Universal Health Coverage: Ensuring Equitable Access to Healthcare in the EU

1. Freedom of movement and the right to an equitable access to healthcare within the EUEIN Seminar Willy Palm, Senior Advisor Brussels, 20 February 2019

2. Overview

3. The right to health care and a renewed commitment to Universal Health coverage • Art. 25 Universal Declaration of human rights (1948): right to medical care and necessary social services • Art. 12 International Convenant of Economic, Social and Cultural Rights (1966): The creation of conditions which would assure to all medical service and medical attention in the event of sickness. • Art. 24 the UN Convention on the Rights of the Child (1989): States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services. • Article 3 Council of Europe Convention on Human Rights and Biomedicine (1997) Parties, taking into account health needs and available resources, shall take appropriate measures with a view to providing, within their jurisdiction, equitable access to health care of appropriate quality

4. The EU mandate on UHC • Art. 35 EU Charter of fundamental rights (2000): Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices.  • Council Conclusions on Common values and principles in European Union Health Systems (2006): The overarching values of universality, access to good quality care, equity, and solidarity have been widely accepted in the work of the different EU institutions. Together they constitute a set of values that are shared across Europe. • Principle 16 - European Pillar of Social Rights (2016): Everyone has the right to timely access to affordable, preventive and curative health care of good quality.

5. The EU mandate on UHC • Accessibility as core value and pillar for action • EU agenda for effective, accessible and resilient health systems (COM 2014 • Increased monitoring of health systems • European Semester: country-specific recommendations on access • Health information and knowledge: health systems performance assessment (HSPA), Joint Assessment Framework (JAF), European Core Health Indicators (ECHI), SDG monitoring • Access to health care services in another Member State • Directive 24/2011/EU on the application of patients’ rights in cross-border health care(foot in the door) Source: Commission Communication on effective, accessible and resilient health systems COM (2014) 215 final, 4 April 2014

6. Definition of UHC (univeralhealthcoverage) The goal of universal health coverage is that all people obtain the good-quality essential health services, including promotion, prevention, treatment, rehabilitation, and palliation, that they need without enduring financial hardship. It involves • Population coverage (who?) • Benefit coverage (what?) • Cost coverage (how much?) WHO Health Report (2015) Tracking universal health coverage. First global monitoring report Access and Coverage

7. Gaps in population coverage: expelled from paradise OECD/EU, Health at a Glance Europe 2018 From I. Kickbush

8. Implementation of the right to health care under the UN Convention on the Rights of the Child (2017) • Ratified by all 28 EU Member States but • only in 4 legal guarantee irrespective of nationality, residence or insurance status • In 7 all categories of children covered through regular or special schemes • In remaining 17 potential gaps

9. Universality continuum Entire population Equalityin access to care Minimum levelof care Urgent medical aid Basic benefit basket Positive selectivitymeasures Emergency care

10. How to measure financial hardship and other access barriers? How well is Europe doing?

11. Incidence of catastrophic spending ... WHO Barcelona Office for Health Systems strengthening 2018 ranges from 1% to 15% of households Heavily concentrated among poorest quintiles higher in countries that rely more on OOPs But national differences

12. More than 10% of low-income people in several EU countries report unmet health care needs due to costs, distance to travel or waiting times. % of population Policies should especially target and financially protect vulnerable groups State of Health in the EU country profiles 2017 Source: Eurostat Database, based on EU-SILC (data refer to 2015).

13. Policy matters: protecting vulnerable groups through co-pay design WHO Barcelona Office for Health Systems strengthening 2018

14. Which types of health care are leading to catastrophic spending? Stronger protection Weaker protection • Medicines: vulnerable groups + systems with weaker protection • Dental care: higher incomes + systems with stronger protection WHO Barcelona Office for Health Systems strengthening 2018

15. Other obstacles to access health care From: Expert Panel on effective ways of investing in health (EXPH) Opinion on access to health services. Access to health services in the European Union (2016) Geographical barriers Organisational barriers Waiting times Choice Quality Preferences

16. Total number of deaths in EU = 562 034 More than half a million deaths can be avoided with more timely and effective health care in the EU Colour coding (based on age-standardised rates per 100 000 population) State of Health in the EU country profiles 2017 Note: Amenable mortality is defined as premature deaths that could have been avoided through timely and effective health care. Source: Eurostat Database (data refer to 2014).

17. Limited access to primary care leads to avoidable and costly hospital admissions Over 1.5 million people in the EU wereadmitted to hospital for thesethree conditions thatcouldbetreated in primary care settings Age-standardised rates per 100 000 population OECD, Health at a Glance Europe (2016) State of Health in the EU country profiles 2017 Note: Rates are not adjusted by the prevalence of these conditions. COPD = Chronic obstructive pulmonary disease Source: OECD Health Statistics (data refer to 2015 or latest year).

18. Cross-border care as “escape route”? • Closer • Quicker • Cheaper • Better Source: Eurobarometer 2015 and 2007

19. Undue delay = powerful concept • Prior authorisation for cross-border care cannot be refused if the same or equally effective treatment (to which patient is entitled) cannot be obtained without undue delay from a contracted provider (ECJ Smits-Peerbooms 2001), taking into account • the clinical needs of the patient concerned (ECJ Müller-Fauré/Van Riet 2003). • the lack of medication and basic medical supplies and infrastructure in that Member State (ECJ Petru 2014) • the method of treatment applied as stipulated in the benefit list (ECJ Elchinov, 2010) • the comparative effectiveness of the treatment aborad (EFTA Court Rindal/Slinning 2008)

20. The future? • Common EU benefit package • European reference networks as top-layer of care accessible for all EU citizens • Joint purchasing of medical services and goods • Patient guidance through the National Contact Points • Cross-country planning of resources • EU-wide data access and sharing to ensure continuity of care • ...

21. Making sense of the evidence Thank you! – Questions?

22. 6 days of intensive academic courses • Group works • Networking • Social events www.theobservatorysummerschool.org infosummerschool@obs.euro.who.int