Interview with Josep Figueras: Focus on health gain to draw the virtuous circle from efficiency to equity

20th May 2015

While increasing efficiency can help reduce inequalities, it is not necessarily so. Meanwhile the reverse case – that addressing inequalities makes for more efficient health systems – may not even be considered. The key to untangling this nexus is to focus investment and reform on health gains, says Josep Figueras, Director of the European Observatory on Health Systems and Policies

In an ideal world, efficiency and equity in health care are self-reinforcing. But if efficiency is inappropriately defined, they can become opposing forces.

“Research shows that if you address inequalities by increasing access for less-privileged sectors of the population, improving access to primary healthcare and prevention services for example, there will be overall savings in the burden of treating disease,” says Josep Figueras, Director of the European Observatory on Health Systems and Policies.

However, the extent to which more efficient systems lead to more equitable systems is moot. “The lesson learned during the financial crisis was that it depends on how you define efficiency,” Dr Figueras says. “Cost-containment does not equal efficiency.”

Furthermore, health systems may make efficiency improvements but not save money. “You may be getting more value from resources, but not containing costs,” says Dr Figueras.

While the final reckoning of the impact of recession-driven cost containment on mortality and morbidity is yet to be made, it is evident that it has resulted in greater inequity, with rationing and co-pay having the greatest impact on the poor. “In some countries, you see the vulnerable people, the unemployed, getting pushed out of the system,” Dr Figueras notes.

For this reason, he sees it as “very important politically” that one of the key messages to policy makers from the upcoming Riga health conference is that, “Success in cost containment does not necessarily equate to efficiency and in some instances in may result in the opposite outcome, decreasing both efficiency and equity.”

What does an efficient health system look like?

Dr Figueras outlined some of the actions that can contribute to efficiency and improve equity. The Observatory has recently completed a study on the economics of prevention, in collaboration with the OECD and the WHO. “We aimed to synthesise the evidence on the cost effectiveness of prevention, and now we have the numbers, which show clearly the potential savings that come from investing in prevention,” Dr Figueras said.

Prevention has a greater impact on less-privileged people, whose economic, social and environmental determinants have a disproportionate effect on their lifestyle and their health, notes Dr Figueras. “Health promotion and prevention can address these determinants of health, both promoting equity and increasing efficiency.”

Another key to reducing health inequalities lies in strengthening primary care and making it free at the point of delivery. “This should be the entry point to patient-centred, integrated care,” says Dr Figueras.

“Reforms to increase efficiency must put renewed emphasis on centring services around the individual needs of patients,” he says, adding, “If there is less access to primary care, people will inevitably end up in hospital with health conditions that are both more severe and more expensive to treat”

Investing in health literacy may not spring to mind as a route to increasing efficiency of health systems, but it is a proven way of forging a link between equity and efficiency. Improved health literacy helps people to look after their health and supports decision-making.

“Those who are less-privileged generally have lower levels of literacy, but when health literacy is promoted, it does not create more demand. Rather, having information both about their health and how and when to access the health system, makes people feel more assured and confident about managing their health. They are able to access the appropriate services and treatments, which often results on better health outcomes without requiring additional resources,” Dr Figueras notes.

Policy makers confronting change

For Dr Figueras, one of the important messages from the Vilnius Conference of November 2013, was in underlining the extent to which health and economic prosperity are intertwined and how health inequalities are not only at odds with our societal values but also impact on productivity.

Analysis of the impact of the recession on health shows a number of negative outcomes, including an rise in suicide rates, mental health problems and of increased rates of infectious diseases.

However, there is also evidence that in some countries budget cuts have been a spur to increase efficiency. While it may have been by default rather than design, measures such as increasing the use of generic drugs, centralising procurement and value-based purchasing have resulted in cost savings, but have not damaged quality or outcomes.

This is not a charter for cuts. However, Dr Figueras suggests it is useful to look to these examples. “There is huge potential to study the variations in health systems performance between countries to learn from each other,” he says.