While such challenges are global, the European region is at the forefront of many demographic and socio-economic shifts that impact health care systems. This article highlights recent reforms in Europe that have sought to reduce barriers to universal, sustainable and adequate health coverage. It focuses on initiatives to expand coverage in Ireland and Romania, organizational reforms to improve service accessibility, affordability, equity and quality in Croatia and Finland, and reforms to improve access to and adequacy of care services in Austria, Germany, and Slovakia.

Context

Achieving universal health coverage (UHC) is a major global priority under the Sustainable Development Goals (target 3.8) (UN, 2015) as governments work to ensure that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship (WHO, 2023a). The path to UHC is complex as is it involves the financing and organization of well-defined, accessible, quality services in a multi-stakeholder environment and the development of an appropriate health infrastructure, along with an effective health workforce. Despite the relatively mature and comprehensive nature of the region’s health care systems, UHC is not yet a universal reality, and policymakers in Europe continue to work to reduce barriers and promote equitable access to health care for their populations (ILO, 2021).

In addition to addressing access challenges to meet health and well-being needs across the life cycle, policymakers are also working to ensure that health care systems are resilient, sustainable and adaptive. Systems must be able to respond to shocks, such as the COVID-19 pandemic, and to adapt to evolving health care needs, the increasing cost of health care linked to population ageing, the rise in chronic conditions and other demographic changes.  

The growth of health care costs (OECD, 2022) can drive up both public expenditure and individuals’ out-of-pocket payments. The latter can be an important barrier to access care. This has a direct effect on efforts to achieve UHC, as the range of services covered and the degree of cost-sharing, contribute to how comprehensive health care coverage is in any given country (OECD, 2019).

In Europe, such concerns for health sector financing are particularly important. Within the European Union (EU), spending on health care in 2022 was 8.1 per cent of the gross domestic product (GDP) (Eurostat, 2023). Of this, approximately 15 per cent was borne by patients through out-of-pocket spending (OECD, 2022). In some countries in Eastern Europe and Central Asia, more than half of health spending was paid out of pocket, rising above 70 per cent in some cases (European Observatory on Health Systems and Policies, 2022a).

To counteract financing pressures, many countries are seeking to increase the efficiency and cost-effectiveness of their systems, while also ensuring that health care costs do not present a barrier to access, particularly for poorer households and those who need to cover the costs of long-term treatment.

As well as financial concerns, geographic and socio-economic barriers may limit efforts to achieve UHC. Uneven distribution of health infrastructure and personnel can impede access to care for rural and remote communities, even when affordable and well-functioning health systems exist at the national level. Health is also impacted by a wide range of economic, environmental, and social factors. These include socioeconomic status, gender and ethnicity, which may limit access to care and perpetuate health inequalities (WHO, 2021b).

In Europe, the high coverage of essential health services, has further increased over the past decade (WHO 2021a). Within the EU, most countries have achieved universal or near-universal coverage of at least a core set of services, usually including consultations with doctors, tests, examinations, and hospital care (OECD, 2022). In other parts of the region, especially in Central Asia and the Caucasus, many countries provide a universal package of benefits through government-run health facilities.

At the same time, some parts of the region have significant coverage gaps (WHO, 2023b). In addition there are  notable differences in access to health care and unmet health care needs along social and geographic divides (European Parliamentary Research Service, 2020). Highlighting the importance of coverage and access to care in achieving UHC, the European Commission lists reducing health inequalities among the main priorities for health care reforms in the EU (European Commission, 2020).

Finally, the COVID-19 pandemic underscored the need for resilient health care systems capable of preparing for, confronting, and recovering from shocks. The pandemic exposed many structural inequalities within existing systems, as well as the importance of sustained investment in the workforce to ensure a sufficient numbers of doctors, nurses, and other health-care and long-term care personnel (Tessier, 2022). Resilience also involves the ability to adapt to changing needs, such as more accessible mental health services. This is a priority for policymakers in Europe, as the resilience of health systems reflects a commitment to promoting health and well-being, fostering innovation, and ensuring health care systems remain responsive and adaptable in the face of challenges.

Recent reforms

Across the region, governments have sought to respond to these challenges with reforms that address the coverage, accessibility, quality, and efficiency of health systems.

Reforms to extend coverage  

Ireland extends access to free primary care

In 2023, Ireland expanded access to general practitioner (GP) care, via its GP Visit Card programme, which provides universal and means-tested access to free primary health care. The expansion is the largest of its kind in the country’s history and aims to ensure that there is no cost barrier to accessing health care (Department of Health, 2023).

Under Ireland’s health care system, all legal residents can access a limited package of health care services, while young children, elderly people, and low- to moderate-income individuals are eligible for a larger package of benefits. As a result of the 2023 GP Agreement (Department of Health, Health Service Executive and Irish Medical organisation, 2023), the income thresholds for means-tested benefits under the GP Visit Card programme have been significantly increased to match the median weekly income, and are now 37 per cent  higher for all legal residents (from 304 to 418 Euros (EUR) for persons living alone; from EUR 441 to 607 for couples and families; and from EUR 271 to 373 for single persons living with their family) (Citizens Information, 2024). The reform also expands universal access by raising the cut-off age for children from younger than 6 years to younger than 8.  To ensure the adequacy of services provided, the initiative also provides support for training additional GP physicians.

The government estimates that an additional 78,000 children and 430,000 adults are now eligible for the GP Visit Card programme due to the reform. Furthermore, individuals with lower incomes may also be eligible for Ireland’s Medical Card programme, which provides a wider range of free medical services. As a result, over half of the population of Ireland now has access to free primary health care (Department of Health, 2023).

Romania integrates domestic workers into national health insurance system

In January 2024, Romania implemented Law No. 111/2022, introducing its household activities voucher programme. In doing so, it encourages formalization and helps integrate domestic workers into the country’s social security system, including the health insurance system.

The programme promotes the voluntary use of vouchers rather than cash for salary payments of occasional domestic workers. Vouchers are worth 15 Romanian leu (RON) (equals EUR 3) and can be purchased by employers from various government sources. Domestic workers may then cash in vouchers and, by doing so, are covered by health insurance providing free access to a basic package of health services. This enrollment is maintained if the worker cashes in at least 85 vouchers per month. Use of the voucher system is incentivized for employers through an entitlement to 75 free vouchers a year for employers purchasing more than 600 vouchers a year, and for workers through reductions in tax and social contributions on income earned in vouchers.

The Romanian government estimates that 16–38 per cent of the economically active population perform some kind of informal work (European Commission, 2022), which includes a large proportion of domestic workers (Romanian Parliament, 2021). The new programme seeks to provide greater job security, formalization, and access to health care for these individuals. The government estimates that 20,000 domestic workers will enroll in the social health insurance system by the end of 2024, as a result of the reform (Romanian Parliament, 2021).

Reforms to the organization and delivery of health care services

Croatia to improve efficiency and accessibility of health care services

In April 2023, Croatia began the implementation of its Law No. 582 of 2023 amending the Health Care Act, (71-10–01/1–23–2), undertaking a significant reorganization of its health care system. The reform aims to increase the system’s efficiency, standardize waiting times, and improve access to health care services across the country.  

Like many countries, Croatia has an uneven geographical distribution of health care infrastructure, with higher levels of unmet medical needs in rural and island communities and duplication of services in urban areas (OECD/European Observatory on Health Systems and Policies, 2023). To address this, each county will now have one health centre, which provides general care as well as psychological, speech pathological and other specialist services, with additional branches serving island communities. The reform also centralizes public procurement and transfers the right to establish general hospitals to the central government. Local governments retain the right to influence the appointment of hospital leadership (HRT News, 2023).  The maximum patient co-payment per health bill increased from EUR 265 to 530 (Croatian Parliament, 2023).

Continuing the trend in health reforms in Croatia in recent years, the restructuring is focused on making health financing more sustainable (European Observatory on Health Systems and Policies, 2022b), particularly given that the public share of health expenditure is higher than other countries with comparative levels of health spending (OECD/European Observatory on Health Systems and Policies, 2023). It also seeks to narrow health inequalities through improving the distribution and accessibility of health care services.

Finland undertakes its largest-ever reform of health care and social services

In 2023, Finland implemented the largest-ever reorganization of its social services and health care system. Under the Law No. 612/2021 on the organization of health care and social welfare, health care and social services are now consolidated into new welfare counties, with the aim of enlarging risk and financial pools, and standardizing the delivery of services across the country (Ministry of Social Affairs and Health, 2023).

Previously, health care and social services in Finland were administered at a local level, managed by Finland’s 332 municipalities and municipal associations. Under the reform, administration of these services has been transferred to 21 new welfare counties, plus the City of Helsinki. Funding for the new welfare regions will come largely from central government, with a small amount covered by user fees. The reform also seeks to improve patient outcomes and reduce fragmentation in the health care system by coordinating medical, social, and psychological services and promoting better integration between primary and specialized care (Finnish Government, 2021).

Overall, the reform, which had been debated since 2005, has sought to address a number of challenges facing the Finnish health system. The previous, highly decentralized administrative structure of the health system presented obstacles for governance and coordination and resulted in inconsistent provision across the country (European Observatory on Health Systems and Policies, 2023). The reform’s focus on strengthening the financial basis of service delivery, guaranteeing equal access to health and social services, and reducing inequalities in health and well-being represents a significant effort to address challenges related to changing health needs, increasing health costs and access to health care in Finland (Kangas and Kalliomaa-Puha, 2022).

Reforms to care services

Going beyond UHC, several other reforms in Europe have aimed to improve the accessibility and adequacy of care services.

In Austria, the care allowance (Pflegegeld) paid to individuals with severe psychological disabilities and dementia was increased in 2022 to cover an additional 20 hours of care per month. A means-tested care bonus (Angehörigenbonus) was also introduced for caregivers with income below EUR 1,500 a month (Parliament of Austria, 2022). The bonus is paid to individuals who have left employment to attend to a family member who requires full-time care (of more than 160 hours of care per month) (Federal Ministry of Social Affairs, Health, Care, and Consumer Protection, 2023). In Germany, as part of a 2023 reform to the long-term care system, cash and in-kind benefit amounts for home and ambulatory care were each increased by five per cent and will be automatically adjusted in line with prices in 2025 and 2028. In addition, the duration of the Support Allowance (Pflegeunterstützungsgeld), which is paid to individuals who must miss work to care for a relative, was extended to up to 10 days per calendar year (Federal Government, 2023).

In Slovakia, a new care benefit was introduced in 2021, allowing individuals caring for a sick relative to receive social insurance benefits through the existing sickness insurance programme. Carers are now eligible to receive up to 90 days of cash benefits that cover 55 per cent of lost wages while providing home or palliative care (Article 39 of Law 461 of 2003 on social insurance).

Final remarks

This article highlights recent reforms in Europe that have sought to reduce barriers to UHC. The above experiences show different ways that countries have worked to continuously adapt their programmes, related policies and legislation to address evolving needs and changing circumstances. They show that realizing UHC will always be an ongoing process and highlight the interconnection between health and other areas of social security, along with the importance of administrative structures in ensuring quality service delivery.

Reforms to improve the coverage, accessibility, quality, sustainability and efficiency of health systems contribute to a country's overall resiliency. Progress towards UHC establishes a robust foundation for the entire population's health and well-being and enhances countries' ability to detect, respond to, and recover from crises, whether they be pandemics, natural disasters, or economic downturns.

Enablers include efforts to extend coverage and access to health care, as seen Ireland, as well as broader initiatives like the one seen in Romania, which encourages formalization and integration in the social security system as a whole, including health care. These reforms involve building an effective administrative strategy and regulatory framework, as well as coordination with other areas of the social security systems, as highlighted in the ISSA Guidelines on Administrative Solutions for Coverage Extension (ISSA, 2022). In particular, Parts A and B provide tools for institutions to support these efforts.

The organizational reforms highlighted in Croatia and Finland show the importance of continuous improvement, a key component of the ISSA Guidelines on Service Quality (ISSA, 2019). Here, systems sought to further consolidate health care services, with the aim of improving efficiency and reducing internal disparities in access to care.

Finally, the reforms in Austria, Germany and Slovakia, related to care services, underscore the importance of the interconnection between UHC and broader care and social services for those in need of long-term care services. Reflecting this commitment, in 2022 the ISSA published a special double issue of the International Social Security Review Review (International Social Security Review, 2022) and the joint ISSA-ILO Working Paper “Long-term care in the context of population ageing: a rights-based approach to universal coverage” (Tessier, De Wulf and Momose, 2022), both of which examined the challenge of extending affordable and adequate access to quality medical and social care for the world’s growing elderly population.

References

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