in hospitals. Uptake of e-health/digital solutions, in particular related to the Digital Single Market and the interoperability of these solutions within and across Member States; Research and innovation in health and lifesciences. Active and healthy ageing, healthy workforce, health promotion and disease prevention; Health workforce (including i.a. training, lifelong learning, workforce planning, retention).

42. More information ESIF: http://ec.europa.eu/health/health_structural_funds/policy/index_en.htm http://esifforhealth.eu/pdf/Mapping_Report_Final.pdf http://ec.europa.eu/regional_policy/en/policy/what/investment-policy https://cohesiondata.ec.europa.eu Contact: sante-consult-b1@ec.europa.eu

43. The Investment Plan for Europe & the European Fund for Strategic Investments (EFSI) Investment Plan for Europe Mobilise finance for investment • European Fund for Strategic Investments (EFSI) • Cooperation with National Promotional Banks Give investment advice • European Investment Advisory Hub (EIAH) • European Investment Project Portal Create an investment friendly environment • Improving the regulatory environment • Structural reforms Aim: to mobilise at least €315 billion in investment across the EU

44. European Fund for Strategic Investment (EFSI) > 10 major health projects granted EFSI support > 500mEUR • Primary care centres (IE) • Medical equipment & care provision(IT) • Medical research (ES, UK, IE, DE) • Healthcare infrastructure facilities reconfiguration (UK, AT, PL, RO) + 2 multi-sector infrastructureprojects incl. health The main channel to deliver on the Investment Plan for Europe New EU financialinstrument(loan-based) – EFSI is a guarantee on lending granted bytheEuropeanInvestment Bank (EIB) and theEuropeanInvestmentFund (EIF – forSMEs) - addressingmarketfailures and sub-optimalmarketsituations Budget (all fields, accross the EU): 21bn EUR, now proposed extension to 33,5bn (EFSI II) to mobilise private financing up to 500bn up to 2020; 183bn investment already committed (May 2017) Priorities in health: • New models of infrastructure (e.g. primary care) • R&D (incl. medical devices & products) • eHealth and new technologies • Health workforce • SMEs and social enterprises

45. EFSI and the Health Sector (I) • This is where EFSI can play an important facilitating role. With EFSI acting as a guarantee against first losses, the Investment Plan for Europe offers an opportunity for the public and private sectors to join together in health investments that are deemed high-risk.

46. EFSI and the Health Sector (II) • New facilities, such as primary care and community care centres that will constitute the "hubs" for transformed care services – "infrastructure" investment • ICT systems that can support the back-end organisation, as well as the implementation of integrated care pathways and decision support systems - "infrastructure and medical technology" investment • New service models and new technologies, such as ICT devices and apps (eHealth and mHealth), which can facilitate remote management of chronic patients at their homes, as well as empowering them to engage in self-care – investment on "soft" elements with medical technologies embedded • Capacity-building and "system re-organisation": education of the care workforce in new roles and associated skills (for example, new roles of "care coordinators"), new care pathways, new governance models, new financing and reimbursement models (more linked to performance, quality and coordination) – investment on "soft" elements of organisational change

47. Case Study:Irish Primary Care Centres PPP • The project comprises the design, build, finance, maintenance and facilities management of 14 Primary Care Centres located throughout Ireland. • The project is in line with the Irish Government Health Reform to reduce reliance on acute sector and is part of the national programme of establishing around 300 primary care centres, 14 of which are procured as a PPP (the project).

48. Case Study:Irish Primary Care Centres PPP The Promoter • Ireland, represented by the Minister for Health, acting by its agent, the National Treasury Management Agency (NTMA) during the construction phase • As of the service commencement, the agent for the Minister for Health will be the Health Service Executive (HSE) • HSE defined the Project scope, the output specifications and the budget for the Project • NTMA is the statutory financial advisor to State authorities for all public investments and it has full responsibility for delivery of most of Ireland’s PPPs (except transport sector)

49. Case Study:Irish Primary Care Centres PPP Conclusions / Summary • The Project will have a strong demonstration effect for future heath care projects to be financed in the country, but also potentially for primary health care projects to be financed across Europe. • The Irish government specifically requested the Bank to support the project. • The improved project funding costs due to EIB presence will be passed through to the public sector by lowering the availability payment due by the public sector to private operators. • The project will facilitate the delivery of accessible, high-quality integrated primary care services aimed at improving the health and well-being of the local population. There is a clear economic benefit because patients can return to the workforce and be more productive as a result of better clinical outcomes and shorter waiting times for treatment.

50. The European Investment Advisory Hub Investment Plan for Europe Support investment in the real economy …through the European Investment Advisory Hub (EIAH) and the European Investment Project Portal Create an investment friendly environment …through improvements in the European regulatory environment (SRSS, CMU) Mobilise EUR 315 bn of additional financing …through the European Fund for Strategic Investments (EFSI)