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Building the future of European healthcare systems

A comprehensive analysis of the experience of 9 EU countries in facing and managing Covid- 19 pandemic challenges


The month of March 2020 will remain in universal history as a watershed date between two different visions of the world and of life: the one before and after the Coronavirus disease 2019 (COVID-19) pandemic. A similar experience was experienced worldwide 102 years ago, when another major pan¬demic struck the world, causing an enormous number of victims, probably higher than that of the two world wars of the twentieth century. The difference in our favour between then and today is that now we have more knowledge and therapeutic choices that can help us mitigate the impact on the health of the population. On the other hand, to our disadvantage, compared to yesterday, the world today is more interconnected and globalized and this implies that the contagion moves much faster, both within and between countries. This means that a few days of delay in taking the right decisions are enough to determine a high or low number of infected people, thus rendering the time factor a fundamental variable. And health systems around the world have largely proved unprepared and unequipped to handle a fast-moving pandemic.
Though we have been able to obtain a vaccine in a relatively short period of time, it would be useful to take advantage of the enormous attention paid to COVID-19 in recent months to rethink the way we manage and prepare these challenges, building on this experience. It is hoped that world leaders, particularly those of the more advanced countries, will recognize the need for greater investment in national health systems in order to remove the state of anxiety and worry that today dwells in the souls of so many of the population, thus avoiding become a regular feature of our life.
The COVID-19 pandemic comes at a time when, also in light of the profound changes that the sec¬tor has undergone in recent years, the national health care systems need a radical rethinking of their overall operating logic. As extensively illustrated in Farmafactoring Foundation (2019), health care systems are rapidly changing their skin, transforming themselves ever more into “ecosystems”, namely complex systems that interact with other complex systems, whose rules of engagement and management are changing at a speed that is no longer what it used to be. A complex system that considers the phases of prevention, diagnosis, treatment and rehabilitation in an integrated way, must be rethought especially in this period of major and rapid changes in knowledge, technologies, institutional structures, political behaviours, social values, and dynamics of the economy. Without a global rethinking there is the risk of the inevitable but continuous wearing down of the principles of equity and accessibility which should be at the heart of any health care system. 
As clearly stated also in last year's BFF Health Report (BFF, 2020), these profound changes come at a moment when all health care systems around the world are striving to address the well-known chal¬lenges of ageing populations and the rise in chronic diseases, as well as the fast growing advance¬ment in technical possibilities and public expectations. Indeed, the elderly population is expected to increase, both in numbers and in proportion to the working age population, leading to a doubling in the ratio of elderly people to those of current working ages. At the same time, the availability of new treatments is pushing up health care costs per patient, determining substantial new costs, with important spillovers also for the social care and the pension payment systems.
The current pandemic adds to those problems by imposing a massive stress test on these already strained systems and the ways respond to patient health care needs. In this Report, we suggest adopting a “contingency” type approach, consisting of identifying the most probable or riskiest sys¬tem “breaking points” in order to formulate policy proposals that can prevent the greatest negative effects from being generated in those places. Limiting the negative effects with appropriate “preven¬tion or early diagnosis” policies is a sine qua non condition to avoid a vicious circle of losing trust in the health care system. This phenomenon can result in flight of patients from the public system, which in turn can further weaken the public system generating a further loss of confidence.
To counterbalance these pressures there is a need for action on the social determinants of health so as to improve the health status of the overall population, but particularly among the most vulnerable. The COVID-19 pandemic has taught us that healthcare system, as we have known it for years, cannot deliver these services alone anymore. Action is required across the whole of society. As main actors responsible for the delivery and financing of healthcare, generally based on the principle of social solidarity, they need to identify policy solutions also outside the health sectors to best address these challenges. This opens up new scenarios for the health care systems and the role they will have to play in the future. 
This report therefore represents an attempt to explain a complex phenomenon which, also due to a not always effective institutional and scientific communication, has left doubts and uncertainties among those who wanted to understand. With the aim of reorganizing the reflection around the pandemic, the report seeks to shed light on areas of a dense, crowded, often excited debate, in which it is necessary to bring a new awareness. Complexity is part of nature and the world and cannot be trivialized. The language can and must be made clearer, it is possible to provide images, examples and anecdotes to return complex concepts which, however, must be disclosed in their full depth. This is the only way to have the opportunity to sow awareness and to bring home lessons for tomorrow. Otherwise the debate, instead of spreading knowledge, will be limited to an overflow of suggestions and further confusion. As has been the case for a long time during the months of the pandemic’s development.
Unlike previous experiences, COVID-19 came at a time when the possibility of “disclosing” and being heard by vast audiences is much wider. From the days of the first infections in Wuhan, there was never a moment when the media did not report on the epidemic, until it reached a point, only a few weeks after the WHO declaration of the pandemic, in which it began to speak of “infodemic”, as an informa¬tion pathology. This has led to the circulation of an excessive amount of information, sometimes not carefully screened and therefore a source of confusion (WHO, 2020). According to Google Scholar, in the months of March and April 2020 alone, the scientific community produced over 36,000 docu¬ments on the subject. At the end of May 2020, just three months after the outbreak of the pandemic, the COVID-19 Scientific Gateway that automatically collects all the research products on COVID-19 and Sars-CoV-2 reported more than 39,000 scientific publications were available, plus 3,000 data¬bases accessible to all for research, over 240 softwares and over 3,200 other research products.
An effort never seen before, to which must be added the thousands of contributions by those who communicate on interpreting the results and opinions of the experts. 
In this context, this report seeks to provide a multidisciplinary perspective that embraces two inter¬connected worlds: life sciences and economics. In fact, the phenomenon cannot properly be under¬stood if the two worlds, their interconnections and the rules that govern them, are unknown. The pandemic is such not only because over 3 billion people have been affected from a personal health point of view. It is also so because, for the first time, it was realized that “global” is not only the finan¬cial system, but also that of production, as demonstrated by the initial shortcomings of both low (e.g. masks) and high technological products (e.g. pulmonary ventilators). For the first time, it became clear that the structure of the so-called supply chains can represent a great advantage in times of “normal¬ity”, but can have a boomerang effect in an emergency like the one experienced during the epidemic.
As a necessary reminder for those about to read the following pages, it is useful to note that although scientific knowledge about COVID-19 is growing, it remains substantially incomplete. Fundamental issues such as the long-term implications of the virus, the strength and duration of post-infection antibodies, and the precise mechanisms of transmission of the infection are still unknown at the time of publication of this Report. Con¬sequently, the debate is still open for many of the topics cov¬ered in the following pages, as well as for the measures that should be implemented. However, far from wanting to give de¬finitive answers to evolving problems, relying on the scientific foundations currently available (sometimes not always solid), the main objective of this Report is to be able to guide readers in this complex and jagged world of the COVID-19 pandemic to help them better understand what happened. 
As usual for our Report, its aim is to offer a comprehensive analysis and comparison of 9 healthcare systems in the EU, namely those in Croatia, Czechia, France, Greece, Italy, Poland, Portugal, Slovakia and Spain. These healthcare systems are based on different funding principles, as a result of hetero¬geneous economic conditions and societal views on issues related to income redistribution, presence of institutions and government interference with healthcare provision, frequently shaped by different historical and cultural footprints. Furthermore, they have different characteristics in terms of basic founding principles, financing, organization, management, and population size. They also have been hit differently by the pandemic and different policies have been put in place to respond to this major shock. Thanks to data obtained from official sources and an ad-hoc survey administered to about 30 professionals and experts, the report offers a multilevel overview of these health care systems, seeking to highlight common challenges and country specific issues that might be crucial from both practitioners’ and policymakers’ perspectives. 
Finally, it is worth highlighting that this is the third in a series of published reports, though this one differs in several respects. First of all, there are plenty of dimensions across which the countries com¬pared in this report differ from each other. From the viewpoint of this analysis, the most important distinction concerns the healthcare system organizational model each country has. On one side, we have a country whose system is based on the Beveridge model, which relates to public tax-financed systems (usually fiscal tools), managed by a National Health System, which usually provides univer¬sal coverage. On the other side, there is the Bismarck model, which implies that the funding of the health care system is obtained through compulsory social security contributions, normally paid by employers and employees. This type of system is frequently referred to as a/the Social Health Insur¬ance System. Among the group of countries selected, the Beveridge system is shared by Italy, Spain and Portugal, while Poland, Czechia, Slovakia and France adopt the Bismarck model. Finally, there is the Private Health Insurance System, which can be interpreted as a hybrid between the two, and is adopted by Greece and Croatia. A second difference refers to the type of information provided in this report, which is now common to all countries and does not vary depending on the type of topic analyzed.


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(1) The COVID-19 Scientific Gateway is a single collection point for all research products on the current pandemic. It is built by OpenAIRE, the European Commission infrastructure for Open Access of which the Italian CNR is the technological coordinator. The site is accessible at the following web address: