Health and wealth in Europe
Authors: David J Hunter, Tessa Richards
Journal: BMJ (2008)

Next week, health ministers from all 53 member states of the World Health Organization’s European Region will meet in Tallinn to agree on a new charter. The first pan-European charter on health systems—signed in Ljubljana in 1989—focused on the purpose, goals, and core values of health systems. The Tallinn charter is more ambitious. Its aim is to spur political recognition of the economic case for investing in health systems, and to promote more effective stewardship of health resources by governments.

Expenditure on health services is still widely viewed as a short term cost, but substantial evidence now exists that it can benefit the economy. According to WHO, increasing life expectancy at birth by 10% increases economic growth by 0.35% each year.1 The view that health and wealth go together was also at the heart of the Wanless report, which argued that putting a high priority on disease prevention and effective early treatment would reduce future healthcare costs.2 Former European Union Commissioner for Health and Consumer Protection, David Byrne, argued for positioning health as a driver of economic development—an approach reflected in the new EU health strategy.3 A similar case has been made for eastern Europe and central Asia.4 Globally, the Commission on Social Determinants of Health, whose final report will appear this summer, has stated that good health enables people to participate in society, with potentially positive consequences for economic performance.5

Not all countries accept the case for investing in health. This is particularly true among those European countries with the poorest health statistics. Disparities in wealth and health within the WHO European Region are wide. WHO data from 2004 showed that gross domestic product per capita ranged from less than $2000 (£1000; €1300) in Tajikistan to over $35 000 in Norway, and that the percentage of total government spending allocated to health varied from about 4% to18%. Inequalities in mortality may be small in some southern European countries, but they are large in most countries in the eastern and Baltic regions.6 Within Europe, the United Kingdom’s record is not one to be proud of. Life expectancy of men in one of the most deprived areas of Glasgow is 54 years compared with 82 years in the most affluent areas of the town.7 Furthermore, inequalities in health are continuing to grow across Europe.8

Increased investment in health will pay dividends only if it is well spent. The charter underlines the notion that governments must improve transparency and accountability for health spending and ensure that spending is aligned effectively to agreed policy objectives. Much hangs on the nature of these policies. According to experts from the WHO European Office, some of Europe’s poorer countries—including Moldova and Kyrgyzstan—have tackled inefficiencies in Soviet era systems they inherited, which has in turn enabled them to improve the coverage and quality of their health services. Others—including Armenia, Azerbaijan, Georgia, and Tajikistan—faced such severe constraints on public spending on health during the 1990s that their systems became highly dependent on private spending. The result has been an increase in health inequalities, with more people impoverished through having to pay for health care. These countries face major challenges in meeting the objective of providing universal access to high quality primary healthcare services.9

The need to improve the performance of health systems and manage limited resources effectively is equally important in rich countries. A promising reform in Germany has seen the government provide insurers with financial incentives to enrol people with chronic disease into disease management programmes. In Switzerland, governance and funding have not been well aligned, and some cantonal governments have had to “rescue” loss making hospitals. Evidence from all countries reaffirms the importance of universal coverage, disease prevention and health promotion, organisational efficiency, high quality service delivery, and interventions aimed at tackling the social determinants of health. For each of these, health systems should measure and aim to improve performance.

Adopting a wider approach to health requires strong, joined up government, which all countries—regardless of their state of development—struggle to achieve; as Wanless concluded, health policy remains stubbornly rooted in health care and in treating the sick. By introducing the “health in all policies” approach, the European Commission has sought to institutionalise a wider approach to health in the development of public policy in all areas, including finance, agriculture, education, housing, transport, and the environment.10 It is now mandatory to carry out health impact assessments in the course of developing new community policies. Evidence on the effect of health impact assessment is limited but suggests that it can be effective in influencing decisions in sectors outside health. A great deal depends on the seriousness with which it is taken by governments.11 A key message in the charter is that health ministers must assume a more active advocacy role in getting other ministers to take health seriously.

It is easy to be cynical about the value of grandiose pan-European charters and wrong to assume that economic development will inevitably improve health outcomes and reduce health inequities. The hope behind the Tallinn charter is that it will galvanise the political will to develop more efficient and effective health systems, which are committed to narrowing Europe’s massive health and wealth divides.