D5.1 Market Overview - inclusive introduction of integrated care

Transcription

Project Acronym:
Contract Number:
Starting Date:
Ending Date:
Deliverable Number:
Title of Deliverable:
Work-Package of the Deliverable:
Deliverable Type:
Distribution:
Contractual Date of Delivery to the CEC:
Actual Date of Delivery to the CEC:
Author(s):
INCA
CIP 621006
01/01/2014
30/06/2016
D5.1
Market Overview
Planning for Sustainability
R
PU
31/12/2014
KENUS INFORMATICA
Contact point: Lars. Berger @ kenus . es
Other Contributors: ALL Partners
Abstract: Providing Health and Social Care Services is becoming increasingly
complex and costly. An aging population, a multitude of public, private and
informal actors, together with a myriad of eHealth systems and technologies
create numerous hurdles to offering efficient and cost-effective care. Hence,
although the European savings potential identified amounts to 100 billion Euros
annually, proactive integrated socio-sanitary care is till now more a concept than
a reality. In reality, healthcare is provided by a plurality of islands and despite
having strong institutions, good hospitals, and primary care getting better
organised, they do not work in a coherent system. In this respect, the virtual
socio-sanitary integration option provided by INCA is a valuable option to let the
users experience the benefits of proactive socio-sanitary integration even before
the different vested stakeholders are ready to go the whole way.
Project Co-ordinator
Company Name: IDI EIKON
Name of representative: Miguel Alborg
Address: C/ Benjamín Franklin, 27
Parque Tecnológico de Valencia
46980 – Paterna, SPAIN
Phone Number +34 96 112 40 00
Fax Number: +34 96 112 40 54
E-mail: [email protected]
Project WEB site address: http://www.in3ca.eu
* (a)
* (b)
PR =
RE =
SP =
OT =
P=
C=
Prototype
Report
Specification
Others
Public, for wide dissemination
Confidential, limited to project participants.
ICT PSP D5.1 v1.0: Market Overview INCA Nº 621006
23/12/2014
COPYRIGHTS
© 2014 The INCA Consortium, consisting of:

Investigación y Desarrollo Informático EIKON, Spain

Ayuntamiento Quart de Poblet, Spain

Interfusion Services, Cyprus

Kenus Informática, Spain

Especializada y Primaria L’Horta Manises (Hospital de Manises), Spain

Dimos Geroskipou, Cyprus

Ventspils Pilsetas Domes Socialais Dienests, Latvia

Ziemelkurzemes Regionala Slimnica Sia, Latvia

Hrvatski Zavod Za Zdravstveno Osiguranje, Croatia

Grad Rijeka, Croatia

Fundación para la Formación e Investigación Sanitaria de la Región
de Murcia, Spain
All rights reserved.
This document may not be copied, reproduced, or modified in whole or in
part for any purpose without written permission from the INCA Consortium.
In presence of such written permission, or when the circulation of the
document is termed as “public”, an acknowledgement of the authors and of
all applicable portions of the copyright notice must be clearly referenced.
This document may change without prior advice.
For further information related to this Deliverable or to the INCA project
please visit the project Web site http://www.in3ca.eu or contact the Project
Coordinator [email protected]
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DOCUMENT HISTORY
Version1 Issue Date
0.1
31/03/2014
0.2
0.3
05/05/2014
05/08/2014
0.4
14/08/2014
0.5
08/09/2014
0.6
0.7
22/09/2014
25/11/2014
0.8
0.9
06/12/2014
17/12/2014
1.0
23/12/2014
1
Stage2 Content and changes
Draft
Structure and contents defined by the WP5
Leader, the WP5 lead contributors and the
Project Coordinator
Draft
Inclusion of changes/additions from FFIS
Draft
Structure update with sections on and
Insertion of review comments received
Draft
Major structural review, formatting revision
and revision of Spanish Socio-Sanitary
System
Draft
Structure reviewed and commented by
Coordinator
Draft
Revision by partner Murcia.
Draft
Integration of Cyprus, Croatia and Latvia
section
Draft
Integration of EU Trends Section 2
Draft
Executive summary, abstract and
conclusion added
Draft
First complete version delivered by the
WP5 leader to all INCA consortium partners
for review and comments.
Final
Document accepted by all partners and
ready to submission
Please use a new number for each new version of the deliverable. Add the date when this version was
issued and list the items that have been added or changed. The ‘what’s new’ column will help the reader
in identifying the relevant changes. Don’t forget to update the version number and date on the header.
2
A deliverable can be in either of these stages: “draft” or “final”. For each stage, several versions of a
document can be issued. Draft: Work is being done on the contents. Final: All chapters have been
completed.
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EXECUTIVE SUMMARY
Achieving INCA Sustainability - the primary objective of WP5 - bears quite
some parallels to problems start-ups face. Hence, to a large extend WP5
activities follow the “Customer Development Model” popularized by Steve
Blank3. We mapped the outputs of the model to the different WP5
deliverables: D5.1 Market Trends Overview; D5.2 Sustainability Strategies;
D5.3 Business Plan Production; as well as to a phase beyond INCA.
To come to D5.1 Market Trends Overview, a market review and exploration
process has taken place during the last 12 month in line with T5.1 of the
INCA Description of Work (DoW). This process lead to a thorough analysis
of statistical data on the current evolutions in the eHealth market and its
stakeholder for each of the pilot countries Spain, Cyprus, Croatia, and
Latvia, as presented in Section 0 to Section 6, respectively. However,
before delving into the details for each country, Section 1 gives a general
introduction to the INCA and the Socio-Sanitary Care environment, while
Section 2 introduces general EU level trends.
In terms of contributions to the different sections, the overall editing was
performed by the WP Leader Kenus Informatica. Kenus is also the main
responsible for Section 1, with lots of input coming from IDI Eikon, and the
conclusions in Section 7. Section 2 was prepared by Interfusion with input
from IDI Eikon and Kenus. The country specific sections were assigned a
country section editor, where IDI Eikon took the lead for Spain, Interfusion
took the lead for Cyprus, Grad Rijeka took the lead for Croatia and
Ziemelkurzemes Regionala took the lead for Latvia. All other country
partners cooperated with their country section editors, providing valuable
inputs and information. Hence, it can rightfully be said that this document is
the result of joint work (teamwork) of all partners.
In terms of findings and results, it can be said that across Europe, providing
health and social care services is becoming increasingly complex and costly.
An aging population, a multitude of public, private and informal actors,
together with a myriad of eHealth systems and technologies create
numerous hurdles to offering efficient and cost-effective care.
In broad terms, 'Integrated eCare' consists of getting actors from
healthcare and social care services to collaborate on multiple levels - from
private doctors to public hospitals and from home carers to emergency
centres for the elderly. They need to be structured efficiently, be aware of
their specific roles in the value chain, and, most significantly, be able to
effectively share information between them. In this respect, the virtual
socio-sanitary integration option provided by INCA is a valuable option to
let the users experience the benefits of proactive socio-sanitary integration
even before the different vested stakeholders are ready to go the whole
way towards integrated socio-sanitary pathways.
3
Blank Steve The Four Steps to the Epiphany [Book]. - 2013.
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CONTENTS
Copyrights.......................................................................................................... 2 Document History................................................................................................ 3 Executive Summary ............................................................................................. 4 Contents ............................................................................................................ 5 1 2 3 4 5 Context ....................................................................................................... 7 1.1 IN3CA – A General Introduction.......................................................... 7 1.2 Work Package 5 Overview ................................................................. 7 1.3 The Customer Development Process in WP5 ......................................... 8 1.4 Methodology and Sources .................................................................. 9 1.5 Introduction to Socio-Sanitary Care .................................................... 9 1.6 Patient Segments and Market Dimensions .......................................... 12 1.7 Information and Communication Technology in Current Care Systems ... 14 1.8 INCA Pilots’ Integration ................................................................... 18 1.9 Section Summary and Further Deliverable Structure ............................ 20 INCA Relevant EU Trends ............................................................................. 22 2.1 Demographic Context ..................................................................... 22 2.2 Healthcare Funding Models .............................................................. 24 2.3 EU Cross-boarder Health Coverage ................................................... 26 2.4 Health Expenditure in Europe ........................................................... 28 2.5 Hospital Discharge Rates and Average Length of Stay .......................... 31 2.6 eHealth Patient Rights ..................................................................... 32 2.7 Social Protection Expenditure ........................................................... 34 2.8 Changes to Public Spending due to Financial Crisis .............................. 39 2.9 Political Support of Integrated Care ................................................... 42 The Socio-Sanitary System in Spain .............................................................. 45 3.1 An Overview of the Spanish Situation ................................................ 45 3.2 The Spanish Health Care System in Detail .......................................... 51 3.3 The Spanish Social Care System in Detail .......................................... 62 3.4 Towards Integrated Socio-Sanitary Care in Spain ................................ 67 3.5 Insights on ICT Tool and the Acquisition Processes in Spain .................. 70 3.6 Spanish Market Participants ............................................................. 77 The Socio-Sanitary System in Cyprus ............................................................ 85 4.1 An Overview of the Cypriot Situation ................................................. 85 4.2 The Cypriot Health Care System in Detail ........................................... 88 4.3 The Cypriot Social Care System in Detail ..........................................101 4.4 Towards integrated Socio Sanitary Care in Cyprus ..............................102 4.5 Insights on ICT Tool and the Acquisition Processes in Cyprus ...............102 4.6 Cyprus Market Participants .............................................................104 The Socio-Sanitary System in Croatia ........................................................... 110 Page 5 of 145
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5.1 An Overview of the situation in Croatia .............................................110 5.2 The Croatian Health Care System in Detail ........................................111 5.3 The Croatian Social Care System in Detail .........................................115 5.4 Towards Integrated Socio-Sanitary Care in Croatia .............................117 5.5 Insights on ICT Tool and the Acquisition Process in Croatia. .................118 5.6 Public Procurement ........................................................................121 5.7 Croatian Market Participants ...........................................................122 The Socio-Sanitary System in Latvia ............................................................. 123 6.1 An Overview of the Latvian Situation ................................................123 6.2 The Latvian Health Care System in Detail..........................................125 6.3 The Latvian Social Care in Detail......................................................133 6.4 Towards Integrated Socio-Sanitary in Latvia......................................134 6.5 Insights on ICT Tool and the Acquisition Processes in Latvia ................134 6.6 Latvian Market Participants .............................................................140 7 Conclusions............................................................................................... 142 8 Appendix - Databases and Other Resources ................................................... 142 8.1 Background Reading and Web Portal List ..........................................142 8.2 Bibliographic Resources ..................................................................144 8.3 Online Statistics Databases .............................................................145 8.4 Online Project Databases ................................................................145 Page 6 of 145
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1 CONTEXT
1.1
IN3CA – A General Introduction
The European project IN3CA (www.in3ca.eu) deploys a multi-channel,
patient centred, integrated socio-sanitary care platform. Social services,
medical organizations, patients, and private care givers are able to interact
with each other through any device capable of running an Internet browser.
Serving content from the Cloud allows access anywhere at any time.
INCA’s aim is to start a pragmatic initial deployment in Europe. For this, five
pilot sites are implemented, two in Spain, the others in Cyprus, Latvia and
Croatia. After having completed the implementation tasks, pilots will run for
more than a year, followed by an evaluation to validate the implementation
of the model and its impact as well as its market replication potential in
other countries. INCA pilots target to impact more than 125000 users and
directly engaged with 1550 active users.
1.2
Work Package 5 Overview
Achieving INCA Sustainability - the primary objective of WP5 - bears quite
some parallels to problems start-ups face. Hence, among others when
developing WP5 we consider key lean start-up movement literature.
Particularly, the interested reader might want to refer Blank 20134, Ries
20115 and Furr & Ahlstrom 20116 to get a more detailed understanding of
the methodology applied throughout WP5.
An overview of all WP5 deliverables is given in Table 1-1. D5.1 Market
Trends Overview, is public and, hence, and will mainly review publically
available information related to the integrated care market and its savings
potential. Additionally, statistics, predecessor and companion projects are
taken into account. Information that is strategically linked to the INCA
objective of sustainability is instead treated in the consortium internal
documents D5.2 and D5.3. Sustainability, from a business point of view can
at the same time be beneficial for society as a whole and we strive to proof
the positive impacts of INCA not only in terms of improved socio-sanitary
care quality but on society as a whole through a Socio-Economic Impact
Assessment (SEIA) as detailed in the public deliverable D5.4. The SEIA
gives decision makers information which they can use in weighing the
potential positive and negative consequences of deploying INCA in their
respective areas of influence.
Table 1-1: INCA WP5 Deliverable Overview.
Deliverable Title
D5.1 Market Trends Overview
D5.2 Sustainability Strategies (public
and private)
D5.3 Business Plan Production
D5.4 Socio-Economic Impact Assessment
4
Month
M12
M18
Nature
report
report
Dissemination
public
confidential
M21
M28
report
report
confidential
public
The Four Steps to Epiphany, Steve Blank 2013
The Lean Startup: How Today’s Entrepreneurs Use Continuous Innovation to Create Radically
Successful Business, Eric Ries 2011
6
Nail It then Scale It: The Entrepreneur's Guide to Creating and Managing Breakthrough Innovation,
Nathan Furr & Paul Ahlstrom 2011
5
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The Customer Development Process in WP5
The mapping of INCA to the startup model phases is outlined in Figure 1-1.
Figure 1-1: Mapping of INCA to lean start up model phases7
We focus on the central model of Figure 1-1, known as “Customer
Development Model”. It consists of four iterative processes, i.e.:
“Customer Discovery – who are the customers for your product or
service? Is the problem you are solving important to them?
7
Sources from top to bottom: Customer Development as a Design Squiggle,
https://fivewhys.wordpress.com/2012/07/03/customer-development-as-a-design-squiggle/; Steve Blank,
The Four Steps to the Epiphany, http://www.productbookshelf.com/2012/02/finding-your-customers-asyou-build-your-product/; N. Furr and P. Ahlstrom, Nail It then Scale It,
http://www.nailthenscale.com/book-graphics/?wppa-album=1&wppa-occur=1&wppa-photo=5
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Customer Validation – proving you have found your customers and
market by building repeatable sales roadmaps and playbooks that will be
used by field sales and marketing teams
Customer Creation – creating and funneling end-customer demand into
the company’s sales channel
Company Building – the point at which the company transitions from
informal learn and discover mode to functionally specialized groups (e.g.,
sales, marketing, business development)”.3
Especially, the final phase Company Building is beyond the lifetime of the
INCA project. Nevertheless, WP5 is forming the foundation for a successful
scaling.
1.4
Methodology and Sources
Many parts of this document are based on content from external sources.
Verbatim citations are marked with quotation marks. Especially for many
figures and tables, the original source is annotated and as far as possible
web links are given.
We have tried to use the most recent data available, something not easy
when trying to cover such a wide topic with so many ramifications.
The figures in this study should be taken with caution because, as we say,
depending on the sources they may differ. The only "reliable" figures date
back several years ago, and, except when unavoidable -there is nothing
else better-, we have preferred to omit them, because it would make no
sense in today's different scenarios.
The study is based mainly on secondary sources: multiple studies done by
reliable and reputable sources National, European and Worldwide. Online
searches through all the official organisms and agencies. Also, to know what
is happening here and now, authorized blogs, local publications, interviews
with responsible have been also used, and lastly, findings have been
completed with the feedback of sector professionals that have contributed
their background and knowledge of the industry they work and live for.
The official vision of the situation (government) and that of those that stand
in front (associations, patients, carers...) are rather disparate. In the study
we have tried to reflect /collect both points of view, not always reconcilable.
1.5
Introduction to Socio-Sanitary Care
Health care services have been the pride of European democracies but they
have not evolved to respond to the modern environment and are no longer
fit for purpose8. While continuing to be based on the common values of
universality, access to good quality care, equity and solidarity, it must
8
This, ultimately, is the fundamental conclusion of the Task Force’s report, Redesigning health in Europe
for 2020. 2012. Toomas Hendrik Ilves President, Estonia Chairman of the EU Task Force on eHealth.
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accommodate new realities and acknowledge the need for cost-efficient
investments. Social care has traditionally a smaller budged as health care9,
which is why the most urgent need for cost savings is felt in the health care
system.
There is now an increasing movement of policy makers, medical personal,
and social care givers agreeing that cost cuttings on the basis of resource
optimization, prevention (pro-action vs. reaction) and an increased shift to
out-patient treatment (care at home) is necessary and can be achieved
under the overarching concept of integrated socio-sanitary care.10An
interesting overview at EU level is provide, for example, in the “Compilation
of Good Practices” by the Action Group B311, with a summary of projects per
country listed in Figure 1-2.
Figure 1-2: Integrated care good practices by countries and by Action Areas11
Integrated socio-sanitary care is still in its infancy and a plurality of
definitions exists. To add to the confusion, other terms such as continuum
of care, coordination of care, discharge planning, case management, and
seamless care are often used synonymously. It is most frequently equated
with managed care in the USA, shared care in the UK, trans-mural care in
the Netherlands, and other widely recognised formulations such as
comprehensive care and disease management. Despite, integrated sociosanitary care is seen as the way forward that will benefit all Europeans (in
particular older people), whilst helping to address resource efficiency and
sustainability of care systems. We define it as "collaboration, alignment,
9
Health at a Glance 2013 - OECD INDICATORS
http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf
10
Source: North West London Integrate care, Pilot: Business Case
11
Source: Action Group B3, A Compilation of Good Practices, 2nd Ed.
http://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/gp_b3.pdf
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training and connectivity among social care, health care, and community
care providers with the mission to provide better services at reduced cost".
Some concepts also include informal caregivers into these integration tasks.
The objective is to achieve integration between hospital, community home
and self-care. Therewith, integrated socio-sanitary care is located at the
interception of two traditional markets, the health service market and the
social service market as indicated in Figure 1-3.
Figure 1-3: Integrated socio-sanitary care
Integration frequently leads to multi-disciplinary networks consisting of care
professionals as well as informal care givers, which tailor their service
provisioning in form of patient-centric models to the patients’ care
requirements. An example of such a patient-centric multi-disciplinary care
network is provided in Figure 1-4.
Figure 1-4: Patient-centric, multi-disciplinary integrated care network
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To enable a practical top level management, patients are segmented and
associated with standardised care plans, also called care pathways, which
are then adapted by the case manager to customized integrated care plans
(ICPs) to cater for each patient’s individual needs.
1.6
Patient Segments and Market Dimensions
Driven by broad shifts in demographics and disease status, long-term
conditions absorb by far the largest, and growing, share of health care
budgets. Over 100 million citizens, or 40% of the population in Europe
above the age of 15, are reported to have a chronic disease; and two out of
three people, who have reached retirement age, have at least two chronic
conditions12. Moreover, it is widely acknowledged that 70% or more of
healthcare costs are spent on chronic diseases. This corresponds to more
than 700 billion EUR in the European Union and is expected to rise in the
coming years13. As this is putting pressure on the sustainability of health
and social care systems, and on the wider economy and society, many
integrated-care deployments focus on high risk chronic patients as outlined
in Figure 1-5.
Figure 1-5: Patient categorization based on risk level following the ‘Kaiser Pyramid’
developed by Kaiser Permanente
The idea is, that by focusing on a relatively small group of only around 30%
of the chronic population, that in the current systems are associated with
70% to 80% of costs, significant cost savings can be achieved.
The current systems are unsustainable in the medium-term due to
demographic and lifestyle changes, the impact of chronic diseases and
12
eHealth Action Plan 2012-2020 - Innovative healthcare for the 21st century. EUROPEAN
COMMISSION Brussels, 6.12.2012 COM(2012) 736 final
13
European Union Health Policy Forum - Answer to DG SANCO consultation on chronic diseases, 13
January 2012
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budget limitations14. Extrapolating the 10% cost saving prediction made in
NWL/NHS201415 to the health care spending in the INCA pilot countries,
leads to the saving potations as outlined in Table 1-2. It gives a glimpse of
the return on investment (ROI) that might be obtained by investing into
integrated care solutions.
Table 1-2: Savings potential assuming a 10% of health care cost reduction due to the
introduction of integrated socio-sanitary care. Health care spending numbers based on
Eurostat16
“The (US) healthcare integration market is expected to grow at a compound
annual growth rate (CAGR) of 9.6% in the forecast period, to reach
$2,745.9 million by 2018 from $1,737.3 million in 2013. Factors such as the
rising healthcare costs, presence of strong government support and
initiatives, growing need to integrate healthcare systems, and high returns
on investment have increased the demand for healthcare integration.
However, various interoperability issues, presence of a fragmented endusers market, and the high cost of implementation of healthcare integration
are the factors that are restraining the growth of this market to a certain
extent.
North America accounted for the largest share of 65% to 70% of the global
healthcare integration market, followed by Europe with a share of nearly
20%. However, the Asian countries represent the fastest-growing markets.
The high growth in these countries can be attributed to the increasing
awareness regarding healthcare, growth in healthcare spending in emerging
countries, and the presence of a large and diverse population in this
region.”17
Besides significantly improving the financial positions of the traditional
health and social care systems other benefits usually expected form the
move to integrated socio-sanitary care are an improved quality experienced
by the patients:

“Stricter adherence by all health professionals to evidence based care
protocols used across multiple organisations
14
Workshop on "e-Health" 24 September 2013 European Parliament, Brussels
North West London Integrated Care Pilot: Business Case [Report]/ North West London Healthcare
Professionals.- London: [s.n.], 2014
16
Eurostat Expenditure of selected health care functions by providers of health care (Data from 2011
except Cyprus and Latvia which are from 2008 and 2009, respectively.
http://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=hlth_sha1m&lang=en
17
Healthcare Integration Market by Products, http://www.marketsandmarkets.com
15
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
The provision of high quality services outside of hospital

Pro-active care to ensure long term conditions do not deteriorate and
patients do not need acute care

Greater support for self-care

Increased involvement in their care planning with multi-disciplinary
teams drawn from the various constituent organisations of the ICP”15
On the other hand, integrated care is also expected to improve the working
conditions and professional experience of the professional caregivers due
to:

“Involvement in development of evidence based care protocols for
use across multiple organisations. The integrated care pilot allows all
clinicians and care professionals the opportunity to develop protocols
to be applied by their colleagues from other settings.

Greater development opportunities across multiple settings and
organisations. All professionals in the integrated care pilot will benefit
from direct input through multi-disciplinary groups and other
opportunities for creating real-time support from their colleagues.

Access to better (more and improved quality) information about their
patient’s care by implementing improved information flows between
providers, allowing each to access the most up to date records
regarding patients in their care.”15
Despite all these advantages, integrated care for patients with complex
needs and long-term illness is currently not yet implemented to its full
potential leading to citizens with long-term conditions having a lower quality
of life.18
1.7
Information and Communication Technology in Current Care
Systems
Health and social care information and communication technology (ICT)
systems operate across Europe largely in silos. Frequently, solutions are
proprietary, from single providers, and with a single focus (i.e. only
telehealth or telecare or social interaction). Examples would be North
Yorkshire County Council (NYCC) telecare and NHS North Yorkshire & York
(NHS NYY) telehealth, doc@HOME® (Docobo Ltd), Distress Care Areíon.
Their main deficiency is that they cannot be easily adapted to different
needs and target groups. Further, when looking, for example, at the
integrated care pilots Chrodis, Linkcare, smartcare and People2People, that
strive to improve life quality for patients with complex needs and long-term
illness, it is noted that in many cases they just achieved to created new
aggregated silos.19
18
The King's Fund. UK 2011
Source: “Strategic Implementation Plan for the European Innovation partnership on Active and healthy
Ageing Steering Group Working Document. Final text adopted by the Steering Group on 7/11/11..OPERATIONAL PLAN” http://ec.europa.eu/health/ageing/docs/eip_operational_plan.pdf
19
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“Integrated care entails professionals from different organizations have to
work together in a team-oriented way to provide high-quality care for a
patient. This requires that healthcare professionals share information about
– and with – patients at appropriate points in the care or treatment process.
The necessary infrastructural arrangements – such as shared patient
records, regional collaboration and a clear, transparent incentive structure - must be in place. It is increasingly hard to imagine integrative initiatives
without a strong information management and technology component.
However, information is a necessary condition but not sufficient to achieve
integrated care; organizational change is the more critical component.”20
1.7.1
Overview of ICT Tools in Health Care
“The healthcare service provider industry has a plethora of information in
the form of patient records, medical images, patient bills, prescriptions,
insurance claims, and research data. Healthcare providers and healthcare
organizations are not only required to store data but are also required to
process and maintain this data using various data management and
processing solutions. The healthcare providers are also required to make
this data available on demand and across boundaries, and at the same time
to focus on their core function of delivery of patient care.
Generally, hospitals and other healthcare providers have various systems
for different aspects of services they provide, which are often unable to
communicate with each other. In such cases, healthcare integration is
recognized as one of the most effective tools for providing a framework for
the exchange, integration, sharing, and retrieval of electronic health
information with advanced security. Thus, driven by information needs,
technologies from healthcare integration market are increasingly being
adopted by healthcare organizations to mobilize the healthcare information
across or within the organization.”21 The systems are known as health
information systems (HIS). A HIS is usually a sum of different components:
a radiology or images system, laboratory system, clinical history, etc. It is
difficult to find one unique application for all the needs of a Hospital and
high degree of fragmentation and self-made solutions is currently the norm.
Nevertheless, “there is general agreement among all that a strong HIS is a
key component of any health system. However, currently the data sources
are often incomplete and fragmented. The challenge is to bring together or
integrate all these diverse data sources into one seamless system”.22
Popular HIS solutions are summarised in Table 1-3.
Table 1-3: Overview of health information systems (HIS) on the market
20
Protti, D., Integrated care needs integrated information management and technology,
http://www.ncbi.nlm.nih.gov/pubmed/20057245 and Healthcare Quarterly, “All together now”
www.healthcarequarterly.com:http://www.ntpf.ie/home/NTPFToolkit/sdu_tech_guidance/library/pdfs/Mu
rray%20%282009%29%20Integrated%20care.pdf#page=28
21
Healthcare Integration Market by Products http://www.marketsandmarkets.com
22
Source: eHealth Reporter
http://www.ehealthreporter.com/en/noticia/verNoticiasPorCategoria/75/health-information-systems
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“The prominent players in the market are InterSystems (U.S.), Corepoint
Health (U.S.), Siemens AG (Germany), Orion Health (New Zealand), Infor
(U.S.), Interfaceware (Canada), Enovacom (France), Cerner Corporation
(U.S.), Capsule (U.S.), Accenture (Ireland), Capgemini (France), IBM
Corporation (U.S.), Allscripts (U.S.), Oracle (U.S.), and AVI-SPL (U.S.)”21,
HP (U.S.), Bull/Atos (France), Ibermática, el Corte Inglés (Spain), TSystems (Germany) and SAP (Germany).
Another ICT category is formed by information systems (AIS). AIS are
dedicated to tracking a patient’s past history at primary care level. An
overview of systems and actors in the market is provided in Table 1-4.
Table 1-4: Overview of ambulatory information systems (AIS) on the market
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Apart from HIS and AIS, satellite tools exist for laboratory management,
imaging, pharmacy, services, appointments schedules, doctor’s rankings
and other patient portals. Examples are exposed in Table 1-5.
Table 1-5: Examples of satellite services related to health care
The landscape is very diverse and apart from the big providers named in
Table 1-5, there are countless smaller providers appearing. As some of
these satellite service features, e.g. appointment schedules and doctor’s
ranking, are also features that can be realized with the INCA tool, a
permanent monitoring effort with respect to these satellite services is
needed.
1.7.2
Overview of ICT Tools in Social Care
When switching the point of focus from health care to social care, one may
note that software platforms are mainly developed towards the procedure
management and in the context of e-government. They are not taking into
account a citizen-centric perspective in order to promote cross-information
with health services; they are just managing citizens “as files”, without
planning future actions or sharing information with health responsible. This
is mainly due because of the division of the political and financial
responsible (social belong to local administrations and health belong to
regional or national administrations); in addition to this barrier we should
also stress the fear of sharing personal data among different working areas.
Many ICT systems in social care are performing social profiling for a more
targeted care delivery process. In many cases, also the dependency level is
of importance as it may directly relate to the amount of benefits a person is
entitled to receive. Systems are sometimes referred to as document
management systems (DMS) that are tracking a person’s history of social
services usage. Many solutions are “home-grown”, with some more
generally available ICT solutions outlined in
Table 1-6.
Table 1-6: Overview of social care document management systems (DMS) on the market
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1.7.3
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Emerging Examples of ICT in Integrated Socio-Sanitary Care
Considering the overview presented in Table 1-3 to
Table 1-6, one notices a very diverse pallet of solutions from very different
providers. This reflects to some extend the profound fragmentation of the
European healthcare and social care systems landscape.
Despite these barriers, models of integrated care start to emerge. Examples
are “Transforming your care”23 (Health and Social Care Board, Northern
Ireland), Dutch Programme Embrace24 and Renewing Health25. They confirm
that an improvement in the quality, in accessibility of care, and a greater
focus on the needs and wishes of patients with chronic conditions can be
achieved through integration. Ultimately, they appear to be cost-effective,
leading to containment or reduction of associated costs (lower costs and
utilization, net cost savings) like integrated care pathways (ICPs).26
Especially, in terms of vision, objectives and implementation methodology
of the currently ongoing North West London Integrated Care Pilots are very
much aligned with INCA. The INCA Consortium agrees with their objectives
and is watching closely the pilots’ evolutions and developments that seem a
reference to learn from.
1.8
INCA Pilots’ Integration
When looking at the starting position for our INCA pilots in Spain, Croatia,
Cyprus, and Latvia, different pre-existing levels of integration are observed,
as shown in
Table 1-7.
23
http://www.transformingyourcare.hscni.net/
http://www.integratedelderlycare.nl/
25
http://www.renewinghealth.eu/en/
26
The European Innovation Partnership On Active And Healthy Ageing 7/11/11 OPERATIONAL PLAN
24
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Table 1-7: INCA pilots and encountered level of socio-sanitary integration
From the overview in
it becomes clear that the various INCA pilots are departing from
very different levels of integration, with a plurality of political and
organizational obstacles to be overcome. However, INCA doesn’t want to
be directly engaged in the titanic task of removing systemic silos that might
take decades to change. Instead, INCA aims to overcome silos creating a
virtual integration in a wise and pragmatic way in order to leverage the
benefits of ICTs, even when other barriers still remain.
Table 1-7
INCA with its partnership and holistic approach can help create good and
effective communication and coordination channels across the entire care
process. Scaling-up and generating critical mass at EU level is a key for
successful implementation, but requires overcoming operational silos,
fostering new organisational changes, innovative business models and
incentive measures, convergence of technology and promotion of standards
towards interoperable ICT tools.
INCA, therefore, acknowledges that this important patient centred holistic
inclusive eHealth care resources need to be integrated and sustained within
regional and local programmes and initiatives, beyond the factual silos,
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“hidden to users” by friendly and smarter INCA interoperability resources27,
so that better coordination and integration of service delivery can be
smoothly achieved, reusing previous investments in health and social care.
The approach of virtual integration is depicted in Figure 1-6, where it can be
seen that INCA is targeting specifically the service integration on the micro
level that has a direct impact on the patient’s experience and on the
standard working practices of care providers, and allows INCA to get
started right away with no need to wait for higher level integration to
happen.
Figure 1-6: Levels of Integration28
1.9
Section Summary and Further Deliverable Structure
As treated in more detail in Section 2, European demographic trends
demand cost cuttings on the basis of resource optimization, prevention
(pro-action vs. reaction) and an increased shift to out-patient treatment
(care at home). It is believed that this change can be brought about
through the overarching concept of integrated socio-sanitary care.
Apart from the INCA pilots, there are numerous other integrated care pilots
emerging, such as epSOS, Integrated Home Care and People2People. An
especially visible set of pilots are run in with support of the UK National
Health Services in the North West London area. INCA is keeping a close eye
on these developments, on the one hand to learn, and on the other hand to
assist and contribute its own experiences.
From the overview in
27
See more details in the pages 36 of the initial INCA Proposal for INCA smart interoperability strategy
Based on Valentijn P., Schepman S. and Bruijnzeels M. Understanding integrated care: a
comprehensive conceptual framework based on the integrative functions of primary care, International
Journal of Integrated Care, 2013. - Vol. 13.
28
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it becomes clear that the various INCA pilots are departing from
very different levels of integration, with a plurality of political and
organizational obstacles to be overcome. Unfortunately, health and social
care systems in Europe are very diverse, making it much harder for service
providers to replicate their services. Not even within a country, structures
and entities are homogeneous, establishing a serious entry barrier for
smaller players and SMEs. For our first role outs it is of utmost importance
to understand existing health and social system care structures as well as
existing market actors in each pilot country. For this reason, Section 0 to 6
are dedicated to the System and Markets in Spain, Cyprus, Croatia and
Latvia respectively. The deliverable is rounded off by Conclusions in Section
7 and delivers some valuable resources for further reading in the Appendix.
Table 1-7
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2 INCA RELEVANT EU TRENDS
2.1
Demographic Context
Developments in healthcare can translated into an increased number of
people that live almost a normal life while they suffer from diseases such as
cardiovascular and strokes. Nonetheless, there is still a need for an
improvement in support and care. Although INCA can be used to handle any
socio-sanitary e-care service delivered also to “healthy” users while they are
not yet chronic and big “health services consumers”, as a conservative way
to determine who its initial target population of users will be, the project
sets the focus on the European elder chronic population in line with the
eHealth Action Plan 2012-2020 which says “two out of three people
(66.66%), who have reached retirement age have at least two chronic
conditions”29.
According to Eurostat, in the year 2012, the EU27 population was
503.663.60130. The population over 65 years was categorized as follows:
the ages 65-79 years represented a percentage of 12.9%; while the ages
80 plus stood for a percentage of 4.9%. Consequently the people in Europe
that are aged over 65 years represented a total percentage of 17.8% or a
number of 89,652,121.
Table 2-1: Population Projections (source Eurostat)
More precisely according to estimated projections for elder population in the
EU between the years 2017-2021 the older population grows a 2.28% each
year. Moreover, population over 80 years in the EU27 is projected to grow
from 5% in 2010 to 11.5% in 2050. The steady growth in both numbers
and proportion of persons aged over 65 years in Europe is demonstrated is
apart from Table 2-1 also presented in Figure 2-1 and Figure 2-2. Actually,
statistics reveal that the highest speed of ageing (in terms of median age) is
most possible to happen in most of the Eastern Europe countries. For the
majority of countries, the percentage of persons aged 65+ is expected to
show the highest increase within two decades (Table 2-8, Table 2-9, Table
2-11) Southern European countries such as Greece, Spain, Italy and
Portugal, though, maybe slow down this pace only after 2030, followed by
some Eastern European countries. According to EUROSTAT “The top pace of
29
Source: eHealth Action Plan 2012-2020, European Commission
http://ec.europa.eu/information_society/newsroom/cf/dae/document.cfm?doc_id=4188
30
Source: Stuckler D, Basu S. The International Monetary Fund’s effects global health: before and after
the 2008 financial crisis. International Journal of Health Services 2009; 39 (4):771–81.
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increase of the old age dependency ratio (OADR) is also spread across
several decades (see Table 2-10), and follows this geographical pattern: the
first countries to reach it are mostly the Northern European countries,
followed by the Western and Southern Europe countries; and eventually,
Eastern Europe countries are expected to reach the higher speed of increase
only towards mid-century31. Additionally, if we not take into account the
median age indicator, the countries that are most likely expected to
experience the earliest demographic changes include central and eastern
European member states such as Germany, Poland, Romania and Slovakia,
the first of these about ten or twenty years earlier. At the same time this is
translated into an increase in the patients that face chronic health diseases.
Figure 2-1: Projected Percentage of Population aged 65 Years and over (per country)32
Figure 2-2: Projected Percentage of Population aged 80 Years and over (per country)32
31
Source: EUROSTAT Population projections,
http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Population_projections
32
Source: Developing a New Understanding of Enabling Health and Wellbeing in Europe, EUROPEAN
SCIENCE FOUNDATION
Page 23 of 145
2.2
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Healthcare Funding Models
The way of funding for healthcare can be different among the Member
states. Nonetheless the majority of funds is being managed directly or
indirectly from the central governments. Overall, in Europe there are three
different ways of healthcare financing.
The first one is the Beveridge model that is a system focusing on public
taxation meaning that the health care is provided and financed by the
government through the collection of tax payments33. Countries using the
Beveridge model or some variations of it include UK and Italy as the main
representatives as well as the Scandinavian countries - Finland, Sweden,
Denmark and Norway. From the INCA pilot countries Spain, Latvia, Croatia
and Cyprus follow the Beveridge model. In this system, the key actors are
the public care provider sectors, namely the state, the municipal primary
care systems, and the municipal specialized secondary and tertiary care
system.
The second one is the Bismarck model that centres on compulsory social
insurance meaning that it uses an insurance system that is usually financed
jointly by employers and employees through payroll deduction34. The
Bismarck model is being followed by Member states such as Germany,
Austria, France, Belgium, the Netherlands, Switzerland, and Luxemburg 35
33
. This model as a mixture of public and private providers allows for more
flexible spending on healthcare.
The third model is the Private Insurance model based on private
financing through voluntary insurance that operates on top of standard
social insurance. In this system, the funding is predominantly private, with
some exceptions on social care and of course the great majority of the
providers in this model belong to the private sector.
The Euro Health Consumer Index (EHCI) 2013 total ranking of healthcare
systems shows in the top position the Netherlands, scoring 870 points out
of 1,000, and in second place follows Switzerland scoring 851 points. Three
Scandinavian countries follow: Iceland 3rd scoring 818 points, Denmark in
4th place scoring 815 and Norway 5th scoring 813 points.35 If we take into
account the EHCI 2006 – 2010 results, we can observe that the top scorers
are countries devoted to the Bismarck model (Netherlands, Austria,
Switzerland, Germany, France, Luxemburg, and Belgium) with some
exceptions of Beveridge representatives such as Iceland, Denmark, and
Sweden which also perform very well35. These few exceptions are mainly
small populated countries and easily managed while large Beveridge
countries like UK and Italy have medium scores (e.g in 2009 they scored in
the 14th and 15th place respectively) as they have problems to reach high
standards of offered value. The same pattern is confirmed in the EHCI 2013
33
Source: Healthcare systems — an international review: an overview, N. Lameire, P. Joffe and M.
Wiedemann University Hospital, Gent, Belgium, 'Renal Division, Holbaek County Hospital, Holbaek,
Denmark and 2Baxter Deutschland GmbH, Munich, Germany.
34
Source: Actuarial Report on the Design of the NMBF – Final draft Actuarial & Analytical Solutions
(A&AS) at Deloitte July 2012 Social Security Commission National Medical Benefit Fund.
35
Source: Health Consumer Powerhouse Arne Björnberg,Ltd., 2013. ISBN 978-91-980687-2-6 Page 24 of 145
23/12/2014
report (Figure 2-3), where again Bismarck representatives such as
Netherlands, Switzerland, Belgium, Germany, Luxemburg, France score in
the top 10 positions with the exceptions of small populated Beveridge
followers such as Iceland (3th), Denmark (4th), Norway (5th) while large
Beveridge systems such as UK, Spain, Italy score relatively low (13th, 18th
and 20th place respectively). Moreover, as the Table 2-2 the Bismarck
systems win in almost all the individual sub-disciplines such as: The waiting
time and treatment (Belgium, Switzerland), Range & Reach of Healthcare
Services
(Netherlands),
Prevention
(Luxemburg),
Pharmaceuticals
(Germany) while Denmark (Beveridge exception) and Netherlands share the
top score in the sub discipline Patient rights & Information, and finally
Iceland (Beveridge exception) wins the category Outcomes.
Figure 2-3: EHCI 2013 total scores36
Table 2-2: Top Countries with maximum EHCI Score per category.36 The score in red with
exclamation mark indicate the maximum possible score in the sub-discipline
36
Source: EHCI, 2013.
Page 25 of 145
2.3
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EU Cross-border Health Coverage
Cross-border EU health care coverage is handled with the help of the
European Health Insurance Card (EHIC). “EHIC is issued free of charge and
allows anyone who is insured by or covered by a statutory social security
scheme of the EEA countries and Switzerland to receive medical treatment
in another member state for free or at a reduced cost, if that treatment
becomes necessary during their visit (for example, due to illness or an
accident), or if they have a chronic pre-existing condition which requires
care such as kidney dialysis. The term of validity of the card varies
according to the issuing country. The intention of the scheme is to allow
people to continue their stay in a country without having to return home for
medical care; as such, it does not cover people who have visited a country
for the purpose of obtaining medical care, nor does it cover care, such as
many types of dental treatment, which can be delayed until the individual
returns to his or her home country. It only covers healthcare which is
normally covered by a statutory health care system in the visited country,
so it does not render travel insurance obsolete.”37
“This card gives access to medically necessary, state-provided healthcare
during a temporary stay in any of the 28 EU Member States plus Iceland,
Liechtenstein, Norway and Switzerland, under the same conditions and at
the same cost (attendance is free in some countries) as people insured in
that country”.38 The Table 2-3 displays typical charges to be expected for
state-funded healthcare in each of 10 European countries, taking as a
prerequisite that you owned an EHIC.
Table 2-3: Medical costs in European countries when using an EHIC39
Guide to European, state-funded healthcare costs when showing the European Health Insurance
Card
Country
Doctor consultation
Hospital treatment
Prescriptions
Notes
Pay upfront. Up to 75%
refund can be claimed
back while in Belgiuma
Pay a daily charge
(generally €15) plus
the cost of medicines
Pay upfront. Nonrefundable charges
vary; reimbursement
for certain medicines.
Up to 75% could be
claimed back in
Belgiuma
Ask for a receipt on a
GP'sattestation de soins
donnésor on pharmacist's
certificate
Croatia
Visits to a doctor who
is contracted with the
CHIF (Croatian Health
Insurance Fund) cost
just 10 Kuna (around
£1)
Visit a hospital
contracted with the
CHIF; GP referral
needed for nonemergencies; inpatients pay 100 Kuna
(around £10) a day,
up to a maximum of
2,000 Kuna
In pharmacies
contracted with the
CHIF, prescribed
medicines cost just 10
Kuna (around £1)
Present your passport as
well as your EHIC. The
CHIF will not reimburse
any charges, so keep
receipts to claim back
from your insurer
France
Pay the GP or specialist
Pay 20% of treatment
Pay upfront. Only some
Get a feuille de
Belgium
37
Wikipedia, European Health Insurance Card, http://en.wikipedia.org/wiki/European_Health_Insurance_Card
Source: European Commission, Employment, Social Affairs and Inclusion;
http://ec.europa.eu/social/main.jsp?catId=559
39
Source: Which?,
38
http://www.which.co.uk/money/insurance/guides/european-health-insurance-card-ehic-/medical-costs-in-european-countries-when-using-an-ehic/
Page 26 of 145
upfront. Up to 70%
refund can be claimed
back while in Francea
costs (in most cases).
In-patients will also
pay a daily charge
(€18)a
23/12/2014
prescribed medicines
are reimbursable their refund rates
range from 15-100%
of sale price.a
soinstreatment form from
the GP or pharmacist.
Private hospitals may be
registered to give state
healthcare
Pay 10% of medicine
costs (€5-10); nonrefundable. Full charge
for minor medicines
GP and dental surgeries
in the state system
usually display a sign
saying 'Kassenarzt' or
'Alle Kassen'
€10 upfront charge
(often cash only); nonGermany refundable in Germanya
€10 per day; charge
for a maximum of 28
days in a year; GP
referral needed for
non-emergencies
Greece
Free or reduced cost
with IKA-ETAMregistered GP; you may
have to pay 25% of the
costs for expensive
treatment (nonrefundable in Greece)a
Usually free - if
referred by an IKAETAM-registered GP,
ask for a 'ticket'; pay
25% for prosthesis,
major appliances or
expensive treatment
(nonrefundable in
Greece)a
Costs vary, but pay a
charge of 25%; nonrefundable in Greecea
It is possible to present
your EHIC to a private
doctor, pay in full and
claim back from the
regional IKA-ETAM office
Ireland
Free with a Primary
Care Reimbursement
Service (PCRS) doctor
Free emergency care.
GP referral needed for
specialist treatment
Must be dispensed by a
PCRS doctor, stating
the medicine is to be
provided for free
No costs to claim back
Normally free with a
Servizio Sanitario
Nazionale (SSN)registered GP
Usually free at SSN
hospitals. Medication
fees vary by region;
nonrefundable in
Italya
Most prescription
medicines free with an
EHIC; some are
charged for and nonrefundable in Italya
Show EHIC on hospital
admission; contact local
Azienda Unità Sanitaria
Locale office for
permitted refunds
Free, but GP referral
needed for nonemergencies
Pay PLN3.20 (around
70p) for basic
medicines, 30%-50%
of the cost of certain
listed medicines, or the Free treatment generally;
full cost for others;
permitted refunds can be
non-refundable in
claimed from the NFZ
Polanda
office
Italy
Poland
Portugal
Spain
Free with a GP at a
clinic showing the NFZ
(Narodowy Fundusz
Zdrowia) logo
Free
Free if state-provided,
but you must present
EHIC and ask for statefunded healthcare
Page 27 of 145
Free
Free. Present EHIC on
admission or be
charged as a private
patient; GP referral
needed for nonemergencies
Prescription medicine
charges are discounted
Any refunds can be
claimed from a regional
branch of Administracão
Regional de Saúde
Pay 50% of the cost
(around 10% with
proof of being a UK
pensioner); nonrefundable in Spaina
With state healthcare,
you have the right to
insist on having your
EHIC accepted - you
don't have to give travel
insurance details; some
facilities offer both
private and stateprovided care
2.4
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Health Expenditure in Europe
According to the 2012 Ageing Report40, the growth of public health care
expenditure has reached an average level of 8% of GDP in 2009 and 7.1 %
in 2010 in the EU41. According to the same source “the public health care
expenditure in the EU27 is projected to increase by 1.3 percentage point
(p.p.) of GDP, i.e. from 7.1% to 8.4% of GDP from 2010 to 2060 (Table
2-4). For half of the countries the expenditure increase lies between 1.1 and
1.6 p.p. of GDP over the whole projection period”40. Moreover according to
EUROSTAT, OECD health data and WHO this level has climbed to a
European average of about 7.8% of GDP in 2011, having increased on a
percentage of 5.7% during the last 30 years.
Table 2-4: Demographic scenario – projected in public expenditure on healthcare over 20102060, as % of GDP42. (The EU and EA averages in all result tables are weighted according to
GDP)
Looking at the latest data available (2009-2012), the first place in this
category (share of public expenditure on health as percentage of GDP)
belonged to Denmark (Table 2-5) with a public health care expenditure level
40
Source: The 2012 Ageing Report, Economic and Budgetary projections for the 27 EU Member States
(2010-2060)
http://ec.europa.eu/economy_finance/publications/european_economy/2012/pdf/ee-2012-2_en.pdf
41
Source: Stuckler D, King LP, Basu S. International Monetary Fund programs and tuberculosis
outcomes in post-communist countries. PLoS Medicine 2008;5(7):1079–90.
42
Source: The 2012 Ageing Report, Economic and Budgetary projections for the 27 EU Member States
(2010-2060)
http://ec.europa.eu/economy_finance/publications/european_economy/2012/pdf/ee-2012-2_en.pdf
Page 28 of 145
23/12/2014
near to 10% on years 2009 (9.8%) and 2010 (9.4) and the last to Cyprus
(with a percentage of 3.3 % of GDP for both years 2009 and 2010), Spain
belonged a level of 7.2% and 7.1% in years 2009 and 2010 respectively,
the level during the last years available (2008 and 2009) of Latvia was
4.2% and 4.1 %, and at last, the percentage in Croatia in 2009 and 2010 is
6.6% in both years43. Generally speaking, the level of public expenditure on
health is much less in the Member States that have entered the EU after the
year 2004, although the observed differences between countries may be
narrowing. Additionally we could refer to OECD findings where we observe
that overall health spending accounted for 9.3% of GDP on average across
OECD countries in 2012, and it was almost the same with the 9.2% of GDP
on average in 2011, but up from 8.6% before the crisis.
Table 2-5: Past trends in total and public expenditure on health in EU Member States 1980201244
Moreover, according to OECD statistics of 2013, spending on inpatient care
and outpatient care (combined) represents a big percentage of health
expenditure across OECD countries – around 62% of current health
expenditure on average in 201145 as can be seen in Figure 2-4.
Spending on inpatient care (including day care in hospitals) was the biggest
costing component for countries, such as France and Greece, where it
43
Source: European Health for all Data Base,
http://data.euro.who.int/hfadb/linecharts/linechart.php?id=lchart_473825001417774390&ind=6712&xpt=809
44
Source: OECD health data, Eurostat data and WHO Health for All database for health expenditure data.
Eurostat data for public (government) expenditure using COFOG. EU and EA averages are weighted
averages by either GDP or public expenditure where relevant and calculated by Commission Services.
45
Source: OECD (2013a), OECD Health Statistics 2013, Online database, OECD Publishing,
http://dx.doi.org/10.1787/health-data-en.
Page 29 of 145
23/12/2014
represented for 37% of total spending. We could refer also to countries with
a high share of outpatient spending such as Israel and Portugal (48% and
45% respectively). The other major category of health spending is medical
goods, where Slovak Republic (38%) and Hungary (37%) account for the
largest spending category of current health expenditure. Nonetheless in
countries such as Denmark, Norway and Switzerland, spending on the
category of medical goods represents only a small percentage (11%) of the
total health spending. The reason might be, that good due to our globalized
economy, are similarly priced in all these countries but salaries levels are
very different.
Figure 2-4: Current health expenditure by function of health care, 2011 (or nearest year).46
Note: Countries are ranked by curative-rehabilitative care as a share of current expenditure
on health; * Refers to curative-rehabilitative care in inpatient and day care settings; **
Includes home-care and ancillary services: 1. Inpatient services provided by independent
billing physicians are included in outpatient care for the United States
At the same time while spending on hospital and outpatient care had
pointed upwards in many countries during 2012, a big percentage close to
66% of the OECD countries (we could refer mainly to countries such as
Spain, France, Denmark and UK) have experienced reductions in
pharmaceutical spending since 200945. There are also differences between
countries in their expenditure on long-term care. Countries such as Norway,
Denmark and the Netherlands, allocate a percentage of over 20% of their
current health spending to long-term care while in countries such as
Portugal, the expenditure on long-term care represents a much smaller
proportion of total spending. The slowdown in health spending experienced
in many OECD countries in recent years has affected all spending
categories, but to varying degrees as summarised in Figure 2-5.
46
Source: OECD Health Statistics 2013, http://dx.doi.org/10.1787/health-data-en.
Page 30 of 145
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Figure 2-5: Average annual growth rates of health spending for selected functions, in real
terms, OECD average, 2008 to 201146
On June 2014, the OECD health statistics announced that health spending is
showing increasing trends after the negative paces in many OECD countries
(especially in Greece, Italy, Portugal, Spain, Czech Republic and Hungary)
during the crisis. But still the pace of growth remains well below pre-crisis
rates. Overall, ageing as well as non-demographic drivers of health care
expenditures will continue putting pressure on the long-term sustainability
of public finances. Balancing the health care needs of the European
population with spending resources, as well as continuous efforts to
increase the efficiency and quality of health service delivery, will continue to
be high on the political and economic reform agenda. According to the same
sources, the estimations demonstrate that the public health expenditure can
reach an average percentage of 8.5% of GDP in 2060 only on accounts of
demographic ageing – and to higher levels when other factors are also
taken into account.
2.5
Hospital Discharge Rates and Average Length of Stay
Hospital discharge rates along with the average length of stay are important
indicators of hospital activities. The average discharge rate globally in 2011
according to OECD was 156 per 1,000 and the highest hospital discharge
rates in Europe were met in Austria (273 per 1,000) and Germany (244 per
1,000), followed by the Russian Federation (219 per 1,000), Hungary (206
per 1,000) and the Czech Republic (202 per 1,000)47, while Spain has one
of the lowest with 104 per 1,000 (excluding discharges of healthy babies
born in hospital) as can be seen in Figure 2-7.
Generally speaking, we can take as a rule that those countries that have
more hospital beds in most cases have higher discharge rates as well. Thus,
member states such as Austria, Germany, Hungary and Czech Republic
score quite highly in the number of hospital beds per capita (Figure 2-8).
According to the OECD “the main conditions leading to hospitalization in
2011 were circulatory diseases (accounting for 12.3% of all discharges on
average in OECD countries), pregnancy and childbirth (10.2%), injuries and
47
Source: OECD (2013a), OECD Health Statistics 2013, Online database, OECD Publishing,
http://dx.doi.org/10.1787/health-data-en.
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other external causes (8.9%), diseases of the digestive system (8.8%),
cancers (8.4%), and respiratory diseases (8.2%)”48. Regarding the
European countries, Hungary (37 discharges per population of 1,000),
Austria (36 discharges per population of 1,000) and Germany (36
discharges per population of 1,000) were scoring again the highest
discharge rates for circulatory diseases, but mainly for diseases related with
cancer (Table 2-6) followed by countries such as Estonia (score 33) and the
Czech Republic (score 28) associated nevertheless mainly with heart and
other circulatory diseases.47 Overall, in about one-third of OECD countries,
the discharge rates have increased over the past ten years including nonEuropean countries such as Korea, Mexico and Turkey and EU countries
such as Germany, Slovenia and Switzerland. There are of course some
exceptions such as Belgium, Czech Republic, Denmark and Sweden that
remained stable whilst in some others such as Finland, France and Italy,
discharge rates have decreased. We must note also that the demand for
hospitalization may rise as populations age, taking into account that the
elderly populations accounts for an unbalanced high proportion of hospital
discharges as in the cases of Austria and Germany, where a percentage of
over 40% of all hospital discharges in 2011 were for people aged 65 and
over, more than twice their share of the population.
Table 2-6: Hospital discharges of inpatients by diagnosis (ISHMT — international shortlist for
hospital morbidity tabulation), 2010 (per 100 000 inhabitants)49
2.6
eHealth Patient Rights
Patient rights are constantly improving all over Europe. As a result
appropriate legislation based on patient rights and easy accessibility to the
48
49
Source: Health at a Glance 2013, OECD Indicators.
Source: Eurostat
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medical record is becoming standard. Regarding the patient rights category,
we observe in the related category of the Health Consumer Index 2013
report (see also the related table below) that Netherlands and Denmark
share jointly the first place as they both have the highest score (142 out of
the maximum 150). Norway follows very closely scoring 138 points whereas
countries such as UK, Estonia (129 points), Germany (125 points), Croatia
(121 points) follow from a distance and France, Finland, Portugal and
Sweden come next, sharing the same position in the category with 117
points. Countries such as Albania (82 points), Cyprus (75 points), Czech
Republic (79 points), Bulgaria (88 points), Greece (71 points), Malta (75
points), Poland (83 points), Serbia (79 points) still lack behind, scoring in
the lowest positions of the category and demonstrating a need for
improvement. Spain also needs improvement as it is scoring only 92.
Table 2-7: Country Score per Sub discipline50
Figure 2-6: Patient Rights and Information scores in EHCI 2013 (The scores have been reweighted to a maximum of 175, as was the case in 2012)50
50
Source: EHCI 2013
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Again in this category according to EHCI 2013 (Table 2-7, Figure 2-6)
Netherlands and Denmark are the best performers in Europe, sharing the
first place with 142 points while Norway follows closely scoring 138 points
and UK and Estonia are coming next with 129 points. The worst performers
in Europe for this category are member states such as Greece (71 points),
Cyprus (75 points), Malta (75 points) and Poland (83 points).
According to EHCI 2013, there is a continuous improvement in the
formation of healthcare legislation all over Europe and “there is a distinct
trend towards expressing laws on healthcare in terms of rights of
citizens/patients instead of in terms of obligations of providers. By 2013,
only 2 out of 34 countries have not introduced healthcare legislation based
on rights of patients: Malta and Sweden”51. There is also a vast
improvement in the crucial indicator on the role of patients organization in
the healthcare decision making from its introduction on 2006. On 2006 no
country did patient organizations while in 2012 16 countries were doing it.
In 2013 this number fell down to 12 countries that are doing patient
organization, maybe due to the economic crisis.
2.7
Social Protection Expenditure
Regarding social protection expenditure in relation to GDP (Table 2-12),
Denmark52 was scoring the highest between 2009-2011 (34.7%, 34.3%,
34.3%, respectively), while France followed with 33.6 % (2009), 33.8%
(2010), 33.6% (2011). Third were the Netherlands with 31.6% (2009),
32.1% (2010) 32.3% (2011)52. Also – according to the same source countries such as Germany, Italy, Austria, Belgium, Greece and Finland are
worth mentioning as they are reporting ratios of around 30.0% or more in
the same period. At the same time (and speaking for the decade 20012011) Malta, Slovakia, Bulgaria, Lithuania, Romania, Estonia and Latvia
score quite low – almost every year under 20.0% of their GDP. Countries
such as Cyprus, Croatia and Poland dedicate on social protection
expenditure a percentage of around 20% of their GDP while the largest
increase was noted in Ireland, where the expenditure was increased from
14.3% in 2001 to 29,6% in 2011. Τhe average percentage of the public
expenditure on pensions across the EU28 was equal to 13.0% of GDP in
2011, having as top scorers Italy with a percentage of 16.1%, Greece with
a percentage of 14.9%, Austria with a14.9% and France with a percentage
of 14.8%.On the contrary Ireland was scoring the lowest percentage (7%)
along Lithuania (7.5%), Estonia and Latvia (Figure 2-9). Expenditure on
care for the elderly in the EU28 accounted for an average of 0.5% of GDP in
2011, but Sweden (with a percentage of 2.5%) was scoring at a level nearly
five times as high as the average following closely from Denmark which has
a 2.1%). On the other hand, expenditure on the elderly was less than 0.1%
of GDP in countries such as Belgium, Germany, Cyprus, Luxembourg and
Romania (Figure 2-10). Expenditure on care for the elderly cover care
allowance, accommodation, and assistance in carrying out daily tasks. In
the 2010 the average (median) pension levels of seniors aging between 65
to 74 years were generally lower than the average gains for the elderly
51
52
Source: Health Consumer Powerhouse Arne Björnberg,Ltd., 2013. ISBN 978-91-980687-2-6
Source: Eurostat, http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Social_protection_statistics
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groups that aged 50 years to 59 years across the EU27 (Figure 2-11). This
ratio called aggregate replacement ratio was lower in member states such
as Bulgaria, Cyprus, Denmark and Greece where the average median
pension levels represented a proportion between 36% to 44% of the
average gains among the people aged 50 to 59. At the same time this ratio
was highest in Luxemburg, France, Romania (2011), Slovakia and Austria,
where it was at least 60%.52
Figure 2-7: Hospital Discharges, 2011 (or nearest year).53 Excludes discharges of healthy
babies born in hospital (between 3-10% of all discharges), includes same-day separations
Figure 2-8: Hospital beds per 1 000 population, 2000 and 2011 (or nearest year)53
53
Source: OECD Health Statistics 2013, http://dx.doi.org/10.1787/health-data-en.
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Table 2-8: Percentage of population aged 80 years and over on 1 January of selected years54
Table 2-9: Change in the percentage of population aged 80 years and over by decade54
54
Source: Eurostat http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Population_projections.
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Table 2-10: Old age dependency ratio on 1 January of selected years54
Table 2-11: Change in the percentage of population aged 65 years and over by decade
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54
Table 2-12: Expenditure on social protection, 2001-11 (% of GDP)55
Figure 2-9: Expenditure on pensions, 2011 (% of GDP)55
55
Source: Eurostat, http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Social_protection_statistics
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Figure 2-10: Expenditure on care for the elderly, 2011 (% of GDP)55
Figure 2-11: Aggregate replacement ratio, 2012 (%)55
2.8
Changes to Public Spending due to Financial Crisis
All European countries have experienced a deep economic recession since
2007. The financial crisis has affected most European countries’ budgets so
public spending has been declined, and healthcare expenditure was not an
exception. One third of EU countries have made extended cuts to the health
budget, mainly those countries hit hardest by the crisis51. In order to reduce
deficits, governments began implementing austerity measures, and proceed
to budget cuts especially in public services provision. Despite the fact that
there is a clear commitment for reducing healthcare costs among the worstaffected countries, the way to introduce and implement these reforms
varies. Many countries such as Greece, Estonia, Latvia, Portugal and Cyprus
have made efforts to decrease public spending on health by shifting costs to
individuals56. More specifically, according to WHO, sixteen countries
reported introducing or increasing user charges for the following services:
56
Source: Health, health systems and economic crisis in Europe Impact and policy implications, WHO
Regional office for EUROPE
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Table 2-13: Countries that introduce charges per service57
SERVICES
AMBULATORY CARE
PRESCRIPTION DRUGS
HOSPITAL CARE
USE
OF
EMERGENCY
DEPARTMENTS
AMBULANCE TRANSPORT
LONG TERM CARE
SPECIFIC ITEMS
OTHER
COUNTRY INTRODUCING CHARGES
TO THIS SERVICE
Cyprus, Estonia, Greece, Iceland, Italy,
Latvia, Portugal, Turkey
Cyprus, Czech Republic, France, Greece,
Ireland, Latvia, Portugal, Slovenia, Spain
Armenia,
Czech
Republic,
France,
Greece,
Ireland,
Portugal,
Russian
Federation
Cyprus, Ireland, Portugal, non-urgent
use in Italy
France ,Slovenia
Estonia
IVF in Denmark, non-routine vaccines in
Czech Republic and Portugal, some
medical devices in Czech Republic,
medical certificates in Portugal, dental
prostheses in Slovenia
Latvia substantially raised the annual
cap on user charges, lowering protection
for those not exempt from user charges,
although some of the increases in user
charges were also reversed.
For instance, in Ireland most of the measures implemented have been
targeting cuts in wages and a reduction in the number of sanitary workers.
Furthermore, cuts affected salaries of professionals and pharmaceutical
providers58. Expenditures for health infrastructures have been frozen in
various EU member states including Iceland, Czech Republic, Estonia and
Ireland, while improvements in efficiency are being envisaged through
implementation of measures such as hospitals mergers or accelerating the
move from inpatient care in hospital to outpatient care and day surgery.58
Nevertheless, against this trend there also exceptions that reduced or
removed charges to protect low-income groups. “There is no inevitable
relationship between recessions and healthcare budget cuts”59. For instance,
Austria and Germany both experienced similar economic downturns during
2008–2009, but Austria’s government reduced public spending on health, at
US$ 90.1 per capita, adjusted for purchasing-power and inflation, while
Germany at the same time increase government spending at US $57.4 per
capita59. As Figure 2-12 shows, policymakers around Europe allocated
health budgets quite differently. Some incremented healthcare expenditure
in order to satisfy the increasing population needs, despite the budgetary
57
Source: WHO Health systems and economic crisis in Europe impact and policy implications.
Source: Health at a glance 2012 OECD Indicators Medical Practices Over Population Ageing”, Annales
d’Économie et de Statistique, No. 83/84, pp. 187-217.OECD (2013a), OECD Health Statistics 2013,
Online database, OECD Publishing, http://dx.doi.org/10.1787/health-data-en.
59
Source: Reeves, A; McKee, M; Basu, S; Stuckler, D (2013) The political economy of austerity and
healthcare: Cross-national analysis of expenditure changes in 27 European nations 1995-2011. Health
policy (Amsterdam, Netherlands). ISSN 0168-8510
58
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constraints.60, 61, 62, 63 While a group of countries (especially Iceland, Ireland,
Spain, Greece, Slovenia) appear to have reduced heavily public healthcare
spending countries such as Belgium, Norway, Austria, Netherlands, France,
Luxemburg and Switzerland are an exception as they keep high health-care
expenditures exceeding by a wide margin the EU average in an aim to
improve the quality and ease of access to the health services while fostering
economic growth51, 59. Taking into account previous experiences of fiscal
austerity in Europe during the decades of 1980s and 1990s, an analysis by
Pierson P. found “that because healthcare spending is highly visible,
accounting for >10% of GDP in most European countries, and is used by
virtually all the population, governments generally found health care to be a
cause of political headaches rather than a target for successful
retrenchment”64. The important position of the healthcare budget within the
state budget makes it an obvious target for governments that choose the
solution of budget cuts rather than tax rises. It is generally acceptable that
the presence of the International Monetary Fund (IMF) is a primary factor
putting pressure to governments towards healthcare budget cuts and social
protection spending 59, 65, 66. Among 135 countries, between the decade
1996 and 2006, countries that did not borrowed from the IMF on average
increased public healthcare expenditures by $0.45 per dollar $1 of donor aid
while countries that borrowed from the IMF increased public healthcare
spending by only $0.01 for every additional dollar59, 67.
60
Source: Spilimbergo A, Symansky S, Schindler M. Fiscal multipliers. Washington: IMF Staff Position
Note: IMF; 2009.
61
Source: IMF. World economic outlook: coping with high debt and sluggish growth. Washington, D.C.:
IMF; 2012.
62
Source: Cylus J, Mladovsky P, McKee M. Is there a statistical relationship between economic crises
and changes in government health expenditure growth? An analysis of twenty-four European countries.
Health Services Research 2012;47(6):2204–24.
63
Source: Reeves A, Basu S, McKee M, Meissner C, Stuckler D. Does investment in the health sector
promote or inhibit economic growth? Globalization Health 2013;9(43)
64
Source: Pierson P. Dismantling the welfare state?: Reagan, Thatcher, and the politics of retrenchment.
65
Source: Stuckler D, Basu S. The International Monetary Fund’s effects global health: before and after
the 2008 financial crisis. International Journal of Health Services 2009;39(4):771–81
66
Source: Stuckler D, King LP, Basu S. International Monetary Fund programs and tuberculosis
outcomes in post-communist countries. PLoS Medicine 2008;5(7):1079–90.
67
Source: Anderson RN, Mini˜no AM, Hoyert DL, Rosenberg HM. In: Reports NVS, editor.
Comparability of cause of death between ICD-9and ICD-10: preliminary estimates. Hyattsville,
Maryland: CDC; 2001. p. 1–32
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Figure 2-12: Change in GDP and change in government spending on health across countryspecific recession and austerity periods. Cross-national variations in healthcare spending, by
country-specific recession and austerity periods, 24 EU countries and the United States68
Figure 2-13: Annual average growth rate in per capita health expenditure, real terms, 2000
to 2011 (or nearest year)69
2.9
Political Support of Integrated Care
The integration of sociosanitary healthcare has been on the European
states’ agendas for more than 20 years, but despite the introduction of
various policies and strategies on national and EU level, and the existence
of many initiatives and projects of this kind in different European regions
68
69
Source: WHO health expenditure database 2013 edition, Eurostat 2013 edition.
Source: OECD health statistics 2013. http://dx.doi.org/10.1787/health-data-en
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(many of them did not pass the pilot stage) and there is still much to be
done. The ground is now fertile for significant changes. Although support
across Europe is currently greater than ever, and we could say it is gaining
"momentum", due to the difficult integration (many different stakeholders
involved), reaching the objectives will take time. It is not the technologies
and techniques that are the main barrier, but the necessary human,
professional and system changes. The major issue is that the nature of the
problem is sociopolitical and not technological as there are separate legal
and funding structures between health and social care. As the average of
older citizens rises all over the European countries at the same time this
translates to higher number of patients that face moderate chronic health
diseases and lack of accessible family support and thus are at risk of
compromised health. These people are suffering more chronic ailments that
require sustained intensive care. There is also a growing need for better,
personalized services from their health providers. The European society has
made many efforts and created many services to help these citizens but
these services are still segmented into many organizational clusters such as
Health, Social Care, Housing, and others. There is lack of coordination
among these clusters and their offered services are separately organized
and delivered (and the same goes for their respective staff). Healthcare
leaders around Europe are seeking to improve the quality of healthcare
delivery and broaden access to basic services for the demanding population.
At the same time, they are trying to keep costs low. Most European
countries –and especially the European South (Italy, Spain, Portugal, and
Greece) are being hit from the financial crisis and as a result their
healthcare systems—are under similar financial pressures, and are facing
many new challenges in meeting increased demands for care.
The lack of coordination among the care stakeholders brings with it
miscommunications among the various involved parties, contradictory
legislations, duplication of procedures and inefficiencies. As a result the
patients are unhappy with their care where the unhappiness stems from
relatively high costs and accessibility problems. Many countries are trying to
take measures to eliminate these inefficiencies and to promote integration
through the establishment of strong regulations at a local and national level
that will promote coordination and collaboration. However, some
governments – apparently mainly due to national culture - delay measures
for the promotion of integrated care, and if they finally decide to do it they
just take soft and inadequate actions70. As a result policy makers are under
less pressure to develop legislative measures and structures of formal
integrated care. Thus the change is easiest to happen in countries will long
tradition of integrated care policy such as the Nordic countries. Nonetheless
there is no guarantee for a successful implementation of measures and
policies even when governments succeed in creating legislation for its
promotion. For instance, decentralization may slow down decision making
processes. Additionally, the presence of too many decision-making
processes and decision makers can be an obstacle to change.
The experiences in many European countries such as Finland, Sweden,
Netherlands and England demonstrate that clear legislation for integrated
70
Source: Comparing integrated care policy in Europe: Does policy matter? Ingrid Mur-Veeman, Arno
van Raak, Aggie Paulus
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care, appropriate financial incentives encourage stakeholders to establish
integrated care arrangements70. Also, the position and the different roles of
the several actors within the institutional framework where the health and
social system operates, define the formation and the implementation of
respective policies. Although, in all countries, the central government has
the final responsibility for implementing and coordinating health and social
care services, its power position differs from country to country. In some
countries the central government (e.g. UK, Greece, and Cyprus) has strong
decisional power while in others the system is characterized by
decentralized powers (e.g. in Sweden, Spain, Finland, Netherlands).
Additionally, the actors that are playing vital role in the decision process
differ per case and we observe that there are countries where
municipalities/regions are playing the main role (Finland, Sweden, and
Denmark) while in others the power lies in the hands of providersprofessionals and non-government organizations. For example we could
refer to the case of Austria where the hospitals and medical specialists have
a prominent role on the decision-making regarding integrated care services.
In the Swedish system, regions along with the municipalities develop a
pivotal role in the process of policymaking and care delivery70. Also the
most essential characteristic of the Dutch health care system is that
important operative decisions are taken, to a remarkably high degree,
jointly by medical professionals and patients.51
Also, the way of promoting integrated care is of importance. In some cases
the central government uses mandatory legislations and obligatory rules
with more hierarchical directions while in other cases (that could be
characterized mostly decentralized) policy makers produce mostly
supporting policy notes, recommendations and guidelines. Local and
regional authorities may have more impact on care delivery, if they own
health care centres, primary care services, or nursing homes.
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3 THE SOCIO-SANITARY SYSTEM IN SPAIN
3.1
An Overview of the Spanish Situation
In Spain, healthcare and social care services are often delivered
independently today. This leads to inefficiencies, duplication of resources,
and potentially to reduced quality of care. Older people are particularly
affected by this situation, since they often need both types of services, such
as support with daily living activities and chronic disease management.
The live expectancy in Spain is on a continuous rise over the last 30 years
and is among the highest in Europe. While this is certainly good news, it
puts stress on the existing health and social systems, and there is no doubt
that a change to a more efficient implementation is necessary.
The population resident in Spain at 1 January 2013 stood at 46.7 million
inhabitants, indicating a decrease of 0.2%, as compared with the previous
year. Persons aged 65 years old and over, represented 17.7% of the total
population.
Figure 3-1: Spanish population71
Life expectancy at birth exceeded 82 years of age in 2012, following the
positive trend registered in recent years. For males, life expectancy at birth
reached 79.4 years, and for females, it reached 85.1 years of age.
In 2012, Spanish women were the most long-lived of the European Union.
Spanish males ranked third at a European level, after the Swedes and the
Italians.
There are various obstacles to more efficiency, in socio-sanitary care, one of
which being decentralization and fragmentation of the Spanish
administrative system. Excluding the EU level, there are several levels of
government administration: National (the Ministry of Health, Social Services
71
Source: Spain in Figures 2014, Spanish National Statistics Institute (INE),
http://www.ine.es/ss/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobheadername1=ContentDisposition&blobheadervalue1=attachment%3B+filename%3Despa_cifras_2014_en.pdf&blobkey=urldata&blobtable=MungoBlob
s&blobwhere=16%2F816%2Fespa_cifras_2014_en.pdf&ssbinary=true
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and Equality: 'Ministerio de Sanidad, Servicios Sociales e Igualdad)
represents the higher level, responsible for proposing and implementing the
Government's guidelines on health policy, planning and health care and
consumer products as well as on Social Affairs; Regional (17 Autonomous
Communities) and Municipalities or Town Halls (Local) (8,112) that have
over them Diputaciones (50 as many as provinces) as presented in
Figure 3-2. The Autonomous Community with the largest number of
municipalities (2,248) is Castile & León, while the region with the smallest
number (45) is Murcia.
Figure 3-2: Number of municipalities by autonomous community72
Apart from this high level of fragmentation, one has to bear in mind that
Spain is one of the most affected countries in Europe by the economic crash
and is experiencing a period of intense social crisis, rising unemployment
and large cuts in public spending. Hence, the Spanish welfare state is
underfunded and undermanned. And, with the cuts of public social
expenditure, the situation is getting worse. The average time for patient
visits to their general practitioners, in the National Health Services, has
been reduced by 30 per cent since the crisis started in 2007. Spain is one of
the countries that spend the least on its welfare state, only 22% of its GDP
vs 27% average for the rest. Recent austerity measures have resulted in
the following impacts:

Pharmaceutical sector: Reduction in drug prices, declining demand
due to the introduction of co-payment for pensioners.
72
Secretaría de Estado de Cooperación Territorial, Ministerio de Administraciones Públicas
http://www.seap.minhap.gob.es/dms/es/publicaciones/centro_de_publicaciones_de_la_sgt/Otras_Publicac
iones/parrafo/01111111115/text_es_files/Regimen-Local-ING-INTERNET.pdf
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
Health professionals: Wage cuts, increased working hours,
incentive for retirement at the age of 65, decline in temporary
contracts.

Health services providers: Drop in contract volume and increase in
payments due.

Citizens: Growing waiting lists, loss of coverage for immigrants and
other minorities, introduction of pharmaceutical co-payment for
pensioners.

Investments: Budget cuts in all Autonomous Regions leading to
falling investment.
The fact is that austerity measures can be effective in the short term to cut
costs, but can have negative results on health in the short, medium and
long term and even a negative economic impact in the medium or long
term.
The fundamental message is that not every cut is “worth it” and the
decision to cut must be preceded by an analysis of the resulting
consequences. The position of the European Union, more specifically of the
Commission for Health and Consumer Policy, has always been that the
economic crisis cannot become a public health crisis. This position is
supported by the WHO which lists a number of measures in response to the
financial crisis in Europe.
Spain lacks infrastructures and funding in intermediate care services, which
should be addressed to meet the health and social needs of the population.
Intermediate inpatient units, also called medium or long-term care units,
belong to a wider set of facilities that aim to respond to the needs of longterm care. These units target patients who do not require the resources of a
general hospital but are beyond the scope of traditional health care facilities
or geriatric institutions. When compared with other European countries,
Spain is bottom tier in terms of number of long-term care beds per 1,000
people over 65, with significant differences between autonomous regions
and lacking a model for this type of care delivery.
Further, there is a strong unbalance between resources dedicated to the
Spanish health and the Spanish social system as can be seen in Figure 3-3.
It is likely that a change towards a Spanish socio-sanitary system will not
be accompanied by new resources. Hence, when making plans for change
they have to be based on a redistribution of existing resources. However,
this would imply a reorganization of human resources that account for the
highest chunk of costs both in the present day Spanish health as well as in
the present day Spanish social system, with the foreseeable resistance to
change on political, organizational and societal level.
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Figure 3-3: Long-term care expenditure (health and social components)73
The Spanish National Healthcare System (SNS) is based on universal
healthcare and provides health care services to all Spanish residents. It is
co-funded by the Central Government and funds coming from each Regional
Government (Comunidad Autónoma). Under the guidance and control of the
Regional Governments, Regional Departments allocate the funds within
their own region to health care service providers. The health care service
providers are either public institutions or organized as public-private
partnerships under various collaboration agreements. To benefit from
medical assistance through the Spanish National Healthcare system,
residents must enrol with the General Social Security Fund (Dirección
General de la Tesorería General de la Seguridad Social - TGSS).
The Spanish National Health Service has an extensive network of health
centres and hospitals throughout the country. The Health centres offer
primary health care services (family/GP services, paediatrics and nursing,
with availability of midwives, physiotherapists and social workers). If
circumstances require, medical attention can be provided in the patient’s
home. Hospitals offer specialized attention, with access via referral from
primary healthcare services. Medication is obtained at pharmacies.
Prescriptions are delivered by doctors, although some medications can also
be obtained at pharmacies without prescriptions by paying their total cost.
Primary care in Spain has been playing a significant role since the early
80's, when a major transformation of the health care system took place,
along with the political reorganization of the state in the Autonomous
Communities (ACs). The principals of the Spanish health system are those
of a National Health System (SNS) model, focusing on universal coverage,
73
Health at a Glance 2013 - OECD INDICATORS
http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf
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with free access to health care for the entire population. This also includes
the integration of different health service networks and political devolution
to the ACs. Primary care plays a central role as a gatekeeper, whose core
functions are integration of promotion, prevention, rehabilitation and
curative activities.
The devolution process in the health sector occurred in different stages
within the 17 ACs, and this has resulted in different models of care under an
umbrella of an SNS, common for all Spain.
The primary health care workforce in Spain is organized around a
multidisciplinary team, who work in primary health centres. They provide a
wide range of services with the main emphasis on prevention and promotion
of health, acute and chronic care, homecare and community care activities.
The core of the team is made up of physicians who are family and
community medicine specialists, paediatricians, nurses, auxiliary nurses,
social workers, dentists and administrative staff. The team works closely
with midwives, gynaecologists, public health professionals, pharmacists,
radiologists, physiotherapists and laboratories.
A characteristic of the Spanish health care model, with different approaches
in various ACs has resulted in a rich variety of models. There are, however,
several barriers for the development of primary care. Its budget has not
increased over the last few years; hospital lobbies still find it difficult to shift
into territory based capitation; and an integrated care perspective is not a
priority. The current economic downturn should be taken as an opportunity
to accelerate the innovative formulae in order to coordinate and integrate
care.
Unlike many European countries, University departments in family medicine
do not exist in Spain. The specialization period is carried out in Family and
Community Medicine Teaching Units, which are responsible for coordinating
the postgraduate and specialization four-year programme of the speciality
in family and community Medicine. On the other hand, the multidisciplinary
team work has resulted in an excellent platform for research and continuous
medical education. It has the support of scientific societies and primary care
research institutes. This compensates for the inexistence of University
Departments74.
Policy makers in Spain should promote experimentation and allow pioneers
to develop new models. It should also provide more autonomy at a local
level. There are still obstacles which impede change, such as the top-down
approach and the civil servant workforce in most of the territories. They are
governed by rigid rules and regulations and a highly politicized system of
promotion with no new public management being incorporated in the
system.
The current crisis, along with the development of IT, provides an
opportunity to develop a more flexible and innovative model of
organisation. Empowering patients in their self-care; new roles of the
healthcare professionals; electronic prescriptions; the use of telemedicine
74
European Forum for primary care, March 2011 (Toni Dedeu)
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and tele-healthcare, along with the implementation of new approaches to
the management of chronic care, are in the agenda in the Spanish health
system. These should all contribute to the sustainability of the system and
guarantee health equity.
On the other hand, the Spanish social care system has been, a competence
shared between regional and local level: some competencies are exclusive
to regions, while others are unique for councils. Following the proximity
principle, the role of town councils has been fundamental to the building of
a decentralised state in Spain, since they can exercised the competences
with an important effect on quality of life of local citizens. At the end of
2013 a new Law (Ley 27/2013 de 27 de diciembre, de racionalización y
sostenibilidad de la Administración Local (LRSAL)) was issued, foreseen to
enter into force on December 2015. This new legal framework for public
administrations modifies substantially their competences and specifically in
what refers to social services that can only be determined by law (LRSAL
art.7). Until December 2015, the Autonomous Communities extend their
influence; the specific legislation must be taken in account when
interpreting the content specific competence of the municipal social
services, which is driven by the Central Government.
In Health, changing paradigms and models are claimed, because the need
to adapt to changing demographics and epidemiological, requires
reorientation in care for patients with chronic disease, neurodegenerative
disease, mental illness, or multiple disorders and clinical complexity.
In the social area, changes are based on the urgent need to simplify and
streamline procedures and the need to invest to alleviate the low level of
coverage, which is shrinking rather than increased, with particular reference
to the collapse of services and dependency and/or disability benefits.
Today, talking of coordination in Spain is to talk about the sustainability of
the Health system and the Care model, and it is talking of the social
services system, very much on the basic features and benefits of the
dependency law. Nevertheless, despite some promising Spanish examples
in, for example, Protocolo de Coordinación Sociosanitaria de la Región de
Murcia, Programa de Intervención Social al Anciano (Guadalajara)
integrated socio sanitary care is still at its very beginnings. Fundamental
structural changes are slow, which considering the virtual integration
capabilities of INCA is providing an interesting market opportunity.
The remainder of this chapter will introduce details of the status quo of the
Spanish health care and social care systems in detail in Section 3.2 and
Section 3.3 respectively. Afterwards the focus shifts to political drivers and
initial first steps undertaken to come to an integrated socio sanitary care
system in Section 3.4. Finally, and with the intention to enable very
concrete future work towards INCA sustainability, Section 3.6 and Section
3.6 provide insight on ICT tool buying processes and peculiarities in Spain,
as well as an identification of main Spanish market actors, subdivided into
users, buyers and providers of INCA related ICT tools and services.
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3.2
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The Spanish Health Care System in Detail
3.2.1
Access to and Coverage of the Spanish Health Care System
The General Social Security Fund - TGSS covers medical treatment in a
health centre and in (a public or private) hospital. It also provides low cost
medicines, surgical prostheses, orthopaedic equipment and ordinary
wheelchairs. However, it excludes dental prostheses or eyeglasses.
Citizens coming from European Union countries are treated according
European Directive 2011/24/EU on the application of patients’ rights in
cross-border health care, which was approved on the 7th of February 2014
by the Board of Ministers to become Spanish national law (Real Decreto
81/2014). Besides regulating access of EU citizens of other EU member
states to the Spanish health system (SNS), Real Decreto 81/2014 also
regulates a reimbursement scheme for citizens insured under the Spanish
health system that access and pay health services in other EU member
states.
In Spain, registration with the Social Security service is done when a person
begins to work for the first time, and is valid for his or her entire working
life. Once a person has registered s/he is given a registration card with his
or her personal details and a personal social security identification number.
The identification number is valid for his or her whole lifetime and is used
for all dealings with the social security system.
Social security contributions are calculated as a percentage (contribution
rate) of the contribution base. These contribution bases and rates are
determined by the government each year. The social security system in
Spain has two levels of protection: the contributory system and the noncontributory system.
The Contributory system is further subdivided into:

a general scheme applicable to all employed persons who are not
covered by special schemes, plus certain categories of civil servants;
and

three special schemes, for: the self-employed, coal miners and sea
workers (sailors and fishermen).
Students are covered by a special protection plan (school insurance) and for
accidents at school; they are also included in the general system. There is
also a special contributory scheme for some civil servants.
The Non-contributory system provides coverage to people who face a
specific situation of need, and whose income is below a certain legally
prescribed level. They may be entitled to this even if they have never paid
social security contributions, or have done so but are not entitled to the
resulting benefits under the contributory system. Non-contributory benefits
include:
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
medical assistance;

retirement and disability allowances;

special assistance for the unemployed (subsidio por desempleo);

family allowances;

non-contributory maternity allowance (subsidio por maternidad de
naturaleza no contributiva).
Access to health insurance is also provided to family members of insured
persons as long as they reside in Spain, including, under certain conditions:

the spouse of the person insured or the person co-habiting with the
insured;

those who are separated or divorced if they have the right to
alimony;

lineal descendants of the insured or his/her spouse, whatever their
legal filiation, brothers and sisters of the insured person, and fostered
children, younger than 26 or with a degree of disability of at least
65%.
Further, the Spanish system provides for the possibility of concluding
special voluntary insurance agreements with the social security services
for the purpose of maintaining, or in certain specific cases extending, an
entitlement to social security benefits. In certain situations this may mean
subscribing to the corresponding social protection scheme, depending on
the person’s occupation. In such cases the insurance contribution is paid
entirely by the subscriber. The subscriber can also aim for a voluntary
insurance to obtain some of the National System of Health’s benefits by
paying some public cost.
Care at private hospitals and clinics in Spain are either paid directly or,
most often, through a private insurance carrier. The main benefit of
contracting private health insurance in Spain is to avoid the sometimes long
waiting times to see a doctor associated with the public healthcare system.
Private healthcare companies also offer quicker service to patients and offer
value-added services such as private rooms, express mailing of test results
and keeping patients informed via email and SMS messages. Some of the
most popular private medical insurance carriers in Spain are Sanitas and
Mapfre.
With the reform, Chapter II of the Royal Decree-Law 16/2012, of April 20,
2012, on urgent measures to guarantee the sustainability of the National
Health System and improve the quality and safety of its services amends
Law 16/2003, of May 28, 2003, on cohesion and quality in the national
health system, by setting up categories in the portfolio of services. To that
end, it creates: (i) a basic common portfolio of welfare services funded
completely out of the public purse; (ii) a supplementary common portfolio
funded partly out of users' contributions; and (iii) a shared portfolio of
ancillary services funded out of users' contributions or subject to
reimbursement for users. Furthermore, the autonomous communities may
approve their own portfolios of services, which must include, at least, the
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three central government portfolios described. Moreover, the Royal Decree
Law 16/2012 reform abolished medicaments free for pensioners,
introducing co-payment based on income level and establishing maximum
thresholds for disbursements. It also extended the type of benefits to goods
and services such as orthopaedic prostheses, diet therapy and nonemergency medical transport:
a) users and their beneficiaries whose annual income is equal to or
greater than €100,000 must contribute 60% of the recommended
retail price of medicinal products;
b) active insured persons and their beneficiaries whose income is equal
to or greater than €18,000 must contribute 50% of the recommended
retail price of medicinal products;
c) active insured persons and their beneficiaries not falling within the
above cases must contribute 40% of the recommended retail price of
medicinal products; and
d) pensioners in the social security system, except for those in case (a)
above, must contribute 10% of the recommended retail price of
medicinal products.
In order to guarantee continuity in the treatment of chronic illnesses and a
high level of fairness among pensioner patients undergoing lengthy
treatments, Royal Decree-Law 16/2012 places the following ceilings on
chronic users' contributions:
a) 10% of the PVP for medicinal products belonging to the reduced
contribution ATC (Anatomical, Therapeutic, Chemical classification
system) groups;
b) €8/month for insured persons who are pensioners in the social
security system and their beneficiaries whose income is less than
€18,000;
c) €18/month for insured persons who are pensioners in the social
security system and their beneficiaries whose income is equal to or
greater than €18,000 and less than €100,000; and
d) €60/month for insured persons who are pensioners in the social
security system and their beneficiaries whose income is greater than
€100,000;
If the users' contributions exceed those thresholds, Royal Decree-Law
16/2012 allows them to be reimbursed. The reimbursement procedure
involves an upfront payment by the user and subsequent reimbursement
within six months by the "appropriate autonomous community”.
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3.2.2
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Spanish Health Care System Participants and Interrelationships
Spanish health care system participants and their interrelations in terms of
financial and service flows are outlined in Figure 3-4. There are 17 regional
health services to deal with.
The taxes and contributions are used by the Autonomous Communities to
support the different Health Regional Services, which divide the amount of
money between different areas of health, as primary attendance centres,
public hospitals, pharmacies, public health, military hospitals and
penitentiary centers, some private hospitals and, finally, some private
professionals.
On the other hand, some of the social contributions are destined to work
accident insurance companies and professional disease insurances.
A percentage of the taxes go from the state administration to INGESA
(Instituto Nacional de Gestion Sanitaria) in Ceuta and Melilla, as well as the
Social Institute of Marine and to the Insurances of Public Servants.
Moreover, some funds are coming from patients by direct payments/copayments of goods and services, for example, for medicines, private
hospital services and private professional services.
The private services are financed, on one hand, by patient’s insurance
premiums and, on the other hand, by the public sector.
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Figure 3-4: The Spanish Health System and its financial Flows75
The Primary Care Centres depend entirely on the SNS (Sistema Nacional de
Salud) or NHS (National Health System), which means, they are directly
financed by the regional health services of each autonomous community.
In the decentralized Spanish health system informatics solutions are also
decentralized. Each community and even each hospital use different
solutions, deriving in a wide range of solutions across the Spanish territory.
Most of today solutions come from solutions delivered years ago on
mainframes and later shifted to client-server infrastructures. Hospitals keep
updating their systems with the aim of improving their solutions and
according to available market solutions. However due to the costly solutions
they pay for, and due to the long time it takes them to accommodate to the
applications and due to the many problems and errors encountered in some
of the deployed solutions, medical personal are usually reluctant to change
and sceptic of new solutions.
It is not easy to compare INCA with other alternatives, because we have to
limit ourselves to specific or modular solutions for chronic management,
which is not always easy or clearly differentiated. Many hospitals use
management systems that need to be appropriately parameterized in order
to function. Not all the professionals are able to perform such functions and
75
Source: Spanish Ministry of Health, Social Services and Equality
http://www.msssi.gob.es/organizacion/sns/docs/flujosFinancieros.pdf
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many of the hospital operative lies in the hands of technical people not
medical doctors.
Some communities are more advanced than others, and a lot of talk is
going on about the so much needed socio-sanitary integration that seems to
be an essential objective all over Spain. Table 3-1 shows the different
Health system in the different autonomous communities of. In the third
column the autonomous communities ticked with an X are those that have
some chronic ICT solution similar to INCA in use or under test. The last two
columns in Table 3-1 are showing the number of health areas (Áreas de
Salud) which exists in each community. These areas can include several
hospitals under their influence/responsibility, especially when it comes to
buying decisions. The areas are the fundamental structures of the national
healthcare system and are responsible for the unitary management of the
health services offered at the level of the Autonomous Community. They are
defined taking into account factors of demography, geography, climate,
socioeconomics, employment, epidemiology and culture. Usually, they are
the ones taking decisions over individual hospitals. These would be the
potential customers (at Hospital level) we could aspire.
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Table 3-1: Health system in the Autonomous Communities76
Autonomous Community Health Service
Servicio Andaluz de Salud Servicio Aragonés de Salud Servicio de Salud del Principado de Asturias Servicio de Salud de las Islas Baleares Servicio Canario de Salud Servicio Cántabro de Salud Servicio de Salud de Castilla‐La Mancha Sanidad Castilla y León Servicio Catalán de Salud Conselleria de Sanitat Generalitat Valenciana Servicio Extremeño de Salud Servicio Gallego de Salud Servicio Madrileño de Salud Servicio Murciano de Salud Servicio Navarro de Salud Servicio Vasco de Salud Servicio Riojano de Salud Instituto Nacional de Gestión Sanitaria 3.2.3
Name
Projects similars to INCA
SAS SALUD SESPA IB‐SALUT SCS SCSalud SESCAM SACYL CATSALUD GVA SES SERGAS SERMAS SMS OSASUNBIDEA OSAKIDETZA RIOJA SALUD INGESA X PAAIPEC X X? X (Healthcare) Organizative Level
Distrito/ Área de Gestión Sanitaria Área de Salud ‐ Sector Área Sanitaria Área de Salud Área de Salud Área de Salud Área de Salud Área de Salud Región Sanitaria Departamento de Salud Área de Salud Gerencia de Atención Primaria Área de Salud / Dirección asistencial Área de Salud Área de Salud Comarca Sanitaria Área de Salud 2011
33
8
8
3
7
4
8
11
7
24
8
7
7
9
3
7
1
157
Spanish Health Care in Numbers
Over 90% of the population in Spain makes use of the public system for
their medical needs while an estimated 21% holds private health insurance
including most civil servants who have the choice of coverage by the public
or the private systems. This insurance is used either as a supplement or an
alternative to public care.
The most frequent model allows publically insured to choose their primary
care doctor (GP), through which they access the rest of the system. In
order to consult a specialist, patients must first be referred by their primary
care doctor (except in emergencies). Unfortunately, as in some European
countries there can be long waiting lists to see specialists and for elective
and non-emergency surgical care.
The advantage of private insurance is that the insurance companies have
their own network of hospitals, clinics and laboratories. Policyholders usually
do not have to wait as long for treatment. The only downside is that these
companies can insist that patients use only doctors who are members of
their group. However, some have programs that refund 80% of the fees
charged by physicians outside the group. Adeslas, Asisa and Sanitas are the
largest private healthcare providers.
In 2012 the private health sector had 462 hospitals with 52,843 beds,
representing 53% of hospitals and 32% of beds. Catalonia, Madrid and
Andalusia are the regions that have a greater number of private hospitals
and beds. 42% of the private hospitals have some type of arrangement with
public administrations.
The satisfaction of the public system has a punctuation of a 6.41 in scale
from 1 to 10. The evaluation is that 66% of Spanish population appreciates
76
Source: Editorial MAD, http://www.mad.es/sanidad/mapa-sersalud.asp
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the public system, 28% think that the system should change and only 6%
want to remake the entire system77.
According to the Hospital Morbidity Survey78, during the year 2012, a total
of 4.6 million hospital admissions with stays were recorded, 0.8% less than
in 2011. The main cause of this was the decrease in pregnancy and
childbirth episodes. The average age of the persons discharged stood at
54.2 years old.
The average stay per hospital admission was 6.68 days. The main reasons
for hospitalization were diseases of the circulatory tract (13.2% of the
admissions) and diseases of the digestive tract (12.0%).
The highest morbidity rates (discharges per 100,000 inhabitants) were
recorded in Aragón and Comunidad Foral de Navarra. In turn, the lowest
were registered in Castilla-La Mancha and Melilla.
An overview of the average length of a hospital stay dependent as a
function of disease is presented in Table 3-2.
Table 3-2: Average days of hospital stays depending on the diagnosis79
The number of registered doctors increased by 1.1%, reaching 498 per
100,000 inhabitants in 2012.
Within the registered health professionals, the group of registered nurses
was the only one recording a negative inter-annual variation in 2012, with
minus 1.0%. This was the first decrease registered since 1977 (when the
comparable series started).
There was a significant presence of women among registered health
professionals. Seven out of eleven professions analysed recorded more
women registered than men. Considering the remaining four, the difference
between both sexes continued to lessen.
77
Source: Spanish Ministry of Health, Social Services and Equality, “Barómetro Sanitario 2013”
http://www.msssi.gob.es/estadEstudios/estadisticas/docs/BS_2013/BS_2013Presentacion.pdf
78
Source: Spanish National Statistics Institute (INE), “Encuesta de Morbilidad Hospitalaria”
http://www.ine.es/prensa/np816.pdf
79
Source: Spanish National Statistics Institute (INE),
http://www.ine.es/jaxi/tabla.do?path=/t15/p414/a2012/l0/&file=01012.px&type=pcaxis&L=0
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Figure 3-5: Registered health professionals 201280
The number of registered nurses and doctors per 100,000 inhabitants have
grown since 2006 to 2012 around 50 new registers. Being in 2012 the
amount about 570 nurses and 500 doctors per 100,000 inhabitants.
In 2013, the average change of the overall Consumer Price Index (CPI)
stood at 1.4%, one point less than the previous year. Among the twelve
large groups of consumer goods and services, the greatest growth changes
corresponded to Education (8.1%) and Health (6.9%). Conversely,
Communications experienced a decrease of 4.2%. At a more detailed level,
medicine and other pharmaceutical products recorded the greatest average
annual change. By Autonomous Community, Cantabria registered the
greatest inflation rate (2.1%) and Canarias the lowest one (0.7%).
According to data from the Ministry of Employment and Social Security, the
number of pensioners reached 8 million in 2013, that is, 1.6% more than
the previous year. Retirement pensions were the most numerous, with more
than 5.4 million, and with an average value of 979.5 Euros per month.
Figure 3-6: Living conditions80
80
Source: Spain in Figures 2014, Spanish National Statistics Institute (INE),
http://www.ine.es/ss/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobheadername1=ContentDisposition&blobheadervalue1=attachment%3B+filename%3Despa_cifras_2014_en.pdf&blobkey=urldata&blobtable=MungoBlob
s&blobwhere=16%2F816%2Fespa_cifras_2014_en.pdf&ssbinary=true
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In 2013, non-contributory pensions (disability and retirement) reached a total
of 446,292. Among them, 250,815 corresponded to retirement (with 56.2% of
the total).
The budget for Spanish public health has decreased by 8.4% since 2010, the
year in which it peaked, also in terms of GDP. Total healthcare expenditure
exceeded its original budget from 2007 to 2010 (the last year for which final
health expenditure data have been published)81.
Primary Healthcare: there are 3,034 Health Centres and 10,140 Local
Ambulatories. Both of them give a sanitary assistance without internment but
Local Ambulatories are smaller and usually located in villages and less medical
professionals respect a Health Centre.
Secondary Healthcare: there are an amount of 789 Hospitals and 162,070
Beds.
3.2.4
Spanish eHealth Trends
eHealth in Spain aims for a decentralised National Health Service model. This
model can only be achieved through extensive and appropriate use of ICT, in
conjunction with appropriate organisational changes that allow all their
potential to be exploited eHealth is the tool which allows substantial gains in
productivity to be obtained today while structural changes are tackled that
would allow for a citizen-driven health system to be achieved and respecting
the cultural and linguistic diversity of the different health systems. The idea is
to change from a view based on infrastructure to a view based on services.
The Figure 3-7 shows which changes must be realized and the keys for obtain
this change using eHealth.
Figure 3-7: Ministry of Health, Social Services and Equality82
81
Barcelona Center For International Affairs
http://www.cidob.org/en/publicacions/articulos/spain_in_focus/february_2013/spanish_public_healthcare
_system_is_it_sustainable
82
Source: Ministry of Health, Social Services and Equality,
http://www.europarl.europa.eu/document/activities/cont/201309/20130923ATT71806/20130923ATT718
06EN.pdf
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Table 3-3: Change of View Point83
Applications Infrastructure
Services Infrastructure
Isolated “legacy” applications
Assembly/Comprised of applications
Several development environments
Orchestration of healthcare services
No communication among them
Integration of multiple platforms
Monitoring / Availability
Management and Control
Aimed at developments
Posting, discovery and safety of services
Impossible to unify by resources and
competences
Routing and message conversion
Figure 3-8: Secure Access to Information and Aid in Decision-Making84, (PCIS: Primary Care
Information Systems, PACS: Picture Archiving and Communication Systems, HIS: Health
Information Systems and NHS: is the equivalent of National Health System in Spain called
SNS, Sistema Nacional de Salud)
By applying technology, the Model enables the SNS to be integrated whilst
maintaining independence with regard to the Partners' organisation,
platforms and applications, thereby turning a weakness into strength. The
Model allows for the development of shared solutions run in the switching
point to drive forward less developed Partners with in-house solutions
devised by more developed Partners.
83
Adapted from Workshop on "e-Health" 24 September 2013 European Parliament, Brussels: eHealth
in Spain: A Strategy for a Decentralised National Health Service
84
Source: Ministry of Health, Social Services and Equality ,
http://www.europarl.europa.eu/document/activities/cont/201309/20130923ATT71806/20130923ATT71806EN.pdf
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3.3
3.3.1
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The Spanish Social Care System in Detail
Access to and Coverage of the Spanish Social Care System
Until 2012 the Spanish social care system was universal and free for all,
inclusive and solidary. However Royal Decree-Law 16/2012 gave a
Copernican turn to previous situation, characterizing the right to assistance
to those insured (under Social Security) and their beneficiaries. Also for
those from abroad working here or from countries with existing
agreements. Leaving out, however, all the immigrants with an irregular
situation, and effective residence with enough incomes to pay for
themselves.
On the other hand, certain limited categories of persons may claim
supplementary benefits from the central or local government. This social
assistance is provided by a different territorial authority (the Municipality) in
many cases is provided primarily to elderly and disabled persons. However,
the reform of the law on local government limits the powers of the
municipalities with less than 20,000 inhabitants, where these powers are
transferred to the next hierarchical level, i.e. Deputations (county councils).
This issue is also seen in Royal Decree Law 27/2013, 27 December, for
rationalization and sustainability of the Local Administration (LRSAL). Taking
social services out from Municipalities, which are believed to be the closest
public authority to citizens, it is a much debated question.
3.3.2
Spanish Social Care System Participants and Interrelationships
The Imserso (Institute for elderly people and social services) managing
social services supplementary benefits for older people and people in
situation of dependency within the Social Security system and the National
Reference Centre for Personal Autonomy and Technical Aids (CEAPAT) to
contribute to the realization of the rights of persons with disabilities and the
elderly, through the integral accessibility, products and technologies to
support and design intended for everyone, belong to the Ministry of Health,
Social Services and Equality. The Ministry has launched also the System for
the Autonomy and Dependency Care (SAAD)85 the National Portal for the
Dependency as well as the Information System for the Autonomy and the
Dependency Care (SISAAD)86. The Figure 3-3 shows how much was the
public cost average per dependency person in Spain. And the Figure 3-4
and Figure 3-5 represent how was the financial contributions in SAAD and
the contributions to attendance system respectively.
85
Ministry of Health, Sistema de Autonomía y Atención a la Dependencia (SAAD)
http://www.dependencia.imserso.es/dependencia_06/index.htm
86
http://www.dependencia.imserso.es/dependencia_06/saad/sisaad/consultas/index.htm
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Figure 3-3: Annual average public expense for each dependence attended87
Figure 3-4: Distribution of financial contributions SAAD87
Figure 3-5: Distribution of the contributions to the system attendance costs87
87
Source: XIII Dictamen del Observatorio, Julio 2014
http://www.directoressociales.com/images/documentos/dictamenes/XIII%20DICTAMEN%20del%20OBSERVATORIO.pdf
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Despite these efforts, the Social services delivered by Spanish Communities
is just about average (4.71 on a scale from 1 to 10) according to the last
Rights, Economy and Coverage Index (DEC)88 published by the Association
of Social Services Managers. Social services development in the Valencian
Community as well as in Canary Islands, Madrid and Murcia are graded as
worst, while the best grade is obtained by the Basque Country. Overall,
based upon quality criteria, the DEC 2013 graded the Spanish social
services with 49.2%, a clear failure, and says this is due to public funding
cutbacks rather than general incompetence. In four years, nearly half a
billion Euros have been slashed from the state social services budget.
Criteria used to evaluate the system included factors such as expenditure
per head and the scope of service provided for each region. Valencia came
out with a poor 6% of social service development, or 0.6 out of 10, way
below the Canaries' 20%, or two out of 10. Madrid and Murcia scored just
2.75 and 2.8 out of 10, and other regions where the Association consider
the system to be "irrelevant" include Galicia (3.65 out of 10) and Andalucía
(4.4 out of 10). Levels of development in the system were graded "weak",
"medium-to-low", "medium" and "high", with only the border region of
Navarra obtaining a high. Two other northern regions, La Rioja and the
Basque Country, were classed as having a 'medium' level of evolution, and
Extremadura and the Balearic Islands were considered 'weak', with all the
rest falling into the 'medium-to-low' category. Speaking of Valencia, the
Canaries, Madrid and Murcia, the Association leader said: “You might as well
say these regions have the poorest-quality social services in the whole of
Europe.”
A direct relationship was found between poverty levels in the 17
autonomous regions of Spain and the positive evolution in the system – the
three communities with the best results were the only ones which have
managed to reduce their levels of poverty during the country's economic
crisis. Out of the 17 communities, 10 have cut their budget for social
services at a time when it is most needed because the numbers of people
calling upon them – largely due to housing issues, financial troubles and for
help with feeding themselves – with the Balearics having made the harshest
cuts at 36.39%, or 43.40 € per inhabitant.
Castilla-La Mancha's social services budget has been sliced by 26.74%, and
Galicia, the Canaries and Navarra between 19 and 16 per cent. Conversely,
in the regions where the social services were found to be the poorest,
funding has in fact increased – by nearly 15% in Valencia, or 22 € a head;
between five and nine per cent in Madrid, La Rioja and Asturias; 2.7% in
Catalunya and 0.25% in Cantabria – which in fact translates to an additional
10.37 € per resident – and 1.16% in Murcia, although here the budget has
only increased by 31 cents per inhabitant.89
88
DEC, “Indice de desarrollo de los servicios sociales 2014”, Asociación Estatal de Directores y
Gerentes en Servicios Sociales
http://directoressociales.com/images/documentos/novedaddiscusion/SINTESIS%20INDICE%20DEC%2
02014.pdf
89
Source: DEC Index, “Social Services Development Index”
http://www.directoressociales.com/images/documentos/novedaddiscusion/SINTESIS%20INDICE%20DE
C%202014.pdf
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The research highlights "enormous imbalances" between regions in
spending on Social Services and on the system quality. One social worker
per 814 inhabitants in Navarra, versus 6,557 in Madrid, or 7.42 places in
residential and nursing homes per 100 people aged over 65 in Castilla y
León versus 2.37 in Murcia.89
It also means those on the waiting list to receive careers’ benefits for
elderly, disabled or sick family members they look after, fall between the
two extremes of only 4.2% of applicants not yet in receipt of these funds in
Castilla y León, and 51.9% of applicants in the Canary Islands. And home
help for the infirm ranges from just 1.9% in the Basque Country to 7.31%
in Madrid, or 36 hours a week in home care in Andalucía compared to just
under six-and-a-half hours a week in Navarra90.
The most popular services working are those of Tele-assistance, until very
recently confined for help at home (calls) and/or a very limited perimeter
around the house. The Red Cross is the main provider of this type of
service, together with other smaller companies, badly hit by public
administrations cuts that are causing the closing and disappearance of
many of them.
Table 3-4: Spain Autonomous Communities Social Services per Development Index 201391
Total
90
91
Inhabitants
Cost
Cost per
inhabitant
Total Spain
45.961.055
12.645.319.776
275,13
---
1,21
---
Andalucía
Aragón
8.301.905
1.309.931
2.253.383.284
352.283.393
271,43
268,93
0,7
0,7
1,60
1,05
0,7
0,2
Asturias
(Principado
de)
Balears (Illes)
1.048.173
351.548.742
335,39
1,3
1,59
0,7
1.103.237
84.308.141
76,42
0
0,31
0
Canarias
2.125.977
268.754.967
126,41
0
0,65
0
Cantabria
577.573
219.756.531
380,48
1,5
1,70
0,8
Castilla y León
2.463.223
702.475.166
285,19
0,8
1,28
0,4
Castilla-La Mancha
2.040.555
718.750.950
352,23
1,5
1,99
0,8
Cataluña
7.251.447
2.168.305.285
299,02
0,9
1,09
0,3
Comunitat Valenciana
5.013.303
759.630.190
151,52
0
0,76
0
Extremadura
1.081.322
365.676.156
338,18
1,3
2,20
0,8
Galicia
2.720.243
582.826.213
214,26
0,1
1,03
0,2
Madrid
(Comunidad
de)
Murcia, Región de
6.405.385
1.408.883.777
219,95
0,1
0,75
0
1.476.957
341.222.002
231,03
0,3
1,25
0,4
Navarra (Com. Foral
de)
País Vasco
622.368
261.471.568
420,12
1,5
1,44
0,5
2.109.651
1.679.549.756
796,13
1,5
2,57
0,8
Rioja (La)
309.805
126.493.656
408,30
1,5
1,59
0,7
thinkSPAIN, Thursday, June 13, 2013
INCA consortium’s own composition based on DEC Index 2013
Page 65 of 145
Score
GDP
%
Score
23/12/2014
Tables 3-5: Spain Autonomous Communities Social Services per Development Index 201492
92
http://www.directoressociales.com/images/documentos/novedaddiscusion/SINTESIS%20INDICE%20DEC%202014.pdf
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The results of the DEC Index 2014 reflect the contradiction between what
the laws say and what happen in practice in what relates to Social Services.
In the last 3 years the annual expenditure per inhabitant in Social Services
has decreased (at National level) 47.11€ per inhabitant and year, what
means a reduction of 13.3%. In absolute terms, the Autonomous
Communities and Local Municipalities have spent 2.212 million Euros less in
Social Services in 2013 in relation to what they spent in 2011. This has
been the impact of the cuts in social services after the law of 2012 (Royal
Decree-Law 16/2012).
All the Autonomous Communities have reduced in absolute terms (Euros
per inhabitant/year) their expenditure in Social Services between 2011 and
2013, although some Communities have increment their expenditure in
Social Services in 2013 with respect to the previous year.93
According to the DEC Index 2014, published by the National Association for
Social Services Managers, the cuts in Social Services are, at the level of
local councils, double than those at Autonomic level. While Autonomous
Governments have cut their expenditure in Social Services an average of
10.5%, the cut of local councils has been 20.8% putting in evidence their
budgetary difficulties, but overall uncover that the greatest deterioration is
happening overall in basic and proximity services
The worry now is even greater since the future of Social Services at local
level is menaced by the Law on the Rationalization of Local Authorities
(December 2013) with effects that are beginning to be felt in 2014 and may
be even more pronounced in the next two years.
3.4
Towards Integrated Socio-Sanitary Care in Spain
Countries typically have distinct systems for health and social care, with the
latter rarely well-funded. This split ignores the reality that use of social care
almost always results from some medical need. Recognizing this, the
integration of care (health and social) is a trend in Europe. In Spain, as
everywhere else, this is also the will and the tendency and different groups
of professionals are aiming to explore new models of contracting, funding
and organising health and social care systems.
Focussing on the patient and his needs, as well as his ability to guide
potential service providers with respect to his circumstances and care
requirements is a paradigm shift that requires profound organizational
changes in the current Spanish health and social systems. Pure top down
solutions have many flaws when it comes to practical implementations and
the inclusion of the local stakeholders is paramount for success. It also
seems necessary to include the users (patients) together with the local
providers into the socio sanitary design process. However, this notion of
coproduction is not very well established in the Spanish society.
But reality shows a different face. Health and Social care integration in
Spain is currently a utopia. Except in very specific places, the only system
93
http://www.directoressociales.com/images/documentos/novedaddiscusion/SINTESIS%20INDICE%20DEC%202014.pdf
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"working" even if with flaws is the Health system, and Social Services in
Spain are, by now, the great losers, with poor budgets and confined to the
second row.
Latest technological developments can contribute to such integration but
there are many other aspects that cannot be overcome with technology
only. The role of public-private partnerships and stakeholders’ involvement
are key to fostering person-centred care. Here, the home is seen as a key
space for essential care and a way to guarantee the sustainability of the
public health system, however, it seems that talking of socio-sanitary
coordination makes no sense in a system that is shrinking, were residential
places for dependent are being closed and ongoing reform is menacing the
future of residences that depend of local halls and other local entities.
The sharing of information between the health and the social sector is one
key to success. Especially the health care system already shares
information between hospitals and primary care centres. It would be
desirable to extend this information sharing to the social services. Despite
the fact that Spain is one of the European countries with highest Internet
technology acceptance, the move to digital information sharing has till now
not widely been extended to health and social services.
The information systems of each Autonomous Region are different and are
not interoperable (e.g. no data is shared), with all that this implies. No
common framework (territorial and joint care) planning has been
constructed where all the existing resources can be adequately exploited,
including the private ones. All this, together with the difference in legal
status and traditional roles, has resulted in the general perception of health
and social sector as confronted, rather than treated as complementary
within a framework of collaboration, cooperation and mutual synergy. This,
contrast with the situation in other surrounding countries where
collaboration between the two systems is the norm. Confrontation and
survival of prejudices (the private is synonymous with prioritizing economic
benefits over health and that public care is equated with quality care), is
how both systems are seen in Spain. Nevertheless, this situation is
changing slowly and Spanish authorities are trying to implement
collaborative strategies as the mental health strategy94, strategy for the
chronicity boarding in the national system of health95 and the realization of
the Spanish socio-sanitary coordination white book96.
Figures 3-6 shows the current organization of health and social areas and
how they should be organized in the future. The figure also shows how the
socio-sanitary coordination will take place if the promised integration
changes are carried out.
94
Source: Spanish Ministry of Health, Social Services and Equality, Estrategia en Salud Mental del
Sistema Nacional de Salud 2009-2013
http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/docs/saludmental/SaludMental2009-2013.pdf
95
Source: Spanish Ministry of Health, Social Services and Equality, Estrategia para el Abordaje de la
Cronicidad en el Sistema Nacional de Salud
http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/pdf/ESTRATEGIA_ABORDAJE_CRONICIDAD.pdf
96
Source: Spanish Ministry of Health, Social Services and Equality, Libro Blanco de la Coordinación
Sociosanitaria en España
http://www.imserso.es/InterPresent2/groups/imserso/documents/binario/asociosanitaria2011.pdf
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Figures 3-6: Evolving towards a Socio-Sanitary model for Health97
Hence, there is not a single community that does not have a plan to
implement socio-sanitary care. Plans have names such as “Planes Marco
Socio-Sanitarios, Planes Estratégicos Socio-Sanitarios”. However, the
execution of these plans is frequently lacking behind and more political
determination and focus on a patient centric approach would be desirable98.
Among the different obstacles one is Spain’s high level of decentralization.
97
98
Fundación Economía y Salud, Noviembre 2013
Deusto Business School, 2014
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3.5
23/12/2014
Insights on ICT Tool and the Acquisition Processes in Spain
This industry is built around the need of governmental institutions to
purchase goods and services from independent contractors. Government
purchasing falls into two main categories: acquisition and procurement.
Acquisition is when an agency figures out what it needs, and then builds a
strategy for purchasing. Procurement refers to the contracting portion of
purchasing: An agency requests proposals, evaluates them, and awards a
contract. Different levels of government have different commercial needs,
but common types of government contracts include defence, medical
services, consulting, construction, R&D, information systems, and waste
management systems.
Public services are those considered as so essential to modern life that for
moral reasons their universal provision should be guaranteed. Public service
industry providers include education, electricity, environmental protection,
fire service, gas, health care, law enforcement, military, public
broadcasting, libraries, public transportation, public housing, social
services, telecommunications, town planning, waste management, and
water supply networks.
According to some publications99, in Spain, 10 companies control the State
informatics with "captive technology" (this citation refers not only to the
health system but to all provisions as a whole). In 2013 the Court of
Auditors denounced that Ministries abandon open standards and replaced
them by captive technology that favours a small number of big providers100
Although the Court of Auditors' report does not cite by name any of these
eight companies, Union sources have indicated that consultants with higher
success rate in the body are Indra, Atos Origin, Insa, Software AG, and
Acenture Conectis. Telefónica is responsible for the provision of
telecommunications services (80%, followed far behind by BT to 7%).
The 2012 IRIA101 report admits than (in 2011) only 34% of the 1,680 million
spent by Central Administration in the buying of technology was awarded by
open competition with the best guarantees. This scenario of "technological
captivity" is interpreted by the Court as a result of the "high concentration
of contract awarded to a small number of companies, noting that during the
period audited only eight companies obtained awards totalling more than
50% of the budget spent.
99
Source: eldiario.es (06/04/2013)
http://www.eldiario.es/economia/informatica-Gobierno-Central-tecnologia-Tribunal_de_Cuentas-Indra-IBM_0_118638745.html
100
As far as we read in other reports too, this seems to be a common practice in the Governments of all
Member States.
101
Source: Ministerio de Hacienda y Administraciones Públicas, Febrero 2013
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Table 3-5: 2012 Spanish Central Government Informatics Costs per Provider102
Table 3-6: 2012 Spanish Central Government Informatics Costs per Contract Type103
Figure 3-12, 2012 Spanish Central Government Software Costs per Provider104
For procurement legal framework at European level the implementation of
eTendering and eProcurement systems requires considerations of:

Directive 2004/17/EC of the European Parliament and of the
Council of 31 March 2004 coordinating the procurement
procedures of entities operating in the water, energy, transport and
postal services sectors
102
Informe REINA 2013 - © Ministerio de Hacienda y Administraciones Públicas, Julio 2013
104
103
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
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Directive 2004/18/EC of the European Parliament and of the
Council of 31 March 2004 on the coordination of procedures for the
award of public works contracts, public supply contracts and public
service contracts
While at National level (Spain), “the implementation of eTendering and
eProcurement system requires consideration of two regulatory blocks:

The report on Procurement, headed by the Law 30/2007 on Public
Sector Contracts.

The report on eGovernment, headed by the Law 11/2007 on
Electronic Access of Citizens to Public Services.”105
Figure 3-7: Ordinances and decrees of the use of electronic means for the administrative
procedure105
When initiating a procurement procedure, a Public Administration relies on a
set of information that has to be available to interested parties (tenderers)
with easy access through Internet. This information is known as the BUYER
PROFILE that contains the tenders called by the Public Administration; the
composition of the procurement board; the expert committee composition;
the award of contracts; the signing of contracts; the conclusion of contract
framework agreements; the statement to keep the effects of a contract
previously declared null and void by the contracting authority; all
information that could increase the openness of the procurement process.
105
Source: National Institute of Communication Technologies, Executive Summary of Guide on
eProcurement
http://es.scribd.com/doc/249332972/Resumen-Ejecutivo-Guia-Econtratancion-Esp#force_seo
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This Buyer Profile must be published by each public administration (in the
Official Journal of the Autonomy). In the case of organizations members of
the Central Government, they have to publish it in the State Procurement
Platform that in the case of Spain is the Platform CONTRATACION under the
Ministry of Finance and Public Administrations.
“The article 27 of Law 11/2007, allows the government to establish as
mandatory the use of the electronic channel as a medium of
communication, provided that the following requirements are met:

Be previously authorized by regulation.

That tenderers are legal persons or groups of individuals, clearly
defined.

That tenderers have enough conditions, economic, technical,
professional dedication or otherwise credited to the use of electronic
media.

That tenderers have
technological media.
guaranteed
access
and
availability
of
There are two phases in which the technical elements (legal issues) are very
important.
Figure 3-8: Essential stages of eProcurement process in which both the technical elements,
such as legal, are important.105
3.5.1
The Award Phase
The process begins with the publication of specifications through the buyer
profile of each administration. If organization is a central one, then will
publish the tender in the State Procurement Platform; if organization is a
Regional or Local one, then the tender will be publish in the corresponding
Official Journal.
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Figure 3-9: First step of eTendering process. Publication of specifications in each public
administration105
Tenderers may request clarifications on conditions and submit tenders.
Using electronic signature certificates and time stamps to guarantee the
identity, integrity and authenticity of acts, is mandatory. After the deadline
for submitting bids, the evaluation team must be constituted. Once done,
the electronic opening offers start.
Figure 3-10: Second step of eTendering process. Clarification on conditions105





Open the bids
Bids evaluation
Correction of errors, if needed
Award of contract to tenderer
Signing of the contract
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Figure 3-11: Third step of eTendering process. Evaluation of the same105
3.5.2
The Management Phase
After the award of contract, the management and execution phase begins,
centered largely on the internal management of the tender dossier. This
phase will include the modifications, terminations, transfers and/or
subrogation of the contract that could occur during its execution.
After this phase, and out of scope of the established by Law 30/2007
(except for the provisions of Final Provision.9º) begins the stage of
electronic invoicing, archiving and custody of dossier. At this stage, it is
mandatory to use time stamp and electronic signature certificates to ensure
compliance with ENI (Esquema Nacional de Interoperabilidad) and ENS
(Esquema Nacional de Seguridad), as well as technical standards for
interoperability.”105
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Figure 3-12: Second step of eProcurement process. Stage of electronic invoicing, archiving
and custody of dossier105
3.5.3
Conclusions on Tendering
Concluding it can be said that if we want to participate in tenders, we
should:

Get the electronic signature certificates to participate in processes of
tendering and eProcurement.

Apply for registration in tenderers registry.

Issue electronic invoices.

Have electronic signature certificates issued in states where we are
going to tender electronically, while there is no centralized system for
the automatic verification of the certificates issued from other states.

Require to the public authorities that they issue certificates or
electronic receipts, that they are duly signed to ensure the
presentation of the documentation associated with procurement
processes, as well as the exact time of the presentation (time
stamp).

Promote among employees the use of information technologies
“However, in December 2011 the Commission proposed the revision of
Directives 2004/17/EC (procurement in the water, energy, transport and
postal services sectors) and 2004/18/EC (public works, supply and service
contracts), as well as the adoption of a directive on concession contracts.
The directives were voted by the European Parliament on 15 January 2014
and adopted by the Council on 11 February 2014. The Member States have
until April 2016 to transpose the new rules into their national law (except
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with regard to e-procurement, where the deadline is September
2018).”106
“The package provides for a simplification and flexibilisation of the
procedural regime set by the current rules, which date back to 2004. To this
end, it contains measures to make procurement easier and administratively
less burdensome and to create flexibility for public authorities enabling
better procurement outcomes. Promotion of electronic procurement as a
more user-friendly feature is a cornerstone of the simplification process.”107
“On 28 March 2014 the new Public Procurement Directive (Directive
2014/24/EU) which will form the legal framework for procurement over the
coming years was published in the OJEU. Two others were published at the
same time, one dealing with Concession Contracts (Directive 2014/23/EU),
the other with procurement by Utilities (Directive 2014/25/EU). Each came
into force on 17 April 2014 and requires to be implemented in Member
States within two years.
In the new directive, amongst the most important change is that more
contracts will be subject to the full regime. The distinction between Part A
and Part B services has gone. Therefore all service contracts above the
threshold will require full procurement. This will bring into scope a range of
services which have until now been largely not subject to the full regime.
Amongst those will be health and social care services. There will be a
lighter touch regime for these with a higher threshold (€750,000). The
Concessions Directive will also subject service concessions, up until now
exempt, to procurement requirements.
The new rules seem to be more evolution than revolution but they do
introduce some important changes and clarifications as well as codifying
some of the case law which has arisen over the years”.108
Accordingly Manises Hospital and Murcia have started considering how their
procedures will need to be amended to comply with the changes and to take
advantage of some of the new tools they will provide. As a Healthcare
organizations that recognized that strategic purchasing is the way forward
in improving efficiency and promoting change in healthcare systems at a
national and international level, both Manises and Murcia, are quickly
reorganizing and pooling their procurement power.
3.6
Spanish Market Participants
Although the following market participants, can have various roles, we have
grouped them into potential users (not paying), potential customers
(paying and maybe using), potential competition, potential alliance
partners and influencers. Especially the user/patient segment has been
106
Source: European Commission, “Public procurement reform”
http://ec.europa.eu/internal_market/publicprocurement/modernising_rules/reform_proposals/index_en.htm
107
Source: Council of the European Union, Presse 64
http://register.consilium.europa.eu/doc/srv?l=EN&f=ST%206337%202014%20INIT
108
Source: Walker Morris LLP
http://www.walkermorris.co.uk/procuring-future-new-eu-public-procurement-directive
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described in large detail from a demographic point of view in the previous
sections and will not be treated again here. Listings of the other segments
are provided in the following.
3.6.1
User - Informal Caregivers
Informal caregivers include individuals providing Long-Term Care services
on a regular basis, typically at home, for example spouses/partners, family
members, neighbours and friends. The category “informal caregivers” also
comprises caregivers that are undeclared to the social security.109
While the need for informal care is growing quickly due to the increase in
life expectancy, the supply of informal caregivers is decreasing due to low
birth-rates, because children tend to live further away from their parents,
and because labour market participation among women, who traditionally
account for the vast majority of informal caregivers, is increasing110. In
response to the growing need for care, policymakers in several countries
have aimed to encourage informal caregiving to reduce the financial
pressure on public long term care (LTC) systems.111
Familiar relations are typically closer in Mediterranean than in Nordic
countries. This geographical pattern manifests itself in the fact that in
Southern Europe, the responsibility for providing care lies mostly with the
family. However, another reason for this may be related to the fact that
Mediterranean systems also involve more time and place constraints for
caring at home than Nordic systems, which may engender a shift in care
responsibilities onto the families of the beneficiaries of formal care.
Spain has one of the highest shares of the population providing informal
care to old or disabled people across the OECD and there is a cultural
assumption that women should assume the caregiver role. Women (and
daughters in particular) are likely to care for elderly relatives (parents)
more than men, what means that the type of support seems to be genderdependent: males are more likely than females to give their parents
financial support, while the latter provide more physical and emotional
support than the former.
The profile of the informal caregiver in Spain is typically a female (up to
85%), aged around 55 years old, quite often the child or child-in-law of the
assisted person, less than half of them being employed, and dedicating
approximately 46 hours/week for 5 years in total to caring.112
3.6.2
Customer - Health Care Insurances
Some of the most popular private medical insurance carriers in Spain are
Sanitas and Mapfre.
109
OECD Health Statistics 2014
Source: Colombo et al., 2011
111
RHUR Economic Papers, 2014: Work and Well-Being of Informal Caregivers in Europe
112
Cuidadoras Informales: una perspectiva de género - UCLM
110
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3.6.3
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Customer - Health Care Providers
Leading healthcare groups are listed below, which are in the focus of our
attention as we see possibilities of making some of them INCA/ADSUM+
customers:
ADESLAS: Health brand controlled by Grupo Mutua Madrileña. More than
1,100 centres and 40,000 health professionals.
QUIRÓN: Group controlled by Doughty Hanson and the Cordón family. 45
centres, more than 2,250 bed and 6,500 physicians.
IDC SALUD: Ex Capio, now held by the private equity firm CVC. 29
centres, 2,090 beds and more than 9,000 professionals
GRUPO VITHAS: Participated by Goodgrower and La Caixa. 10 hospitals
and 3,100 professionals.
ASISA: From Medical Cooperativa Lavinia. 14 hospitals and clinics and 16
medical centres. 3,000 professionals.
HOSPITEN: in the hands of the Cobiella family. More than 1,000 beds in
Spain, the Dominican Republic, Mexico and Jamaica.
HM HOSPITALES: Controlled by the Abarca Cidón family. Six centres in
the Community of Madrid with 4,000 workers.
SANITAS: BUPA Group. Two hospitals in Madrid and one in Barcelona. And
Milenium Medical Centres in 10 provinces.
HOSPITALES NISA: Strongly implanted in the Valencia Community, has
eight hospitals and two medical centres.
3.6.4
Customer - Socio-Sanitary Care Providers
SpainCares is the brand of the medical tourism cluster “Federacion
Empresarial de la Dependencia” (FED)113. It was constituted in 2006,
defined in its charter as "a business organization, state-wide, with
operations throughout the Spanish territory, set up to represent and defend
the interests of retirement home carriers, day care canters, home care
givers, tele-assistance providers and social services providers. Its mission is
the "defence, representation and management of general, economic and
socio-occupational interests of its partners".
The Fed is composed of 17 organizations covering the entire portfolio of
operators in dependency care. In its capacity, its members control members
representing 2,400 residential centres with 154,000 places. Further, they
control 28,000 places in day centres; have 230,000 beneficiaries of home
help and 315,000 users of Tele-assistance.114
113
114
http://federacionfed.org/wp-content/uploads/2014/04/Presentaci%C3%B3n-SpainCares.pdf
Spanish homepage of the association. http://federacionfed.org/fed/acerca-de/
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3.6.5
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Competition - IT Tool and Service Provider
It is well known that nowadays there are no healthcare centres without
“Health Information Systems", be it for managing centres control, clinical
histories, budgets, etc. There are already plenty of solutions in place, even
if none solving all the complex problems of healthcare delivery. Electronic
Health Records, Hospital Management Systems, Human Resources, CRMs....
are all of them applications existing internally at medical centres.
But INCA is not competing against any of them. INCA approach is at the
level of Health Departments looking to establish CHRONIC programs with
easy and efficiency and making place for the integration with other services
around the patient, still in many places, at different hands outside medical
competences. Only those solutions addressing the problematic of chronicity
and the integration and coordination of care, can be considered direct
competitors of INCA.
The Spanish Healthcare system, despite the recognition achieved is
internally characterized by its complexity. The low level of knowledge in
matter of ICT of many sanitary professionals, leaves the Hospitals systems
in the hands of informatics ignoring the voices of the medical professionals
dealing with patients and that can only, burdened with the higher workload,
show their unconformity, resulting in a by a "de facto" rejection of the
"imposed" solutions.
Usually medical centres are served by big players (Accenture, Cerner,
Orion, Everis, Indra, Atos, Telefónica, Siemens...) and in Spain we can find
a wide range of solutions, some (most of them) with a US origin, and others
developed internally by the own informatics departments of the centres (the
unusual cases), but also from other European countries.
Telefonica:
(http://ehealth.telefonica.com/)
Telefonica
is
offering
technology solutions, including hardware for “Telehealth”, “Telecare”, and
“Health IT”.
Hewlett Packard (hp): provides hardware, software and services to
consumers, including customers in the government, health and education
sectors. Hp has health solutions like HP 3PAR StoreServ Storage y StoreAll
Storage.
Dedalus:
Software
development
designated
to
guarantee
the
interoperability and the health systems cooperation. Millennium srl is the
best Dedalus solution.
APD: specialist introduction of technology and software solutions for
businesses. Varied health solutions which include all health areas.
SIA: Spanish ICT Company. Inside the health area, SIA operates in data
protection, interoperability and the improvement of citizen.
SAVAC: Gfi incorporated SAVAC Consultants for the Health sector. His
objective is to collaborate with the Health Organizations in improving their
processes through rational use of Information Technology.
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Ibermática: ICT Spanish company. His activity is mainly focused on the
implementation of SAP.
Capsule: the medical device information systems (MDIS) company, is the
leading global provider of medical device integration solutions for hospitals
and healthcare organizations
Atos: French multinational IT services, that provides hi-tech transactional
services, consulting and technology services, systems integration and
managed services.
GMV: ICT Company which is present in the area of Health through a
complete portfolio of products, solutions and services that affects health
care, from diagnosis to monitoring of patients.
FUJITSU: Japanese multinational information technology equipment and
services. It is the world's third-largest IT services provider measured by
revenues (after IBM and HP). TsClinical DDworks21 Global is one of his
health solutions.
EMC: offers data storage, information security, virtualization, analytics,
cloud computing and other products and services that enable businesses to
store, manage, protect, and analyze data. VMware and EMC VPLEX are
health products of EMC.
Bitac: is a technological and technical services platform which serves the
knowledge of an equipment of specialists in clinical laboratory tests a
specialized database and a powerful group of tools.
Sociedad Española de Informática de la Salud: is a scientific society
non-profit, nationwide and welcomes all professionals interested in the
application of information technology to health.
T-Systems: offers international ICT services. T-Systems has experience in
the fields of planning and management of the health system, providing
comprehensive ICT services and health management processes.
Microsoft: develops, manufactures, licenses, supports and sells computer
software, consumer electronics and personal computers and services.
CSC: ICT consultancy services, system integration, Outsourcing and ebusiness. CSC’s eSIAP is a CSC health solution used by SESCAM (Castilla-La
Mancha health service, Spain).
Siemens: is a German multinational conglomerate company. The company
is a prominent maker of medical diagnostics equipment and its medical
health-care division.
Intersystems: privately held vendor of software systems and technology
for
high-performance
database
management,
rapid
application
development, integration, and healthcare information systems. One of his
products is InterSystems HealthShare, a health information exchange
platform.
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Indra: Spanish business which offer consultancy services. Indra has spent
more than 750 million euros in I+D in the last four years. One of Indra
health projects is TRAM (Telerehabilitación Audiovisual Motora).
IBM: manufactures and markets computer hardware and software, and
offers infrastructure . One IBM solution is Cúram Universal Access.
Informática El Corte Inglés: is a Spanish business of technology
consultancy, ICT solutions and outsourcing. It has some innovation projects
in health area.
Oracle: specializes in developing and marketing computer hardware
systems and enterprise software products. According to Fortune magazine,
14 first health care organization use Oracle solutions.
3.6.6
Competitor - Autonomous Community Initiatives
Some autonomous communities are taking initiatives to reform and
regenerated chronic patients situation in their autonomies. Thus the ICT
providers behind developing and deploying such systems for running those
initiatives could be considered INCA direct competitors.
All regional initiatives can be structured around three axis: population
stratification, which allows for informed and proactive interventions,
facilitating resource planning for the treatment of various segments of the
population efficiently; management of population health, which includes
the set of initiatives to improve the health outcomes of patients and are
adapted to the risk of suffering a deterioration in his health, and finally,
transformational initiatives, that facilitate the implementation and
maintenance of a new management model more efficient in treating
chronic. An overview of involved areas the salud has already been given in
Table 3-1.
3.6.7
Alliances - Related Field Actors
In terms of possible alliance partners it is interesting to note the
Observatory of Integrated Care Models – OMIS: “The Observatory of
Integrated Care Models (OMIS) has been born with the purpose of
promoting the integration of care and the coordination of social and health
care in Spain through the registry and evaluation of the ongoing
experiences in the country”115.
Further, there are also several peripheral players that neither constitute
users, competitors or customers. For example, there are the pharmaceutical
companies Grifols, Rovi, Esteve, Almirall, Pharma Mar y Ferrer, the
biotechnology companies INGENASA, Health InCode, as well as the medical
technology companies Bexen Cardio, Emergencias 2000, Grupo Inibsa,
Sibel, Telic, Grupo Matachana, Sedecal, Oncovision. As they are of
peripheral importance but have the potential to either become competitors
115
http://www.omis-nh.org
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or strategic partners at some point, their activities are monitored but not
treated in further detail in this market study.
3.6.8
Influencers - Other Interested Parties
Remains to mention influencers in the field with a list of people provided in
Table 3-7.
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Table 3-7: List of Influencers116.
Name
Alberto Ledesma
Alberto De Castro
Ana Miquel
C. Inmaculada Sánchez
Position
Responsable del Programa de Prevención y Atención a la
Cronicidad Departamento de Salud de Cataluña
Secretario Provincial de Cruz Roja
Gerente adjunta de Planificación y Calidad de la Gerencia
de Atención Primaria de la Comunidad de Madrid
Técnico de Coordinación Sociosanitaria del Departamento
de Salud del Gobierno Vasco
Cándido Mena
Subdirector médico del Servicio Extremeño de salud
Carlos Capataz
Coordinador Nacional de Cruz Roja
Carlos Santos
Carmen Garde
Jefe de Servicio de Coordinación de Servicios Sociales
Comunitarios de la Xunta de Galicia
Coordinadora Sociosanitaria del departamento de salud de Navarra
Cesar Antón Beltran
Director General del Imserso
Chris Stewart
Director de Modernización de Sanudad en Irlanda del
Norte
Emilio Herrera
Director de Enterprising Solutions for Health
Genma Botín
Directora de la agencia de Navarra para la autonomía de
personas
Gerardo Amunarriz
Director General en Fundación Matía
Irati Herrero
Senion Consultant en Schuman Associates
Javier Oleaga
Responsable de Cruz Roja del País Vasco
Jesús Marcial Méndez
Consellería de Traballo e Benestar de la Xunta de Galicia
José María Pino
Director General de Asistencia Sanitaria de Castilla y León
Juan Bautista Pino
Director Gerente Dpto. de Salud de la Consellería de
Sanitat de Valencia
Jual del Llano
Director de la Fundación Gaspar Casal
Juanjo Rubio
Gerente del Servicio Navarro de Salud
Karmele Acedo
Gerente de Servicios Sociales Integrados
Luis Lorenzo
Gerente Adjunto del
Igualdade e Benestar
Mª Teresa Antoñanzas
Subdirectora de Acción Social del Gobierno de la Rioja
Manuel Ollero
María José Pérez
María Mercedes
Consorcio
Galego
de
Servizios
Director del Plan Andaluz de Atención Integrada a
Pacientes con Enfermedades Crónicas
Dirección de atención primaria de la Consellería de
Sanidad de Valencia
Subdirectora General de Planificación y Programación
Asistencial del Servicio Galledo de Salud
Mayte Sancho
Asesora técnica de la Fundación Matía
Susana Quintanilla
Directora Ejecutiva Asistencial de Sanitas
Susana Fernández‐Monge
Responsable Organización y Calidad del Hospital Aita Meni
Susana García‐Heras
Directora de la Fundación Sociosanitaria de Castilla‐La
Mancha
Toni Bruel
Coordinador General de Cruz Roja
116
Deusto Business School Health, PASANDO A LA ACCIÓN: El papel de los gobiernos en la Alianza
Sociosanitaria.
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4 THE SOCIO-SANITARY SYSTEM IN CYPRUS
4.1
An Overview of the Cypriot Situation
In 2011, Cyprus' total population was 838,897, an increase of 21.7% from
the previous census in 2001. Of the total population, 78.6% are Cypriot
citizens, with the remaining population comprising Europeans (13.4%) and
third-country nationals (8.0%)”117. “The total fertility rate that has
decreased further to 1.43 in the period 2005 – 2008. In 2009 the total
fertility rate was 1.51118.
Based on data from the Demographic Report for the years 2010 and 2011,
“the expectation of life at birth is estimated at 79.0 years for males and
82.9 for females for the period 2010/11. The proportion of old-aged persons
65 and over increased to 12.8% in 2011, compared to previous years and
the age dependency ratio was at 42% in 2011, showing a steady decrease
from the previous years (2000: 51%, 2005: 46%, 2010: 42%). Women
represent the largest number and proportion of elderly people, as they tend
to live longer. However, women at the same time are faced with more
health problems and the greatest need for social and nursing care”.119
According to Eurostat data available in 2012, the crude death rate was 6.5
per 1000 inhabitants in 2009, which was one of the lowest rates in the
EU27. Thus, the second highest natural population growth in the EU in 2009
was registered in Cyprus (+5.5%).
Cyprus demonstrates the typical characteristics of an ageing country with a
declining rate of population growth: a declining proportion of the population
is aged less than 15 years and an increasing proportion of the population
aged over 65 years (Table 4-1: Trends in population/demographic
indicators, selected years). Actually there has been a steady increase in the
over-65 population (0.3% growth from 1995 to 2005, compared to 0.9%
growth from 2005 to 2009)120. This fact enables the Cyprus government to
introduce policies targeted at older people such as the development of
primary care centres, chronic disease management programmes and other
community services, in addition to policies that support young couples with
children121.
117
Source: Statistical Service, 2012.
Source: Statistical Service, 2011
119
Source: ENEPRI, 2006, Demographic Report, 2010 & 2011
120
Source: Eurostat, 2012a
121
Source: Theodorou M, 2012
118
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Table 4-1: Trends in population/demographic indicators, selected years122.
Moreover according to the European Health Interview Survey 2008123,
“79.6% of the population aged 15 years and over considers their health
status as good or very good, 15.2% consider their health status to be fair
and 5.1% bad or very bad”124.
The major health problems are reported are hypertension, lower back
disorders or other chronic back defects, hyperlipidaemia (including
hypercholesterolaemia), allergies, neck disorders or other chronic neck
defects, severe headaches, asthma, ulcers and diabetes.
The Cyprus National health system consists of two parallel delivery
systems: a public one and a private one. The public system is exclusively
financed by the state budget, with services provided through a network of
hospitals and health centres directly controlled by the Ministry of Health.
The private system is financed mostly by out-of-pocket payments and to
some degree by the Voluntary Health Insurance (VHI).
Despite having coverage, a big percentage of Cypriots who enjoy free care
from the public sector select to receive care from the private sector due to
long waiting lists. Those excluded from free coverage under the public
system are mostly Cyprus and EU citizens with high annual income, i.e.
15,377.42€ for singles, 20,503.42€ for families without children plus an
increases of 1,708.06€ for each child. Further, all non-EU immigrants are
excluded.
122
Source: Statistical Service 2012
Source: European Health Interview Survey 2008 published in 2010
124
Statistical Service, 2010a
123
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Health services in the public system are provided by the six major public
hospitals of the island, four specialist centres, three small rural hospitals
and 38 health centres, as well as many sub-centres for primary services.
Moreover the private sector is comprised of for-profit hospitals, polyclinics,
diagnostic centres and independent practices.
The main stakeholders in the health care system are the Ministry of Health,
the Ministry of Finance, the Ministry of Labour and Social Insurance. Also,
professional associations such as the Cyprus Medical Association, the
Cyprus Nurses and Midwives Association, the Union of Public Doctors and
the Union of Public Nurses, as well as the Pancyprian Association of Private
Hospitals play a vital role.
The public administration system in Cyprus can be considered as highly
centralized. As said above public health care services and the public health
centres are directly controlled by the Ministry of Health. Public revenues are
allocated from Ministry of Finance to all other ministries, including the
Ministry of Health. Then the Ministry of Health is responsible for the
implementation of the budget and no public provider is able to spend
beyond approved amounts .So we can characterize Health care financing in
Cyprus as very centralized and as a result all public organizations, including
hospitals, must make all spending decisions based on their approved
budgets. There is no autonomy either administrational or operational or
financial to the public healthcare centres. Actually all the payments are
made directly by the Ministry of Health so the public healthcare centres
manage only a part of their budgets. The Ministry of Health 2012 budget,
estimated at €609 million, is lower than in 2011 (€643 million) and around
the same level as 2010 (€603 million)125.
As a result of a discussion (that started 20 years ago) for the reorganization
of the Ministry of Health and the transfer of authority to the public
hospitals126, in 2004 the Council of Ministers approved the legal framework
for the reorganization of public hospitals (Decision No. 60 377). Towards the
effort to provide more autonomy to the hospitals in 2007 the Council of
Ministers approved a set of guidelines to be incorporated in a draft bill
concerning, issues on the establishment of a legal entity that will be
responsible for the management of public hospitals127. Thus, the ministry
would be limited to a strategic role in planning health policy and public
health. This decision will provide with enough power to the public hospitals
for managing their own resources while at the same time will remain
accountable to the Ministry of Health.
Nonetheless, the delay of the General Health Insurance System (GHIS)
implementation has also led to the delay of any attempts at
decentralization.
The low percentage (5.3%) of health expenditure to GDP in Cyprus can be
attributed to factors such as the financial crisis, the absence of a national
125
Source: Annual Government Budget, 2012
Source: Nuffield Institute for Health, 1994
127
Source: National Reform Programme of Cyprus, 2007
126
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health insurance scheme, the relatively young structure of the population
and the limited spending on medical research.
As a result of the absence of a national health system offering universal
cover and the outdate and inefficient system, the oversized private health
care sector often duplicates the freely (or at reduced cost) provided state
health care128.
Cyprus health care and social care systems in detail in Section 4.2 and
4.6 provide insight on ICT tool buying processes, as well as an identification
of main Cypriot market actors, subdivided into users, buyers and providers
of INCA related ICT tools and services.
4.2
4.2.1
The Cypriot Health Care System in Detail
The Ministry of Health
The Ministry of Health is the main responsible public body not only for the
provision of health care but also for the realisation of constitutive
arrangements of social care ensuring a descent standard of living for those
who are confronted with particular problems such as the elderly, the
persons with special needs, minorities and socially excluded. The budget of
the ministry is approved by the government after a budget creation process
that involves numerous stakeholders. The creation of the Ministry of Health
annual budget is a complicated “bottom up” process, involving discussions
between the various stakeholders such as directorates, hospitals and
organizations financed or subsidized by the Ministry of Health. Most
precisely the health system in Cyprus is financed mainly through the state
budget, OOP payments, and to a small extent by VHI. Moreover the public
system does not secure universal coverage. It was estimated that prior to
the financial crisis only 83% of the population had the right of access to the
public health system totally free of charge, while the rest of the population
must pay to use public services according to fee schedules set by the
Ministry of Health. The legal basis for entitlement to public services is
Cypriot or EU citizenship and proof of having earned below a certain level of
income, although for some groups, free-of charge coverage is granted
without proof of income or other criteria. The services provided by the
public system include primary care, specialist services, diagnostic tests,
paramedical services, emergency services, hospital care, pharmaceutical
care, dental care, rehabilitation and home care.
4.2.2
Access to and Coverage of the Cypriot Health Care System
According to the Ministry of Health, 83% of the population in 2007 had
comprehensive coverage that was almost free of charge at the point of
128
Source: Golna et al., 2004.
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service. The rest of the population has access to public health care services
but must pay out of pocket at either reduced or full rates (2% and 15% of
the population, respectively).
There are three categories of Beneficiaries:

Beneficiaries A enjoy almost free-of-charge provision and have
access to an extended package of health services that includes
general practitioner and specialist outpatient care, diagnostic tests,
paramedical examinations, medicines, inpatient care, dental care,
medical rehabilitation and provision of prosthetics, home visits,
ambulance and emergency services, public health and preventive
services, mental health care, services for the treatment of
thalassaemia and treatment abroad for patients who cannot be
treated in Cyprus. Include:
o
any individual Cypriot or EU citizen living permanently in
Cyprus with income below €15,380 per annum, two-member
families with household income below €30,750 per annum
(increased by €1,700 for each dependent child) and families
with three or more children are eligible for a medical card type
“A”.
o
Citizens of EU member-states (mostly pensioners) living
permanently in Cyprus who are entitled to free medical
treatment in their own country also have access to free publicly
provided medical treatment in Cyprus.
o
Almost free access regardless of annual income is granted to
all civil servants and their families,

Beneficiaries B are entitled to reduced rates and are consisted
mainly from those Cypriots or EU citizens whose gross annual income
is between €15,380 and €20,500 for individuals, or €30,750 – 37,590
for two-member families, increased by €1,700 for each dependent
child. Overall Beneficiaries “B” have access to the same services with
Beneficiaries A but must pay higher user charges.

Non-beneficiaries. Non-beneficiaries include all Cypriots of high
annual income and EU citizens who are not eligible for public health
care in their home countries, as well as all legal and illegal
immigrants from non-EU countries living in Cyprus.
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Table 4-2: User charges for health services provided by the public sector129.
4.2.3
Cypriot Health Budget
In many countries, public spending on health was maintained in 2009 while
GDP was falling strongly, but this was followed in 2010 by the
implementation of a range of measures to reduce government health
spending as part of broader efforts to reduce large budgetary deficits and
debts. Cyprus with 3.2% was scoring well under average 7.4%. As a further
comparison, consider that the Netherlands spent 12% and France/Germany
both spend 11.6% and Cyprus’ proportional health spending was even
surpassed by Bulgaria (4.0%) and Latvia (4.1%). We can conclude taking
into account not only the OECD report but also the WHO estimates
(WHOSIS and WHO HFA Database), that Cyprus’s health care expenditure
as a share of GDP is one of the lowest among EU countries and well below
the EU average (Table 4-3 and Figure 4-2).
Cyprus’ total health expenditure as a percentage of GDP and government
health spending as a percentage of total government expenditure are both
quite low (Table 4-3). Per capita spending in 2010 was $1,842 US
Purchasing Power Parity (PPP), which is below the EU average (Figure 4-2).
129
Source: Theodorou M, Charalambous C, Petrou C, Cylus J. Cyprus: Health system review. Health
Systems in Transition. 2012; 14(6):1–128
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Table 4-3: Trends in health expenditure in Cyprus, selected years130.
Figure 4-1: Trends in health expenditure as a share (%) of GDP in Cyprus and selected
countries, 1995 to latest available year130.
130
Source: WHO Regional Office for Europe 2012
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Figure 4-2: Health expenditure in PPP per capital in the WHO European Region, latest
available year130.
Figure 4-3: Health expenditure from public sources as a percentage of total health
expenditure in the WHO European Region, latest available year130.
Public expenditure as a share of total health expenditures (THE) has
remained at least below half of THE since 1995 (Table 4-3), and is among
the lowest in the European Region (Figure 4-3). Additionally, at only 5.3%,
low health spending as a share of total government spending reveals that
the health sector is a low priority for the government. The private share of
THE has consistently been high in comparison with other EU countries.
Private expenditures primarily consist of direct payments for private sector
health care services, statutory co-payments and premiums for private
health insurance schemes. In 2010, 83.5% of private expenditures were
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OOP (out of pocket) payments and 9.4% were payments by private
insurance schemes.
4.2.4
Cypriot Health Care System Participants and Interrelationships
The public healthcare system has a large network of providers throughout
the country operating alongside that of the private sector, which offers
primarily ambulatory care and to some extent hospital care. Its main
characteristic and weakness is fragmentation as there is little continuity of
care and furthermore weak communication between the health care
providers within and between the private and public sectors. This results to
inefficiencies in both sectors, duplication of services and underutilization in
the private sector. The Department of Medical and Public Health Services
within the Ministry of Health is responsible for organizing and delivering a
wide spectrum of preventive and health promotion activities, including:

epidemiological monitoring

control of sexually transmitted diseases

services for expectant parents, pregnant women and children

school health services

immunization services

control of environmental and communicable diseases

occupational health

health education and promotion.
The organization of health services in Cyprus has the following structure:
1. Distribution of responsibilities among ministries

Ministry of Health: is the main political body responsible for Health, it
determines policy and is responsible for the organization of the public
health services that serve citizens. It implements all the necessary
preventive measures for public health.

Ministry of Agriculture: Have some responsibilities for public health. It
controls agricultural and livestock activities that affecting the public
health through the food provision to the public health centres.
•
Ministry of Labour: The Ministry of Labour is responsible for the
health of the workforce and the provision of care to the employees
through the Social Security system.
•
Local authorities: They have part of the responsibility for public
health and the responsibility for taking health control measures such
as inspections and walkthroughs in various buildings, provision of
sanitation, and organizing health services for the residents of each
area.
2. Suppliers of health services
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Cyprus has three types of suppliers of health services:
Public sector with three levels of service:
1-Tier Services: They offer basic services for outpatients such as: diagnostic
services, community services, mental health services and provision of
medicine.
These services are spread across Cyprus and offered through:
•
Urban Health Centres (total of 26 centres in the wider urban areas).
•
Rural Health Centres (11 centres in large rural communities) and a
number of Sub-centres.
2-Tier services for inpatient and outpatient services:

Three small rural hospitals in relatively isolated geographical areas
(Kyperounta, Polis and Paralimni- 77 beds).

The six main general hospitals in the 4 main cities of the free
territory of Cyprus (Nicosia, Limassol, Larnaca Pafos- with 1,320
beds).
3-Tier services for inpatient and outpatient services:
•
Nicosia General Hospital offers tertiary services not available in the
rest General Hospitals (such as Heart Surgery services, Neurosurgical
department, MRI units and CT units).
•
The same stands for the specialized hospitals: Hospital of Athalassa
(for psychiatric cases), and Makarion Hospital for Mother and Child
(230 beds, new-born intensive care, paediatric oncology).
Private Sector: offering services for profit and is organized in the following
way.
Primary:
•
Private doctors (915 clinics) and dentists (548 clinics),for outpatients
•
Medical and other services (360 units throughout Cyprus)
•
Laboratories, provision of radiological and radio-therapeutic services
etc.
•
Pharmacies
Secondary:
Private clinics. They offer inpatient and outpatient services. Some have
tertiary level qualifications in 2006; 86 private clinics were operating with
1.434 beds, corresponding to 16,76 beds per clinic.
Non-profit activities:
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They represent the third form of organized providers of specialized health
services such as:
•
Provision of therapeutic services (Bank of Cyprus Oncology Centre,
Paraskevaeidio Transplant Centre, Institute of Genetics and
Neurology). Part of their operating costs is being covered through the
state budget.
•
Provision of Support services to chronically ill patients such as heart
diseases, cancer, diabetes, etc. These non-profit organizations enjoy
state subsidies as well.
4.2.5
Registered health professionals
The number of active physicians has risen consistently over the past years
reaching a current total of 2,444 physicians (Cyprus Medical Association,
2011); with a percentage of 70% (1,704 physicians) are employed by the
private sector (Figure 4-4: Number of physicians per 100 000 population in
Cyprus and selected countries, 1990 to latest available year). These
numbers include trainee physicians who are in the specialization process.
Physicians are predominantly male (64%, 1,563 physicians). More than half
the physicians are over 45 years old. The total number of practicing
physicians per 100,000 inhabitants (287 in 2008) is well below the EU
average (326 in 2008.) Physicians include generalist and specialist medical
practitioners. Over the last decade most of the newly qualified physicians
have pursued careers in non-primary care specialties. As a result there has
been a decrease of 20% in the number of GPs between 1995 and 2000131.
Since patients have direct access to specialist care in the public sector,
public primary care physicians mainly treat minor illnesses, provide
prescriptions and order laboratory tests. Currently there is currently no
government policy to increase the number of GPs.
131
Source: Samoutis, Samoutis & Tedeschi, 2010
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Figure 4-4: Number of physicians per 100 000 population in Cyprus and selected countries,
1990 to latest available year130.
4.2.6
Number of nurses
Cyprus has had a fairly constant supply of nurses since 1990, although
significantly fewer per 100,000 populations than the overall EU average
(Figure 4-5).
There are approximately 1.6 nurses for every physician in Cyprus, which are
among the lower nurse-to-physician ratios in Europe (Figure 4-6 and Figure
4-7). Although the private sector employs the most doctors, the
overwhelming majority of nursing staff is employed in the public sector. In
1980, of 1,707 total nurses, 1,427 (84%) were employed in the public
sector. In 1990 of 2,478 total nurses, 1,858 (75%) were employed in the
public sector and 620 (25%) in the private sector. In 2008, 3,710 nurses
were employed by the public (80% total number) and 736 in the private
sector (20% of the total number), an increase of nearly 260% from 1980
(Table 4-4). Actually during the last decade there was a significant increase
in the number of registered nurses .From a total of 2,931 nurses in 2000
they had reached the number of 3.710 in 2008. There was a significant
presence of women among registered health professionals. Recently created
nursing programmes at four local universities (one public and three private)
have also contributed to increases in the nursing supply. The increase in
nursing school graduates in the last few years may have led to difficulties in
absorption by the labour market.
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Figure 4-5: Number of nurses per 100000 population in Cyprus and selected countries, 1990
to latest available year130.
Table 4-4: Health workers in Cyprus and relative percentages (selected years)132.
132
Source: Ministry of Health 2012
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Figure 4-6: Number of physicians and nurses per 1 000 000 population in the WHO WEST
European Region, latest available year130.
Figure 4-7: Number of physicians and nurses per 1 000 000 population in the European
Region, latest available year (AVERAGES) 130.
“The Nursing Services of the Ministry of Health provide community nursing
and in urban and rural areas in Cyprus mainly for the elderly, for people
with serious/chronic illnesses and for the disabled persons. Pancyprian
mental health community nursing is provided for serious cases for adults
(elderly people included), children and young people. Community medical
care is also provided in cases of serious / chronic illness especially in areas
far away from general hospitals.”130
The main reasons for hospitalization in Cyprus were firstly injuring
poisoning and certain other consequences of external causes (average
895.7 per 10,000 inhabitants) following by diseases of the circulatory tract
(average 802.6 per 100,000 inhabitants) and diseases of the digestive tract
(average 713.7 per 100.000 inhabitants). The average length of a hospital
stay was generally highest among those patients suffering from cancer
(average stay 7.4) or problems relating to the circulatory system (average
stay 6.1 days).The average stay per hospital admission was 5.68 days.
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Table 4-5: Hospital discharges of inpatients by diagnosis (ISHMT –international shortlist for
hospital morbidity tabulation) average length of stay 2010 (days) SOURCE: EUROSTAT
4.2.7
AVERAGE Days
5.68
Cancers
7.4
Circulatory Tract
6.1
Injures and poisoning
5.6
Respiratory Tract
5.1
Digestive Tract
4.8
Pregnancy and child birth episodes
5.1
Outpatient visits
Outpatient visits per capita are the number of visits to health care facilities
per capita, including repeat visits. As being displayed in the Figure 4-8, this
number has increased through the years and more precisely from 1.89 in
1994 has increased to 1.99 in 2000 and to 2.03 in 2004.
Figure 4-8: Outpatient visits in Cyprus133.
4.2.8
Hospital beds (per 1.000 people) in Cyprus
According to the Eurostat during the year 2010 the average number of
hospital beds in Cyprus was 344.5 (per 10,000 inhabitants) in comparison
with the average number of hospital beds in the EU-27 per 100,000
inhabitants that was 538.2 in the year 2010. The number of hospital beds in
Cyprus averaged 402.9 in 2000 and fell to 345.1 in 2005. Moreover
according to the World Bank134. Hospital beds in Cyprus was reported at 380
in 2008. Thus we observe a reduction in bed numbers between 2000 and
2010 in Cyprus as well as across the whole of the EU-27. Actually during
133
134
Source: World Bank Indicators Cyprus Health Services
Source: World Bank http:/www.tradingeconomics.com
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the 10 years between 2000 and 2010, the number of hospital beds per
100,000 inhabitants fell in every Member State, except Greece.
Figure 4-9: Hospital beds (per 1.000 people) in Cyprus135.
4.2.9
Reformations in the Health sector
As a result of the Memorandum signed on March 2013 with the
International Monetary Fund (IMF), the European Central Bank and the
European Commission (Troika), following a request for financial assistance
from the Cyprus government, changes took place in the Health sector as
well. More precisely starting from the first of August 1, 2013, all patients
visiting the outpatient departments of the state hospitals shall pay 3 euros
for a visit to a general practitioner and the amount of 6 euros to visit a
specialist. In addition there is a charge of 0.50 cents for each administered
drug and a maximum fee of 10 euros per prescription medicine for each
laboratory test or for any laboratory examinations form reference
respectively. While the health system in Cyprus is financed mainly through
the state budget, the situation may change and the public hospitals are
likely to become more autonomous in the near future with the
implementation of the new Global Health Insurance System (GHIS). Under
the new GHIS, health care financing will change as follows: the main source
of financing will come from revenues from employee contributions,
employer contributions and the state budget, in addition to co-payments
and will be transferred to a central fund that will be administered by the
Health Insurance Organization. The Health Insurance Organization will act
as the exclusive purchaser of health care services for all beneficiaries
through contracted public and private providers.
Furthermore, the financial crisis that affects Cyprus puts even greater
pressure and challenge government intervention in un-preceding ways.
Under the Memorandum signed on March 2013 with the IMF, the European
Commission and the European Central Bank, the Government of the
Republic of Cyprus has committed to keep social expenditure at the same
levels and in the near future to decrease it. Having this in mind, it is
135
Source: World Bank Indicators
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essential for Cyprus to do a revision of its social welfare system and at the
same time establish a general health scheme.
4.3
The Cypriot Social Care System in Detail
The Social Welfare Services (SWS) are basing their work on a personcentred approach as the frequency of home care or day care or the need for
residential care is based upon individual needs. The claimant cooperates
with a Social Services Officer for developing his/her personal care plan
based on individual needs for care services in kind and/or cash benefits. The
home carer gets familiar with the persons beyond the diagnosis, respect
their preferences, and involve them as equal partners in the process of
goals definition and in care planning.
Long-term social care in Cyprus is organised centrally by the Social Welfare
Services (SWS). Services are delivered through District and Local Welfare
Offices throughout Cyprus and are financed by the State budget. In
addition, long-term social care programs are also implemented by the
private sector and at local level by non-governmental organizations (NGOs),
partnerships of NGOs and local authorities. There is no particular definition
for long-term care in Cyprus, which may pose problem especially as regards
entitlements, i.e. to health or social care. Issues of care are mentioned in
the Public Assistance and Services Laws of 2006 and 2012, L67 (1)/2012.
“Home Care in Cyprus can include housework and personal care. The State
may pay (fully or partly) a private home carer. Home care is also provided
by state home carers. As regards the Home Care training, the private sector
has a great involvement with various organisations. It is important to
underline that home care in Cyprus is currently under reformation covering
four main domains: the provision of home care services, the beneficiaries,
the funding and the evaluation and monitoring. “Only persons entitled to
public assistance may be entitled to free of charge long-term care. Persons
who have adequate means and are not entitled to public assistance are
expected to cover the cost of their care”136. It should be also mentioned,
that for people with disabilities an extra social care benefit is provided by
the Department for the Social Inclusion of People with Disabilities for homecare by a private home carer. This benefit is provided regardless whether
the person is a public assistance receiver or not. Moreover, the home care
service recipient has the freedom to select the service form (full-time
service by a private home carer living with the person, help for some hours,
or service levels in-between) and the service provider.
At the moment there is no legislation regulating the provision of home care
despite the fact that it is provided by both the government and the private
sector. The SWS are now working on the development of such a law.
Towards the efforts for reformation of the social welfare system, long-term
social care is expected to take a different form and be disconnected from
public assistance.
136
Source: Dignity first: priorities in reform of care services, Patheodoulou, Agathangelou
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4.4
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Towards integrated Socio Sanitary Care in Cyprus
Actually there is no formal definition of integrated care in Cyprus. Overall
the nature of integrated care based on coordination and collaboration, which
implies that no one has overall responsibility, may hamper decision-making
and accountability. To address several problems in the health sector such as
delays in planning, lack of beds and suffering of patients in the public
hospitals the Ministry of Health prepares for deploying the Integrated Health
Information System in all government hospitals and medical centres.
It is a complete online program that offers: "enormous medical, social and
economic benefits and aims to become the cornerstone for the complete
health care reformation in our country and the smooth implementation of
the National Health System." says in a recent interview in newspaper
Phileleftheros, the Minister of Health Mr Philippos Patsalis. The cost of
implementing this System will be shared from the private sector and the
public sector .Moreover the computerization of all public hospitals, rural and
urban, and other related public laboratories, pharmacies and other centres
or organizations is a strategic objective of the Ministry of Health since 2001.
The aim now is to build an Integrated Information Health System.
The System includes 13 different software as follows: Personnel
management, billing, and coding, patient management, orders, radiology,
clinical laboratory, histopathological, blood bank, prescription, inventory
management, pharmacies and Smart Card The implementation of the
system is expected to lead to better control of the processes , introduction
of best practices, cost reduction in terms of medical orders, supplies and
medicines, better management of beds and accuracy in billing and
auditing".
4.5
Insights on ICT Tool and the Acquisition Processes in Cyprus
The integrated socio sanitary care field in Cyprus is open, emerging, still low
competitive, and immature. It is characterized by relatively unsophisticated
consumers and weak or non-existent domestic competitors.
As an open market the characteristics are the following:
•
No external constraints
•
Prices are flexible
•
Low barriers to entry
•
Stable regulatory framework
•
Immature technologies
•
Costs can be high and unpredictable
•
Supplier relationships are underdeveloped
•
Distribution channels just emerging
•
No government intervention to try and influence the market
•
Lack of competitiveness
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There is still no solid governmental planning towards the implementation of
a strategy and much improved coordination across the various services.
According to the findings, eHealth in Cyprus aims for developing a
decentralized National Health Service model. This can be achieved only
through the proper reformations and structural /organizational changes.
There are already plenty of solutions in place, even if none solving all the
complex problems of healthcare delivery.
Looking at other ICT tools already in use we could note:

Electronic Health Records,

Hospital Management Systems

Hospital Information Systems (HIS)

Radiology information systems (RIS)

DICOM (Digital Imaging and Communications in Medicine)

PACS137 is the software that is responsible for the transferring and
archiving of medical images from medical equipment to appropriate
storage media. It consists of four major components: CT (computed
tomography and MRI, network from transmitting patient data,
workstations for image processing, and archives for storage
The above are all of them applications existing internally at medical centres
and private hospitals.
Regarding providers of such solutions we could refer for example to
InfoCape Ltd138 that is a company with extensive experience and expertise
in installing PACS systems in radiology centres. InfoCape Ltd has numerous
facilities with PACS systems in Cyprus and abroad. Its Health Care Solutions
include systems for single doctors to large clinics in private and in public
sector (systems for Radiologists like Worklist, PACS etc).
Moreover a worth mentioning system is the InfoCape Patient Portal139 .This
is a system that allows the patient, to interact with their healthcare centre
(clinic) and to access their medical records from everywhere, (after a
confirmation process). The system140 consists of a web framework than can
be related to an existing web-site of the clinic or as a standalone
application, providing patients with various services. Those services include
arranging an appointment from device, requesting an examination result,
sending alerts, schedule examination alerts through Email and SMS, request
hard copies of certain examinations etc.
Although INCA is not directly competing with all these systems except
perhaps with some common functionalities with the Patient Portal,
137
http://cypruspacs.com/index.php/pacs
http://www.infocape.com/
139
http://www.infocape.com/article/productdefaultview/Patient-Portal-As-Plugin
140
http://www.infocape.com/Home/Products#PatientPortal
138
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knowledge about them is still of paramount importance for INCA when
trying to penetrate the Cyprus market mainly due to three reasons:
1. It can be a significant sales argument if INCA is seamlessly
interfacing with systems that a potential INCA customer already has
in place. For example, interfaces to the hospital management system
might facilitate us to close a deal with a specific hospital.
2. Furthermore, knowledge about the above systems is important as
system providers, which already have a road to the customer open,
can decide to enter into direct competition to INCA and add INCA like
services to their existing products.
3. Finally, already existing providers with a road to the customer open
could be interesting partners for INCA alliances, e.g. providing a
distribution and service infrastructure in the Cyprus market (and may
be beyond if they are international players).
It can be concluded that the Cyprus healthcare has a place for systems such
as INCA.
4.6
Cyprus Market Participants
Similar to the section on the Spanish market participants, we have divided
the Cyprus market participants into users (not paying), potential
customers (paying and may be using), potential competition, potential
alliance partners and influencers. Especially the user/patient segment
has been described in large detail from a demographic point of view in the
previous sections and will not be treated again here. Listings of the other
segments are provided in the following.
4.6.1
User - Informal Caregivers
We can refer here to the Pancyprian Organisation of Volunteers141:
141
142

The Pan Cyprian Volunteerism Coordinative Council represents
more than 350 voluntary organisations both at national and local
level. The member organisations represent the interests of civil
society and of almost all social groups .The Council's structures
render the PVCC as an 'umbrella' or a 'platform' - where the member
organisations are shaping the voluntary sector policy and action,
through their participation in decision-making processes.

The Pancyprian Thalassaemia Association142 was established in
1974 by parents of thalassaemic children in an aim of dealing actively
with the disease. It also aimed at helping thalassaemics become
integrated into society as smoothly as possible. It is a member of the
Thalassaemia International Federation that was established in 1987.
Pancyprian Organisation of Volunteers http://www.volunteerism-cc.org.cy
The Pancyprian Thalassaemia Association, http://www.thalassemia.org.cy/
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
The various community/municipal volunteerism councils that as
their
primary
concern
is
the
identification
of
the
municipality/community’s social needs and the provision of quality
social services in order to satisfy the needs to vulnerable groups of
the area such as the elderly ,people with disabilities, and children.

MedicAlert143, is working as a data bank in which, persons with any
kind of medical problems or allergies can deposit all relative
information. It is responsibility to make such information known to
medical or paramedical personnel only in medical emergencies, so
that they can offer appropriate medical care and avoid risks of
potential fatal developments.

The Cyprus Anticancer Society144 was established in 1971. It is a
non-governmental, charity organization established to fight cancer
and offer palliative care to cancer patients and their families.
4.6.2
Customer - Health Care Providers
Primary/ambulatory care services are delivered by a mix of public and
private providers. Public sector services are delivered by a network of a
total of 38 health centres. Additionally, primary/ambulatory care services
are delivered by the outpatient departments of the 6 district and four
specialized hospitals. All centres are well equipped and adequately staffed
by a variety of health professionals. The outpatient departments of public
hospitals also cover all specialties and visits are scheduled by appointment.
Moreover a significant portion of primary/ambulatory services is provided by
the private sector. According to the Ministry of Health in 2011, 134 private
health care group practice facilities (hospitals, polyclinics and clinics) were
operating, all of which may offer primary/ambulatory health care services.
A list of the most important public and private facilities are provided below:
Governmental (Public) Hospitals
143
144
•
Nicosia New General Hospital
•
Nicosia Old General Hospital
•
Makarios Paediatric Hospital, Nicosia
•
Limassol New General Hospital
•
Limassol Old General Hospital
•
Larnaca New General Hospital
•
Larnaca Old General Hospital
•
Paphos General Hospital
•
Ammochostos Hospital
•
Kyperounta Hospital
MEDICALERT, http://www.medicalertcyprus.com/aboutus.html
Cyprus Anticancer Society, http://www.anticancersociety.org.cy
Page 105 of 145
•
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Polis Chrysochou Hospital
Private Hospitals
•
Near East University Hospital
•
Mediterranean Hospital of Cyprus, Limassol
•
Nicosia Polyclinic, Nicosia
•
Aretaeio Hospital, Nicosia
•
Apollonion Private Hospital, Nicosia
•
Hippocrateion Private Hospital, Nicosia
•
American Heart Institute, Nicosia
•
Ygia Polyclinic, Limassol
•
Saint Raphael Private Hospital, Larnaca
•
Iasis Hospital, Paphos
Health Centres (the biggest)
•
Kentro Ygeias Lanias
•
Iatriko Kentro Mhtera & Pedi
•
Kentro Ygeias Pyrgoy
•
Kentro Ygeias Daliou
•
Kentro Ygeias Pomos
•
Agios Anastasios Clinic
•
Polykliniki Timios Stavros
•
Hajihannas Polyclinic
•
Ketro Ygeias Avdimou
4.6.3
Customer - Social Care Providers
These providers include mainly the Social Welfare Services and some
departments such as the Department for Social Inclusion or Persons with
Disabilities.
The Social Welfare Services aim to provide social protection and to succeed
social inclusion promoting at the same time the interests of the Cypriot
citizens. More specifically the Social Welfare Services provide the following:

Support citizens who are facing various social problems;

Provision of care to vulnerable groups of people;

Upgrade and improvement of Services, provided by governmental
bodies

Inform and influence other governmental organizations and local
authorities towards the provision of quality social services;
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
Provision of training to public assistance beneficiaries in order to
enter/reenter the labour market, hence succeeding their social
inclusion;

Provision of support to the family unit so family members may
effectively perform their role.
4.6.4
Customer - Sanitary Care Providers
These providers include the various social care centres established by
Municipal/Communities volunteerism councils that have as a main target
the provision of mainly social and (sometimes) sanitary care. Through these
centres the community/municipality manages to address the citizens’ needs
for entertainment, socialization and promotion of social activities. Moreover
through these centres they are offering free services to vulnerable groups
such as personal home care-giving, medical treatment, house cleaning,
personal exercise and food provision. These centres are mainly staffed from
volunteers and representatives of the council. In particular, these centres
aim to achieve:

Social integration and rehabilitation of disabled and elderly people,

Care, training and education of children,

Help through various ways people with disabilities, Offer homecare in
vulnerable groups of the area,

Offer sanitary services in some cases.
4.6.5
Competition – IT Tool and Service Providers
We can refer here to Cyta, Primetel, Cablenet that are the three ISP
providers

Cyta145 is of semi-government ownership and it is incumbent -

Primetel146 is the second biggest ISP provider in Cyprus. It is a
private company that owns and operates a private regional
broadband network, spanning Cyprus, Greece, UK and Russia. They
offer Triple play services to business and wholesale services to
carriers, mobile operators, content and internet providers.

Cablenet147 is the only cable TV and cable Internet carrier in Cyprus.
Currently the coverage is limited only to several urban areas.
national telecommunications provider of the island. It is the dominant
provider of integrated electronic telecommunications as it occupies
the biggest market share. Cyta owns an extensive submarine fibre
optic cable network linking Cyprus with neighboring countries and, by
extension, with the rest of the world.
145
Source: Cyta Official Web https://www.cyta.com.cy/
Source: Primetel Official Web: www.primetel.com.cy
147
Source: Cablenet Official Web www.cablenet.com.cy
146
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Cablenet also offers an ADSL product which is available at more
locations.
Specifically, with respect to eHealth, we can refer to:

Earth International Medical Health Services LTD148 The
company was established in January 2011. Its purpose is the
development of technology and information systems in order serve
better the citizens with regard to health.

InfoCape Ltd (described above) that is a company with extensive
experience and expertise in the provision of Health IT tools.
4.6.6
Alliances – Related Field Actors
We can refer to:

The Atlantic Insurance, a well-known leading general insurance
company established in 1983 by a group of local business people.
Atlantic commands a profound knowledge of the local market.

The G.T. Radiological Health Care Services LTD. The Radiological
Health Services Ltd was established in 2009 in order to cover a gap in
the provision of health services that has to do with access to
specialized and technologically advanced practices. They have
created a diagnostic center where the main concern is to serve all
those who visit it through a climate of trust and mutual respect
Also, there are some important pharmaceutical providers in Cyprus such as:
• Cypromedica Trading Ltd149 was established in 1989 as a
Pharmaceutical Agency with a product portfolio ranging
dermatological creams, anti-inflammatories and antibiotics.
from
•
Phadisco150 was officially established in 1966. Phadisco is one of the
leading pharmaceutical companies in Cyprus involved in the exclusive
representation, distribution and sales of branded pharmaceutical
products, over the counter products, medical equipment and
Diagnostics.
•
Remedica151 is based in Limassol, Cyprus and is maybe the biggest
pharmaceutical company in the country dedicated to the
development, production and sale of high quality generic
pharmaceutical products.
•
Medochemie152. Was established in 1976 and is one of biggest
pharmaceutical companies in Cyprus. Today, Medochemie Ltd has
148
Source: Earth International Medical Health Services, Cyprus http://www.ehealthcyprus.com.
Source: Cyrpomedica Trading Ltd Official Web: http://www.cypromedica.com/
150
Source: Phadisco Official Web: http://www.phadisco.com.cy
151
Source: Remedica Official Web: http://www.remedica.eu/
152
Source: Medochieme Official Web: http://www.medochemie.com/
149
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eleven manufacturing plants and facilities nine in Cyprus, one in the
Netherlands, and one in Vietnam. They employee over 1,250 people.
In terms of biotechnology, we can refer to DELORBIS Pharmaceutical
LTD153.Their products include:

Anti-inflammatory and analgesics

Anti-infectious

Cardiovascular and metabolism

Central nervous system

Dermatological and allergies

Gastroenterology

Genetic

Oncology

Respiratory
4.6.7
Influencer - Other Interested Parties
We could refer to NGOs that are involved with healthcare and social care
such as:

•
153
The NGO Cyprus Association of Cancer Patients and Friends
(PASYKAF). Their main objectives are:
o
To provide information to the public on matters of prevention
and early detection.
o
To initiate intervention aiming at rehabilitation.
o
To support cancer patients and their families with various
ways.
o
To contribute in the improvement of cancer diagnostic and
treatment services in Cyprus through education and awareness
on both professionals and the public.
The Pan Cyprian Council for People with disabilities that consists of
representatives
of
governmental
services,
non-governmental
organisations and users of services.
Source: Delorbis Pharmaceutical LTD Official Web: http://www.aegispharma.com
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5 THE SOCIO-SANITARY SYSTEM IN CROATIA
5.1
An Overview of the situation in Croatia
Since health and social care of the population and its health and social
status do not solely depend on the activity of the Health Service and Social
Welfare Service, they can’t be considered in isolation from demographic,
economic and ecological indicators, as well as population's educational
structure. Despite the fact that health care standard in Croatia is mainly
satisfactory, health care system and social welfare system are facing
several challenges:
•
High costs of the Croatian health system’s performance (insufficient
efficiency of available resources managed)
•
Growing expenditures
•
Increasing needs (aging population, dominance of chronic and noncommunicable conditions, economic crisis)
•
Insufficient institutional structure and capacity of the publicly funded
health sector and social welfare sector
•
Insufficient connectivity/coordination within health care across levels
(primary, secondary, tertiary) in the health system as well as
between social welfare system and health care system
Demographic changes in Croatia will probably increase the future strain on
public finances and health and social welfare systems. International
experience shows beyond a doubt that the demand for health services will
increase in the future as the population ages. This could threaten the
financial sustainability of the health and social welfare systems.
According to the Croatian Central Bureau of Statistics (CBS) population
census, for 2011 were 4,284,889 inhabitants. Years of decline in the
number of births, increase in the mortality of younger age groups during
the war and negative migration trends of the last decade have influenced
the overall population trends. In 1991 Croatia entered a depopulation stage.
Croatia’s natural population increase rate was negative, -2.5. Since 2001,
the 65-and-over age group has grown and is now larger than the population
aged 15 and under. For 2011 Croatia had 758,633 inhabitants aged 65 or
older (17.7%). This has implications for public finances, since the proportion
of working-age population is declining.
According to the Croatian Central Bureau of Statistics, life expectancy at
birth in Croatia in 2013 was 77.2 years for both sexes, 80.2 years for
women, 74.2 for men.154
Croatia has gone through six consecutive years of recession since the
outbreak of the global financial crisis in 2008. By 2013, projected real GDP
was 12 percentage points lower than in 2008. While the rate of GDP
contraction slowed to one percent in 2013, another year of recession is
likely in the wake of further fiscal consolidation underpinned by the
154
Source: Croatian Central Bureau of Statistics (CBS) Croatian National Institute of Public Health Page 110 of 145
23/12/2014
European Union’s Excessive Deficit Procedure. With monetary policy
constrained by the need to keep the Kuna-Euro exchange rate stable,
progress with structural reforms and attracting foreign direct investment
needs to be accelerated. Otherwise, growth prospects over the medium
term will remain limited.155 Unemployment rose to above 17% for surveybased unemployment by September 2013.
The disease burden in Croatia has shifted from being dominated by
maternal and child health and communicable diseases to being dominated
by chronic and non-communicable conditions. Heart and blood vessel
diseases, for example, are the leading cause of death and account for 49
percent of deaths from all causes; cancer, the second-most-frequent cause,
accounts for 26 percent. The two combined are responsible for three of
every four deaths.
Out of the total number of the diseases and conditions recorded in the
general practice/family medicine, about 30% occurred in patients aged 65
and older. Most common groups of registered diseases and conditions in the
elderly were: diseases of the circulatory system (20.8%), musculoskeletal
system and connective tissue (12.4%), diseases of the respiratory system
(7.9%) and endocrine, nutritional and metabolic diseases (7.7%). The share
of hospitalizations at the age of 65+ in 2013 (excluding hospital
rehabilitation and day hospitals) was 36.9% of overall treatment cases in
Croatian hospitals (35.9% in 2012). The number of 213,027 hospitalization
cases involving persons aged 65+ (rate of 274/1.000) totalled 2,326,660
days of hospital treatment. An average duration of treatment was 10.9
days.156
Croatian health care and social care systems in detail in Section 5.2 and
Section 5.3, respectively. Afterwards the focus shifts to political drivers and
5.7 provide insight on ICT tool buying processes and peculiarities in Croatia,
as well as an identification of main Croatian market actors, subdivided into
users, buyers and providers of INCA related ICT tools and services.
5.2
The Croatian Health Care System in Detail
By Constitution, the Republic of Croatia is defined as a social state, which
takes care of the social security rights and basic existential needs of its
citizens.
5.2.1
The principles and organization of health care
The basic aim of health policy is not only extension of life expectancy, but
also the endeavour to improve the quality of life. In addition to health
service promotion and development, this includes the promotion of healthier
155
156
Source: World bank
Source: Croatian National Institute of Public Health
Page 111 of 145
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life styles, reduction or elimination of preventable health risks, and
improvement of the quality of life of chronic and disabled patients.
The standard of health care services in remote and marginal areas including
islands is limited, which mostly refers to specialist/conciliar health care,
while primary health care and emergency medicine are available in all parts
of Croatia.
The healthcare system in Croatia is controlled centrally and managed by the
Ministry of Health that is responsible for legislation in the area of health
care, for proposing of budget expenditure, monitoring of the population
health status and needs, staff training and the health care system reform.
Having joined the EU on 1 July 2013, Croatian citizens have been given the
opportunity of cross-border health care in keeping with EU legal regulations.
At the same time, a vast number of EU insurances have been guaranteed
health care services during their stay in Croatia by using the European
Health Insurance Card (EHIC).
5.2.2
Facilities
The health care activities are held out at the primary, secondary and
tertiary level. A primary health care physician refers a patient for treatment
to a secondary or tertiary health care facility when needed. This allows the
patient free access to hospitals and polyclinics contracted to provide
mandatory health services (contractual facilities). Secondary and tertiary,
as well as specialist/conciliar and hospital health care services in larger
cities are rendered mostly by hospitals.
Facilities involved in health activities are either state- or county
(municipality)-owned or private. Teaching hospitals, clinical hospital centres
and state Institutes of Public Health are state-owned. Health centres,
polyclinics, general and special hospitals, pharmacies, institutions for
emergency medical aid, home care institutions, and county institutes of
public health are county-owned. Out of 76 hospital institutions and
sanatoriums, nine special hospitals and five sanatoriums were privately
owned.
Table 5-1: Health Institutions in Croatia (2013)157
2008
Institutes of public health
General Hospitals
Polyclinics
Clinics
Special hospitals
Health centers
Pharmacies
Care organizations
Health companies
157
22
23
331
14
40
50
178
155
142
2009
22
22
348
14
40
49
176
154
207
2010
22
22
352
10
39
49
181
157
264
Source: Croatian National Institute of Public Health
Page 112 of 145
2011
22
22
363
12
40
49
184
167
300
2012
22
22
362
13
41
49
187
187
346
2013
22
22
360
13
34
49
187
199
383
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According to the Croatian National Institute of Public Health by the end of
2013, there were 5,590 private practice units (doctors’ offices, laboratories,
private pharmacies, private physical therapy practices and home care
services) registered. Out of these, 2,363 were private doctors’ offices, 1,735
of which were rentals.
By the end of 2013 Croatia’s health care had a permanent work force of
74,489. Out of these, 57,395 were health professionals and associates,
5,050 administrative and 12,044 technical staff. Structure wise, the most
permanently employed workers were of high school education (37.7%).
Administrative and technical staff had a 23.0% share and physicians a
share of 17.4%. As there were also additional 7,857 health professionals
and associates temporarily employed, 65,252 health professionals and
associates were employed in total on 31 December 2013 in health care in
Croatia. In 2013, by place of primary job, 9,929 out of the 12,946
permanently employed physicians worked in state health care institutions,
635 in private health care institutions, and 2,382 in private doctors’
practices, out of which 1,735 in rentals.
Permanently employed medical doctors had a share of 61.4% women, and
70.6% specialists.
Table 5-2: Health workers (2013)157.
Total
Population per one health worker
13731
312
467
9175
473
9059
911
4704
Junior college education
10069
426
High school education
32986
130
468
9156
Medical doctors
Medical biochemists
Other university health workers
Other university degree staff
Semi‐skilled
During 2013, there were 9,132,084 specialist examinations in outpatient
services in Croatia, out of which 8,167,846 in physicians’ offices with
contract with Croatian Health Insurance Fund (CHIF) and 964,238 in
physicians’ offices without such contract.
In 2013 there were 81 hospital institutions and treatment centres in
Croatia: 5 clinical hospital centres, 7 clinical hospitals and clinics, 22 general
hospitals, 35 special hospitals and treatment centres, 1 hospice, 10 general
wards and 1 out of-hospital maternity ward.
In 2013, Croatian hospitals treated 744,188 people (762,658 in 2012). The
Table 5-3: Hospital type facility operation shows the number of beds
(expressed per 1,000 population) in all hospital-type institutions in 2013
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was 5.86 (in 2012 it was 5.89). By bed structure per 1,000 inhabitants in
2013, there were 4.04 acute beds (1.66 in general hospitals and 2.28 in
teaching hospitals). For chronic and subacute patients, 1.82 beds per 1,000
inhabitants were available. In Croatian hospitals, in 2013 there were
6,624,586 days of hospital treatment. In other words, the average length of
treatment per stay was 8.90 days (against the 1990 average length of
treatment of 15.37 days). Average length of treatment in general hospitals
has been reduced from 12.3 days in 1990 to 6.56 days in 2013. The
average length of stay in teaching hospital centres, teaching hospitals and
clinics was reduced from 12.05 to 7.36 days and in special hospitals from
34.83 to 23.42 days. In 2013, general hospitals, hospital-type institutions
and out-of-hospital maternity wards had a turnover interval (average
number of days of bed nonuse between two patients) of 2.98. In teaching
hospital centres, teaching hospitals and clinics the interval was 1.87 days,
in special hospitals 11.83 days.
The leading disease groups in inpatient care were diseases of the circulatory
system, neoplasms, diseases of the digestive system, injury, poisoning and
certain other consequences of external causes and diseases of the
genitourinary system.
Croatian hospitals generally admit more women than men (1.07:1 ratio).158
Table 5-3: Hospital type facility operation.158
5.2.3
No.of beds
25119
No. of beds per 1.000 population
5,86
No. of doctors
5861
No. of beds per doctor
4,29
No. of patients discharged
744188
No. of bed days
6624586
Average lenght of treatment
8,9
Annual bed occupancy
264
Bed utilitization (%)
72,25
No. of patients per bed
29,63
Financing
With overall health spending at 7.8 % of GDP in 2011 Croatia remains lower
in comparison to the EU average (7.8% and 10.1% respectively), but
Croatia spends significantly more than countries with similar GDP per capita
in the region. At 17.7 percent, the health sector’s share of public
expenditures (about EUR 3.1 billion) is higher than the 15.6 percent
average for all EU countries (although some social security expenses
beyond the strict health system, such as sick and maternity leave, are also
included in that figure).
158
Source: Croatian National Institute of Public Health CBS
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Majority of funding is invested from the public sources (84.7% in Croatia
and 77.1% in the EU). The share of expenditures for prevention in 2010
was also lower in Croatia and it amounted to only 0.68% of the total
expenditures for health care (EU average 2.68%).
In this fiscally constrained environment, the Croatian health system faces a
mismatch among available public resources, growing expenditures, and
increasing needs.159
The financing of the health care system is organized according to social
health insurance principles and it is based on compulsory health insurance,
which is organized as a social insurance. The Croatian health system
produces reasonably good outcomes, but at high costs that are difficult to
sustain in an environment of fiscal constraints.
Croatian Health Insurance Fund (CHIF) is the state-owned health insurance
institution in Croatia. It does not function as an independent health
insurance fund in terms of having its own treasury, but is dependent of the
National treasury (all the funds are placed at the National Treasury). At the
beginning of next year (2015) CHIF will exit the State Treasury system and
will become an independent out-of-treasury fund.
Croatian health care system is funded from different sources. Health
insurance contributions are mandatory for all employed citizens, that is,
their employers. Occupationally active Croatians cover the cost of health
care services for their dependent family members through the contributions
paid for by their employers. Self-employed workers must also pay
contribution fees for their health insurance. Citizens categorized among the
socially vulnerable – groups such as the retired or low-income persons – are
exempt from paying health care contributions. Nevertheless, they are
insured and have access to CHIF-contracted health care facilities. Lastly,
Croatian citizens have the option of private health care services, whether by
direct payment to non-contractual health care centres or by coverage
through voluntary complementary health insurance.
Croatian citizens share in with the fixed amount of 1,3€ the cost of their
health care, with the exception of certain insured categories such as
children under 18 or insurant suffering from specific diseases when using
health care services to treat these diseases (such as malignant and chronic
mental diseases). Certain health care services, e.g. plastic surgery, are not
covered by health insurance and need to be paid for in full.160
5.3
The Croatian Social Care System in Detail
By Constitution, the Republic of Croatia is defined as a social state, which
takes care of the social security rights and basic existential needs of its
citizens.
159
160
Source: World Bank, Ministry of Health
Source: Croatian Health Insurance Fund, CHIF: http://www.hzzo.hr/en/croatian-health-care-system
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5.3.1
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The principles and organization of social welfare
The Social Welfare Act aims at improving the quality of social welfare
services provisions by encouraging the process of deinstitutionalisation and
preventing institutionalisation, process of introducing quality standards of
social services, as well as system of certification of services and making it
possible to develop innovative services on the local level that would target
persons in need. Ensuring minimum quality of services in regards to space,
equipment, minimum content of services as well as minimum of number of
experts and other workers is regulated in the Government regulation on
minimum conditions for provision of social services.161
Croatia operates a complex social protection system, with a fragmented
administration. Three ministries set policies and four ministries administer
social protection programs. The Ministry of Labour and Pensions Systems
covers employment and pension policies, administered through two
specialized agencies and their networks: the Croatian Pension Insurance
Institute and the Croatian Employment Service.
The Ministry for War Veterans set social protection measures for war
veterans. The Ministry of Social Policy and Youth has policy authority over
most social assistance programs, but administers only some of them, along
with social services, through its network of Centres for Social Welfare. A
child allowance program is administered by the Croatian Pension Insurance
Institute, while birth grants and maternity and paternity allowances are
administered by the Croatian Health Insurance Fund.
Compared with other EU countries, the share of benefits received by
poorest quintile from the total social assistance spending is relatively good.
The share of non-contributory social assistance spending (excluding war
veterans’ pensions) that reaches the poorest 20 percent of the population
was 51 percent in Croatia in 2010, placing it in number six among the 28
countries (EU-27 plus Croatia)162.
The fragmented administration of cash benefits impedes coherent policy
making, increases administrative and private costs of delivering cash
benefits, and augments the risk of error and fraud. Many cash benefit
administration functions (eligibility determination, payments, recertification,
oversight and controls, monitoring and evaluation) are scattered across
different administrative bodies and are either underdeveloped or
unnecessarily costly.
The Croatian social welfare system can be defined as non-contributory cash
transfer programs, policies, and social services. There are three main
groups of the Social Welfare Services Providers, i.e.
1) Social Welfare Centres
161
Source: Official gazette 712/2014
Source: World Bank, Croatian Partner Ship, Country Program Snapshot, October 2014
https://www.worldbank.org/content/dam/Worldbank/document/eca/Croatia-Snapshot.pdf
162
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2) Social Welfare Residential Institutions/Homes (both state and nonstate residential institutions)
3) Other social welfare service providers like, help and care centres,
legal entities that provide care outside of their own family without
establishing a home – (e.g. different associations that provide social
services), and physical entities that provide care independently and
outside of their own family in professional capacity (family home).
In 2012 there were 12,373 beneficiaries of social services, and 62% of them
were in some form of institutional care. Further, of all children and youth
without adequate parental care, 68% were beneficiaries of institutional
care. Besides, from all the children and youth with behavioural disorders,
35% were provided services in institutional care, as well as 44% of persons
with intellectual, physical or sensory disorders and 96% of persons with
mental impairment.
5.3.2
Financing
Most social care financing comes from the central budget. Croatia spends a
large share of GDP on different types of non-contributory programs and
policies – about 4.8 percent of GDP in 2011. This definition includes war
veterans’ pensions, a child tax allowance, and more traditional cash transfer
programs for poor and vulnerable families. The spending level remains
substantial even if the focus is on more traditional cash transfer programs
for the poor, vulnerable and families with children – about 2.4 percent of
GDP in 2011. Social services, including residential and community based
services, total about 0.4 percent GDP. Services for the elderly are financed
at the local level.163
5.4
Towards Integrated Socio-Sanitary Care in Croatia
As it is evident from the previous subsections there is no single/unique or
integrated socio-sanitary system in Croatia. But of course there are various
forms of integration at different levels.
For example, visiting nurses already act as socio-sanitary providers.
According to the Croatian National Institute of Public Health, there were 917
nurses in Visiting Nurse Service in 2013. Each nurse had an average of
4,990 insures, and in total, 1,346,088 visits were recorded (11.87% less
than in 2012). In Home Care Service in 2013 there were 1.010 health
professionals employed (nurses, physical therapists).
Moreover, social welfare residential institutions/homes (both state and nonstate residential institutions) are often providing both social and health
services (doctors – general practitioners, nurses, social workers).
163
Source: World Bank http://www.worldbank.org/
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5.5
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Insights on ICT Tool and the Acquisition Process in Croatia.
Regarding the current and future situation in the social and health systems,
it is important to refer to the laws and strategies that define the long-term
position of the health and social welfare system. As it is stated in National
Health Care Strategy 2012 - 2020164 informatisation and eHealth
development is the first priority within modernisation of the health care
system. Activities related to this priority are: •
standardisation of data models, common code lists, manners of data
transfer and mutual communication in the systems,
•
integration of information systems in hospitals and specialist-conciliar
health care, and information exchange both among individual
entities, and with the central information system,
•
interoperability of information systems in health care with all state
administration bodies (joint services), as well as with the EU
countries,
•
standardisation of official web pages and portals of key health care
institutions,
•
joint procurement and harmonisation of standards for computer
equipment, licenses, communication infrastructure, maintenance and
technical support.
Informatisation and eHealth development will need a significant increase of
funds from the total health care budget. In the Operational Programme
Competitiveness and Cohesion (OPCC) 2014–2020165 there are funds
dedicated for investment priorities such as:

Investing in health and social infrastructure which contributes to
national, regional and local development, reducing inequalities in
terms of health status, promoting social inclusion through improved
access to social, cultural and recreational services and the transition
from institutional to community-based services;

Strengthening ICT applications for e-government, e-inclusion, ehealth;

Increased R&D&I activities of enterprises.
The program Health System Quality and Efficiency Improvement with the
budget of 180 million Euro, co-funded by the World Bank and the
International Bank for Reconstruction and Development is already
ongoing.166 Some of the priorities supported under this program are:

164
implementing of a hospital accreditation,
Source: Ministry of Health of the Republic of Croatia, National Health Care Strategy 2012 – 2020
http://www.zdravlje.hr/content/download/10238/74922/file/National%20Health%20Care%20Strategy%202012-2020.pdf
165
Source: Final draft OPCC,
http://www.mrrfeu.hr/UserDocsImages/EU%20fondovi/OPKK_2014_20_FINALNI_NACRT_21_07_2014.pdf
166
Source: World Bank
http://web.worldbank.org/WBSITE/EXTERNAL/EXTABOUTUS/EXTIBRD/0,,menuPK:3046081~pagePK:64168427~piPK:64168435~theSitePK:3046012,00.html
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
implementing Health Technology Assessment (HTA) of all new health
technologies,

building a body of clinical protocols and care pathways; further
development of central procurement, outsourcing of nonmedical
services167.
An important process in social welfare care is the process of
deinstitutionalization in the provision of social services as set out in the
National Plan on Deinstitutionalization and Transformation of Social
Welfare.168 Linked with the planned deinstitutionalization is the development
of community based services, outsourcing of service provision to NGOs and
private service providers as well as adjusting IT infrastructure.
Efforts to consolidate some cash transfer programs improve targeting and
provide better social welfare services have been legislated in a Social
Welfare Law169. Linked with the aim of reducing the time and cost of
application for social assistance beneficiaries and social services users, as
well as the administrative costs of processing applications and recertifying
beneficiaries is establishing a single service point (One Stop Shop) for
applying for a range of social services/assistances.
According to the National Health Care Strategy 2012 - 2020170, the main
problems of informatisation are insufficient funds and disorganisation in the
context of standardisation and exchange of data, operational
methodologies, mutual integrations and linking with the central system.
Funds invested in information technologies in the health care sector are
three to four times smaller than the European and world average.
According to the Ministry of Health170 Central Health Care Information
System in Croatia (CEZIH) with more than 17,000 users and a large
number of information systems makes a good basis for informatisation of
the entire health care system in Croatia. At the moment, all primary
medical offices as well as some offices on the secondary level of healthcare
have been connected to CEZIH, as well as the information system of the
Croatian Institute for Health Insurance. The approximate number of users is
shown in Table 5-4: IT users.
167
Source: World bank
http://www.worldbank.org/content/dam/Worldbank/document/eca/Croatia-Snapshot.pdf
168
Source: Croatian Ministry of Health and Social Welfare
http://www.mspm.hr/content/download/6414/49251/file/JIM_REPORT_2010_pdf.pdf
169
Source: Official Gazette
170
Source: Ministry of Health of the Republic of Croatia, National Health Care Strategy
http://www.zdravlje.hr/content/download/10238/74922/file/National%20Health%20Care%20Strategy%202012-2020.pdf
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Table 5-4: IT users171.
Participant
General practice/family medicine
Paediatrics
Gynaecologic
Dentist
Pharmacy
Primary healthcare laboratory
School medicine
Out-of-hospital spec ialistc onsiliary health c are
Number of users (approximate value)
2350
270
270
1900
1150
120
153
800
Participants in the system send data to the central database in real time,
and receive advanced reports on operation of the health care system from
that database.
The functionality of e-prescription has been introduced on January, 2, 2011,
and since than a complete national coverage was achieved. This has marked
a significant step towards the “paperless medical office”. Over 50 million of
e-prescriptions are issued through the CEZIH system each year. The
functionality of e-referral was introduced on January, 15, 2011. A full
national coverage has been achieved in referrals to biochemical
laboratories, and millions of electronic referrals and results of laboratory
examinations have been exchanged. By implementing the electronic
information exchange mechanisms (e-prescription, e-referral, notes after
each examination in primary health care, sick leave report, and four
messages to Croatian National Institute of Public Health: “Pompidou” form,
reports of malignant neoplasms, reports of infectious diseases, and
unwanted side effects related to mandatory immunisation), a good ground
was set for the central electronic health record of patients in the scope
necessary for various health care professionals both in Croatia and entire
Europe. An extremely important part of such data is a medical treatment
history, which already exists in the system as information.
Since 2006, 17,000 health care workers have obtained basic information
system training and training on the use information technology applications
in their daily work. Out of the total of approximately 45,000 employees in
Croatian hospitals, about 200 are experts in information technology (36
hospitals have an IT department). A hospital IT system is present in 42
public hospitals, while about 20 hospitals still have almost no central IT
system. Integration of hospital information systems with CEZIH system is
for the most part possible through already developed mechanisms, i.e.
definitions of data exchange protocols (referral/discharge letter/eappointments). By implementing the e-referral mechanism in hospitals, the
process of writing a discharge letter is informative, as well as
communication with the primary health care physician. Hospitals send
invoices to CHIF on a daily basis, and they also validate a people insurance
171
Source: Croatian Health Insurance Fund, CHIF http://www.hzzo.hr/en/
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status in real time against the central CEZIH portal. However, there is no
mutual IT connection among hospitals, nor is there a unique set of data
monitored and sent, and there is no reporting system which would include
hospital data as well. The project of establishing e-waiting list and eappointment is currently in progress, as the first step in integration of the
hospital system.
The public health IT system, which is a separate system that is not
integrate and does not have a name, manages more than 33 registers
which are, however, neither linked nor standardised. Messages sent to
CEZIH – Pompidou form, reporting of malignant neoplasms, reports of
infectious diseases and unwanted side effects related to mandatory
immunisation – due to poorly developed reporting systems, are used with a
delay. The health care system as a whole has more than 60 registers. A
large number of health reports are still produced by manual data
processing.
There are IT systems for county centres for emergency medicine in Rijeka,
Karlovac and Zagreb. As a part of the emergency medical service reform,
partially funded by a World Bank loan, preparation is in progress for
construction of a central IT system for all 21 county emergency centres,
with a central call centre and advanced system of data exchange with
ambulance vehicles.
In Croatia, telemedicine service, i.e. medical services provided from a
distance through information and communication technologies, are currently
provided at the primary, secondary and tertiary level of health care.
5.6
Public Procurement
The public procurement environment in the Republic of Croatia is defined by
the Croatian Public Procurement Act effective as of January 1, 2012 and
amended in June and November 2013.172 The act regulates the procedures
for award of public contracts and framework agreements for the
procurement of supplies, works or services, legal protection in relation to
those procedures and the competences of the central state administration
body competent for the public procurement system. It is aligned with and
has transposed the EU acquis communautire which on public procurement
includes general principles of transparency, equal treatment, free
competition and non-discrimination. In addition, specific EU rules apply to
the coordination of the award of public contracts for works, services and
supplies, for traditional contracting entities and for special sectors. The
acquis also specifies rules on review procedures and the availability of
remedies. Specialized implementing bodies are required. All of the
procurement in the Croatian e-health system has been performed according
to these regulative, but using two distinctive approaches:
1) Centralised procurement - the CEZIH system was procured centrally,
and has since then been constantly adapted with new functionalities
and maintained, and the new users were connected.
172
Official Gazette 90/11, 83/13, 143/13, 13/14
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2) Open market procurement - the procurement for the IT applications
for the medical practitioners (doctor, pharmacies, hospitals…) have
been open to the market. They can procure their system according to
law, either with use of the direct bargains, or with standard
procurement policy. CHIF remains in control of the applications that are connecting to the CEZIH
system by implementing the strict certification procedure, which are
repeated every year or with another major release of the application.
5.7
Croatian Market Participants
A rough division of the Croatian market participants can be undertaken
along the following categories:
•
Contracting authorities / outsourcers - institutions respectively health
and social care providers on the local, regional and state level
•
Suppliers – different companies / businesses that provide various
types of goods and services
•
Patients as the end users or beneficiaries
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6 THE SOCIO-SANITARY SYSTEM IN LATVIA
6.1
An Overview of the Latvian Situation
In Latvia, the health and social care services are delivered independently, in
national level these sectors coordinates different ministries – Ministry of
health and Ministry of Welfare. Often the delivery of these services
together, you can effectively use the funding for these sectors. In recent
years, as shown by Latvian demographic indicators, population decreases
and number of older people increases and they are the ones who often need
bought – medical services and caregiver help.
The population in Latvia is still reducing. During the last four years (since
the beginning of 2010), population has diminished by 119 thousand, and at
the beginning of 2014 it comprised 2 million 1.5 thousand (Figure 6-1:
Population number in 2005 – 2014 (at the beginning of 2014, thsd).).
Population decline continued in 2013 at a rate of 1.10%, as compared to
2010 when it comprised 2.16%. In 2013, as the number of deaths exceeded
the number of births, Latvia population reduced by 8.1 thousand. Further,
long term migration attributed to 14.3 thousand. Since 1991, natural
increase in Latvia has been negative.
Figure 6-1: Population number in 2005 – 2014 (at the beginning of 2014, thsd)173.
Death number last year comprised 28.7 thousand persons, and crude death
rate (number of deaths per 1.000 population) accounted for 14.3. Average
age of males at death constituted 68.1 years, while of females – 78.3 years.
Death rates are not significantly lower, since the number of population aged
70 and over is increasing – at the beginning of 2010 those were 270
thousand people (12.7% of total population), while at the beginning of 2014
– 282 thousand persons (14.1%).
173
Central Statistical Bureau of Latvia, 2014. Demographic Overview
http://www.csb.gov.lv/dati/latvijas-iedzivotaji-teritorialais-izvietojums-28319.html
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Figure 6-2: Number of death in Latvia in 2005 – 2013 (per 1000 population) 174.
Mortality prevalence over birth and negative net migration in Latvia caused
also changes in age structure of Latvia population. It should be noted that
since 2010, the share of children and youngsters (0 – 14 years) in the total
population has slightly increased (that may be explained by a modest rise in
the birth number); nevertheless the number of people at working age (15 –
61 years) is continuously reducing and the share of population at retirement
age (62 years and over) is rising. The number of persons at working age
since 2010 has dropped by 121 thousand, while the number of people over
working age had gone up by 7 thousand.174
Figure 6-3: Age structure in year 2014.174
Latvian health care and social care systems in detail in Section 6.2 and
6.6 provide insight on ICT tool buying processes in Latvia, as well as an
174
Central Statistical Bureau of Latvia
http://www.csb.gov.lv/dati/latvijas-iedzivotaji-teritorialais-izvietojums-28319.html
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identification of main Latvian market actors, subdivided into users, buyers
and providers of INCA related ICT tools and services.
6.2
6.2.1
The Latvian Health Care System in Detail
Characteristics of Health Care
In general, public health in Latvia is evaluated negatively: Latvia
substantially falls behind not only 15 EU member-states, but also new EU
member-states. As classified by the World Health Organization, Latvia is the
country with extremely low birth rate and high death rate among
productive-age adults, leading to considerable economic losses.
The most common causes of death in Latvia (like in other EU memberstates) still include cardiovascular diseases and oncological diseases. So,
over 10 thousand new oncological patients are registered in Latvia each
year (over 60 thousand according to the registry data). The main problem
in Latvia compared to economically developed countries is a high first year
death rate, which can be attributed to the late disclosure of cancer at stages
III-IV in 60% to 70% of the cases. Moreover, about 50% of all patients are
of active working age.175 Since there is a bias in society talk about
oncological problems, they are reluctant to participate in non-governmental
organizations, resulting there is a little number of oncological patients
associations. Therefore, numerous decisions (laws, Cabinet regulations,
guidelines, political viewpoint documents) are adopted without active and
conscious participation of non-governmental organizations not only at the
national, but particularly at the regional level, thus, preventing patients
from participating in active healthcare processes.
A lot of decisions in the sphere of the healthcare are made blindly, ignoring
people, deprived of the opportunity to live normally. This fact is also proven
by the Eurobarometer research conducted in late 2010. It shows that
Latvian citizens express distrust in the healthcare system (16% of
respondents), unlike the results of surveys in other countries.176
Life expectancy for Latvian citizens after reaching the age of 65 is one of
the lowest in the European Union (EU), as indicated by the EU statistical
office Eurostat reports based on data for 2010. Life expectancy for Latvian
women, who have reached the age of 65, is expected to be 18.2 years,
being the fourth lowest level in the EU, and that of men is predicted as 13.3
years, which is the lowest level among the EU member-states.177
175
Oncology, Statistical data on the number of patients according to regions, tumor localization,
treatment, sex and age groups from 2007 till 2009, VEC,2010
http://vec.gov.lv/uploads/files/4d00e5a140ac1.pdf
176
EUROBAROMETER74, Public Opinion in the European Union, Autumn 2010
177
EHEMU state reports http://www.eurohex.eu/pdf/CountryReports_Issue4_translated/Latvija.pdf
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6.2.2
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Healthcare System Structure
Healthcare services in Latvia are provided in state, local government and
private medical institutions, and are partially publicly funded and partially
covered by patients.
Publicly funded healthcare services are rendered in medical institutions,
which entered into the agreement with the National Health Service (NHS),
and in state administrative institutions, which provide healthcare services
pursuant to regulations.
The National Health Service is directly subordinate to the Ministry of Health.
Its aim is to implement the state policy for availability of healthcare services
and to administer the state budgetary funds prescribed for health care,
ensuring rational and the most effective use of the state budget in providing
healthcare services, as well as to pursue the state policy in implementing
the eHealth program, compiling and analysing health care and public health
data.
Information on whether a certain agency, medical institution or state
administrative institution maintains contractual relations with the NHS is
available at the NHS website: www.vmnvd.gov.lv. The website contains
information about doctors working for medical institutions, which signed
agreements with the NHS regarding the provision of healthcare services and
public funding, specifying medical institution, doctor’s name, surname,
specialty and whether they are entitled to prescribe publicly funded drugs
and medicinal products for undergoing outpatient treatment.
State guaranteed medical care in Latvia is provided to citizens and noncitizens of Latvia, as well as citizens of the European Union member-states,
the European Economic Area states and the Swiss Confederation, who
reside in Latvia due to their employment or as self-employed persons, and
their family members, and foreigners holding permanent residence permits
in Latvia. Tourists and the foreign nationals who arrive in Latvia from a
country which is not the member state of previous described countries and
stay in Latvia on the bases of temporary residence permit have to cover the
costs of the health care services or they have to use their medical
insurance. They may turn to health care institutions – outpatient clinics,
health centres, medical practices, private practices and hospitals to receive
health care services based on their free choice.178
The Latvian health care system can be subdivided in primary, secondary
and tertiary healthcare:
Primary healthcare is the first and main level of the healthcare system,
the first stage of interaction or contact between patients and the provider of
healthcare services, during which the main health problems of the
population are resolved, applying simple and cost-effective medical
technologies. The primary healthcare for patients registered in patients lists
is ensured by family doctors and their team (doctor’s assistant or nurse and
midwife), as well as dentist, dentist’s assistant, nurse and sanitarian in
178
National Integration Centre, http://integration.lv/en/health-care
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outpatient medical institutions and the outpatient department of hospitals.
Family doctors are selected by patients completing a registration
questionnaire.
The NHS assigns funds for payment for the primary healthcare services to
territorial offices of the NHS, which administer them. Public funds are
assigned for: healthcare services provided by family doctors; services of
nurses and doctor’s assistants (feldshers179); healthcare services provided
by dentists, dentist’s assistants, nurses and sanitarians; services of head
nurses and doctors on duty; services of nurses and doctor’s assistants
(feldshers), providing home-based healthcare services.
Secondary healthcare is the aggregation of healthcare services provided
to a person by a medical person, specializing in any disease profile in an
outpatient medical institution, in the outpatient department of a hospital, in
the institution of emergency medical care, providing outpatient medical
care, or in a day patient facility.
The secondary stationary healthcare is the stationary healthcare oriented at
emergency, acute or planned type healthcare (which is provided by an
outpatient medical institution, in the outpatient department of a hospital, in
the institution of emergency medical care, in a day patient facility, or in a
hospital). Respectively, a day patient facility services are medical or
diagnostic services at the medical institution, in which patient treatment
and healthcare are ensured on a partial-day basis and patients are required
to be supervised after manipulations for at least three hours during the day.
A day patient facility provides medical services, which due to their
complexity, risk or time consumption cannot be rendered in an outpatient
institution; however stationary treatment is not required.
The amount of funds for the secondary outpatient healthcare is determined
in accordance with the amount of contract-based services for the past year
and forecasted services rate. The amount of funds may be adjusted based
on the available public funding for healthcare services. In addition to the
budgeted funds for the secondary outpatient healthcare, the NHS plans the
amount of funds for outpatient laboratory services for family doctors,
doctors working in prisons and secondary outpatient healthcare specialists.
If next year, compared to this year, the amount of public funding for the
secondary outpatient healthcare is reduced or increased, the NHS will
proportionally reduce or increase the amount of funds for payment for
planned outpatient laboratory services.
Tertiary healthcare are highly specialized healthcare services, which are
provided in specialized medical institutions by specialists or professionals of
multiple fields of medicine, who in turn have extra qualification associated
with a diverse and technically sophisticated medical technology. These
services are provided to patients who have a complicated diagnosis or
patients with complications, which require specialized treatment.
179
Feldsher is a medical person who provides primary health care services - take care of patients,
participating in treatment, educate patients on health issues, as well as examining patients, diagnose
diseases according to their qualification and take the treatment.
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6.2.3
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Healthcare Financing
75.1% of healthcare funding is coming by the state budget as can be seen
in Figure 6-4. The share for patients paid medical treatment, not covered by
state budget, services are constituting 8.9%. Major proportion or 43% from
the expenditures are comprised by remuneration expenditures.
Expenditures for public utility payments on average constitute 3% and for
medication, chemicals, laboratory products, medical devices and medical
instruments – 19% from total expenditures of the medical institutions.180
Figure 6-4: Revenue structure of medical institutions180.
It is generally true that the main reason for problems in the healthcare
system in Latvia is the low level of public funding. Within the period from
2000 till 2005 it did not exceed 3.65% of GDP. Only in 2006 it increased to
3.8% of GDP, but in 2007 and 2008 it again decreased to 3.5-3.6% of GDP.
In 2010-2012, the public healthcare funding percentage of GDP was rapidly
falling, and in 2012 it was 3.47%, being the second lowest indicator for the
past eight years. These trends are shown in Figure 6-6. For comparison
average in EU public healthcare funding percentage of GDP is 7.8%, in
other Baltic states, Lithuania and Estonia – 4.7%.
In 2008 Latvia passed through the financial crisis, experiencing fall in GDP.
The amount of financing was reduced, however, due to the GDP fall, till
2010 it maintained its growth against GDP, and after the improvement of
the financial situation in 2011 – it decreased.
180
Ministry of Health http://www.vmnvd.gov.lv/uploads/files/5369e708b27ba.pdf
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Figure 6-5: Health care financing180.
As it is stated in the European Union Statistics on Income and Living
Conditions (EU-SILC) survey, during the crisis the percentage of persons,
stating that, when it was necessary, they did not undergo health checks due
to inadequate availability of medical services, has increased – from 10.1%
in 2008 to 16.2% in 2011. According to the survey, inadequate availability
of services is based on three reasons: 1) too expensive; 2) too far; 3)
waiting too long until getting appointment with the doctor. It should be
noted that the indicator “too expensive” has increased, because if in 2008
6.8% of respondents admitted that the service was not accessible due to its
high price, then in 2011 this reason was stated by as many as 14.7% of
respondents. At the same time, the indicator “too far” remained
unchanged– 0.7% of respondents admitted that the service was not
accessible, because they needed to go too far to get it, in 2008 and in 2011,
but the indicator „waiting too long until getting appointment with the
doctor” has decreased from 2.5% in 2008 to 0.8% in 2011.181
In 2009 the healthcare industry was undergoing considerable changes,
resulting in the substantial reduction of the number of persons working and
institutions operating in the healthcare industry, and, therefore, it was
possible to ensure healthcare services to the minimum extent necessary.
The number of hospitals was reduced, reaching one of the lowest indicator
of the number of hospitals per 100,000 citizens in the European Union
compared to 2006, 2007, when Latvia had one the highest indicators of the
number of hospitals – 106 hospitals in 2006 against just 39 hospitals in
2010.182
181
Eurostat database, Health care: indicators from SILC survey,
http://epp.eurostat.ec.europa.eu/portal/page/portal/health/public_health/data_public_health/database.
182
Informative message. Regarding the situation in the healthcare industry
www.vm.gov.lv/images/userfiles/phoebe/tiesibu_akti_informativie_zinojumi_bda100dbcea27d1dc22576f800338630/vmzino_140610.docx
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6.2.4
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Home-Based Health Care
Home-based health care services are provided by certified nurses and
physician assistants (feldshers) at a patient’s residence, in cases when a
patient needs the outpatient medical assistance, but cannot visit a medical
institution because of medical indications. Indications could be:

A patient has chronic disease and movement disorders because of
which a patient cannot visit a medical institution.

A patient has been discharged from an inpatient medical institution or
a day hospital after a surgery.

Since January, 1, 2012, for stroke patients (with the diagnosis of I60,
I61, I63, I64 or I69)183 that require medical rehabilitation services
and their provision has been launched within six months after illness.
From the state budgetary funds also rehabilitation house visits are paid for
the patients who receive services provided by the rehabilitation specialists
within the home-based care.
In comparison with 2011, in 2012 the number of providers of the homebased health care services has increased by 27 and on December, 31, 2012,
the home-based health care services were provided by 208 medical
institutions. The number of the providers of the services has increased in all
the territorial departments, which can be explained by involvement of the
providers of rehabilitation services in provision of the home-based care
services. In 2012 throughout the territory of Latvia, home-based
rehabilitation services have been provided by 67 medical institutions.
Assistant doctor or nurse home-based health care services in 2012 have
been provided by 185 medical institutions.
183
Diagnosis group and description,
http://www.cihi.ca/CIHI-ext-portal/pdf/internet/HSMR_TECH_NOTES_EN
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Figure 6-6: Number of medical institutions providing home - based health care service
180
.
In 2012, 0.68% of all Latvian residents used home-based health care
services. Increase of the proportion of residents having received this service
in 2012, is due to enlargement of the service, through ensuring the homebased health care services provided by rehabilitation specialists for patients
having specific diagnoses.
Figure 6-7: Share of Latvian residents who have received home based health care services in
%.180
Number of unique patients, who have received home-based health care
services, has increased in dynamics of years. In 2012, this service was
received in total by 15,201 patients, wherefrom 14,466 have received
home-based health care services provided by assistant doctor or nurse, and
1,081 have received home-based health-care services provided by
rehabilitation specialists.
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Figure 6-8: Number of unique patient.180
In 2012, there have been 296,870 home-based health care visits including
23,718 to patients receiving home-based medical rehabilitation services.
When compared with 2,011, the total number of home-based health care
visits has increased by 27%.
Figure 6-9: Number of home - based health care visits180.
6.2.5
Healthcare Concepts in the National Development Plan
The National Development Plan for 2014–2020 (NDP2020)184 is the
hierarchically highest medium-term planning document at national level.
The NDP2020 is closely related to the Long-term Development Strategy of
Latvia till 2030 (Latvia 2030)185 and the National Reform Program for the
Implementation of the ES2020 Strategy (NRP)186.
The goal of the NDP2020 is to agree on the most essential medium-term
priorities, their headlines, purposes, and results. The NDP2020 was created,
with experts of the Cross-Sectorial Coordination Centre (CSCC) cooperating
with the governmental social and cooperation partners, ministries, planning
regions and local governments.
184
Source: Valters Bolēvics, Cross–Sectoral Coordination Centre Republic of Latvia
http://www.pkc.gov.lv/images/NAP2020%20dokumenti/NDP2020_English_Final.pdf
185
Source: Saeima (Parliament of the Latvian Republic)
http://www.varam.gov.lv/in_site/tools/download.php?file=files/text/dokumenti/pol_doc//LIAS_2030_parluks_en.pdf
186
Source: European Commission
http://ec.europa.eu/europe2020/pdf/nrp/nrp_latvia_en.pdf
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Since NDP2020 is a long-term planning document, the healthcare concepts
incorporated therein are of essential importance. The plan contains several
forward-looking concepts, which are closely related to the objectives of the
INCA project:
 The priority is health promotion and preventive measures aimed at
the healthy lifestyle and fighting against alcoholism, smoking and
other harmful habits. People are educated and well-informed of how
various factors affect their health, quality and duration of life.
Unhealthy habits are not advertised as part of a modern lifestyle.
Health education is ensured for all age groups, emphasizing its
importance at schools, thus, contributing also to the prevention of
sexual violence.
 At the same time, healthcare became more accessible. The role of
family doctors in the prevention and supervision of diseases is
enhancing. Family doctors help care for developing healthy lifestyle
habits, improve health and ensure timely diagnostics and treatment.
The outpatient healthcare services network, which closely interacts
with family doctors, is well developed. Emergency care is timely
accessible to everyone.
 The healthcare quality is enhanced, ensuring systemic approach to
disease prevention, timely diagnostics and qualitative treatment, in
particular, in case of cardiovascular, oncology, mental diseases, as
well as perinatal care. The healthcare system management is
improved for people to timely receive necessary healthcare
services.187
6.3
The Latvian Social Care in Detail
Social care centres engage in the provision of various social and
rehabilitation services for the population. A strong impact on these centers
left the funding cuts during the crisis. Even before the crisis, these
institutions were inadequately financed and experienced various
organizational problems relating to reforms implemented before, i.e.
mechanical separation of social and health services, without creating an
alternative regulated system for ensuring adequate and qualitative services.
In the social care centres, where the healthcare sphere is closely related to
the social sphere, healthcare problems are becoming still more urgent.188
The procedure for receiving social services and social care is determined in
the Cabinet Regulation No. 288. In order to receive home-based services
and social assistance, a person or their lawful representative should apply
to the municipal social service.189 Benefits may be received by lonely
pensioners and lonely disabled persons, living separately, who comply with
all the criteria listed below:
187
National Development Plan of Latvia for 2014 - 2020,
http://www.varam.gov.lv/in_site/tools/download.php?file=files/text/dokumenti/pol_doc//20121220_NAP2020_apstiprinats_LV.pdf
188
On ensuring healthcare services in social care centers,
http://www.vm.gov.lv/lv/aktualitates/preses_relizes/4126_par_veselibas_aprupes_pakalpojumu_nodrosinajumu_socialas_apr/
189
Cabinet Regulation No. 288
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6.4
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
whose income for the last three months does not exceed EUR
257,82 per month (exclusive of supplementary pension and after
taxes);

who due to the state of health are unable to fully or partly care for
themselves;

in whose favour no maintenance agreements were concluded;

who have no lawful supporters as determined in the Civil Law
(children, grandchildren), except where:
-
lawful supporters as determined in the Civil Law are
pensioners or disabled persons, who due to their state of
health are unable to support their dependents, which fact is
confirmed by the family doctor’s statement;
-
lawful supporters as determined in the Civil Law are
persons not reached the age of 24, who continue intramural
studies at the general or vocational educational
establishment, college or are full-time intramural students
at the higher educational establishment.190
Towards Integrated Socio-Sanitary in Latvia
In Latvia nowadays social and healthcare services provides different
organizations and these systems are not integrated. Sometimes there is
available some social services such as health care support services.
After economic crisis government started to think about integrated system,
at least in some levels. Ministry of health and Welfare ministry has set up
working group that has to clarify best model for integration. The Ministry of
Health for its part, is preparing a Cabinet rules that will allow Social Care
Centres to build health departments - health points that will provide
integrated health care services and social care will constitute a "bridge"
between the social care system and the health care system.
6.5
6.5.1
Insights on ICT Tool and the Acquisition Processes in Latvia
National program E-health Latvia
E-health is a health program191 for more efficient use of information and
communication technology tools. The main objectives of e-health
developments are to: improve health; promote individual control of their
health; reduce wasted time spend on patients contacts with medical
institutions; increase the effectiveness of the health care; providing health
care specialists with a quick access to necessary patient health data; reduce
the amount of information that health care specialists need to enter into the
documents; increase the amount and usability of a structured information;
190
Ventspils City Local Government Regulation for Receiving Benefits for Home-based Care
http://www.ventspils.lv/lat/pakalpojumi/kategorijas/socialie_pakalpojumi/1118-pabalsts-aprupei-majas
191
Source: Official Site of the National Health Service Latvia http://www.vmnvd.gov.lv/en/e-health
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increase effectiveness of medical institutions; increase health care data
reliability and security.
Patients can easily access care records using the state e-services' portal
(authenticated with ibank information or electronic signature). These eservices are: "My state paid healthcare services"; "My general practitioner";
"My new-born children data"; "My data within the diabetes mellitus patients'
register". The eHealth solution architecture is developed as modular system,
which consists of three layers (Figure 11-12):

The first layer - for business users, who integrate with systems
using their business systems;

The second layer - is e-health system which includes all core
models;

The third layer - is national e-governance infrastructure for data
exchange with registries.
The first layer
The second layer
The third layer
Figure 6-10: E-health solution architecture192.
As it`s shown in Figure 11-13 National health billing system collects data
from all health care providers about state paid medical services. Billing and
payments processes are almost fully digitized. This figure describes
information flow: after the health facility visit, information about services
patient received is entered into National Health billing system. Through the
State e-services portal www.latvija.lv patient may obtain information
regarding the received health care services.
192
For further information: National Health Care Service Latvia http://www.vmnvd.gov.lv/en/e-health
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Figure 6-11: National health billing system192.
Benefits of e-health system implementation:

Centrally stored health records reduce risk of faulty course of
treatment.

Effective health service booking process allows patient to choose
health service provider using information about waiting queues, time
schedules, price of services whether paid by state, personally or by
insurance companies.

More effective prevention activities such as reminders of required
vaccinations; invitations to preventive cancer screening tests etc.

More effective, safer and faster process of getting prescriptions and
medicines reducing risk of erroneous prescriptions.

Better supervision of the financial flow, saved states budget by
eradicating unfair practices and decreasing amount of repeated
medical tests.

More information for evidence based decisions in health care.

Open interfaces allows every software provider alter their solution to
exchange information with central e-health platform.

Patients have more information about their health and are more
involved in the treatment process.

Process allows for transparency and budget economy as unfair
practices are easily detected.

Payment process is quick and convenient.

Easily gathered statistics
decisions in health care.

Authentication services and verification against state registers are
provided by state e-services portal integration platform and are used
across many e-services' portal services.

Data flows to billing system are electronic.
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provides
means
for
evidence
based
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Next steps for e-health system development:

Centralized e-health solution, funded by European Regional
Development Fund, includes e-referrals and e-booking, eprescriptions and electronic health records as well as e-health portal.
Solution provides published interfaces for interconnectivity,
authentication and classifier distribution services.

Patients or healthcare professionals after authentication can access
related information either using the software of health care providers
or e-health portal.

All those modules provide fundament for future development.

E-health portal will include also publicity available information about
the health care sector in Latvia, such as prevention, illnesses and
diseases or legal framework of Latvia's health system.

New e-services are going to be electronic records and referrals to
health care services; and the electronic health card, which will have
their medical records and information about received health care
services as well as there will be other e-services.
6.5.2
Commercial health information systems
As already mentioned in paragraph 6.5.1., in E-health Latvia architecture at
the first layer are located business users, who integrate with systems using
their business systems. Main business systems in this field, used in
Northern Kurzeme regional hospital, are Doctor Office, SmartMedical 4.0
and Laboratory Information System (LIS). These solutions are based on
providing medical services in medical institution - from patient registration
to the administrative level reporting, linkage with other health authorities'
databases. Below is the detailed information about these systems.
Doctor Office is an information system for health facilities and individual
specialists, which helps to automate the workflow, starting from simple
financial accounting tools up to creation of different types of reports and
documents on administrative level. The system was developed by SIA
Meditec, which was founded in 1999 and till 27th March 2006 had the name
Medicine Information Technology Centre (MITC). The office is located in
Riga, Graudu Str. 68. Doctor Office is on the market since 2001, covering
over 80% of the total market with 70 realized projects in Latvian health
care facilities. The health care process can be divided in three sectors –
hospitals, health centres and private practices. Platform developed by
Doctor Office can be adjusted to each of these sectors:
Doctor Office Practice is suitable for individual health care specialists and
doctors’ practices. The system ensures basic business management
processes, starting from planning the working hours, patient registration,
outpatient ticket creation and sending them to National Health Department.
Further, Doctor Office Practice provides the storage and exchange of data,
preparation of reports and formatting of bills.
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Doctor Office Health Centre is meant for clinics and health care centres,
providing effective information exchange from registry to specialist cabinet.
Doctor Office Health Centre administrates the institutions financial
management process, as well as providing reports on the usage of the
institution’s finances. Using Doctor Office Health Centre statistic tool it is
possible analyse a clinic’s or a health care centre’s efficiency.
Doctor Office Hospital is meant for big health institutions. The system plans,
administrates and organizes the institutions work on outpatient, as well as
inpatient care. Doctor Office Hospital does a quick and precise information
exchange between specialists and diagnostic cabinets. The board tool
performs a precise hospital management, showing free rooms in the
department and the necessary manipulations for the concrete patient. The
Doctor Office Hospital report form and statistic tool allows analysing the
institution’s work load and usage of the finances.
SmartMedical 4.0 is a system meant for clinics, dental clinics, hospitals
and physician practices. It automates the daily work flow of health facilities
and doctors, speed up transaction processing and document movement.
The system was developed by SIA „Blue Bridge Technologies”, which was
founded in 2007 and has its head office in Riga, M. Nometnu Str. 31, 2nd
floor, room 206. It has branches in Spain and USA. The company also
develops and maintains the electronic registry system piearsta.lv, which
gives the possibility to sign up for a doctor appointment using medical
facility and doctor catalogue.
The system SmartMedical has 5 main modules for medical facilities –
payment module, patient registry module, patient management module,
record module and information internal exchange between the health
facilities and 5 modules for insurance companies – price list harmonization,
identification of insurance program, transaction import, operation online
authorization and use of E-card.
The payment module allows to prepare an electronic bill for the patient,
offering different ways of payment, including that the patients pays himself
or with the insurance, and also to control if the bill is paid and to do bill
records. You can add a cashing machine system to this module and it allows
different sort of payment. In this module the transfer processing with
insurance companies and data exchange with National Health Department
(NHD) is done online, faster and more efficient, reducing errors, which are
made by processing payment operations manually.
Patient’s registry module allows registering the patient for an appointment
and for tests, to control and manage the patient’s appointments as well as
print out the appointment history and to help do reports, which you can sort
out by days, weeks or month for one or more doctors. Using the information
of this module, it’s possible to send the patient a remainder about his/her
appointments and hand out electronic bills.
This module saves data about who had visited your establishment –
information about the doctor visits, patient treatment history, referrals to a
specialist, about prescriptions, notices, patient appointments, sick-leave
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certificates, insurance and NHD coupons. During the patient’s visit it is
possible fast and easy to access the patient’s medical history.
Is meant for filling out medical forms like patient’s card and appointments,
dental cards, prescriptions (using National Medicine Agency medicine
register data), sick-leave certificates, forwarding to a specialist and other
forms in accordance with LR CM (Latvian Republic Cabinet of Ministries)
approved document forms.
Ensures electronic patient’s hospital medical record filing in and printing. It
allows to control the treatment process, the given services and
manipulations. After the patient is signed out of the hospital, the bill is
prepared electronically, and it’s possible to indicate in it the way of paying
for the service and do the payment through the SmartMedical system.
Writing notes and working with the payment module and patient’s registry
module, the report module provides detailed reports about – finances,
insurance, patient, appointment, vaccination, prescriptions and NHD. You
can filter the reports indicating different criterions – date, specialist, service,
patient, insurance company, diagnose, and NHD manipulations.
This module is important for medical centers, hospitals, facilities with more
than one user. It allows sending internal messages to SmartMedical system
users, to attach and forward important files, inform about changes in the
price list, and working hours.
It is an easy and comfortable instrument for marketing activities and for
communication with patients. Some of its possibilities: remind the patient
about his/her appointments and planned vaccinations, notification about
changes in the working hours, new services, special offers and other useful
information.
Laboratory Information System (LIS) is a program and hardware
complex, which is specially developed for medical clinical diagnostic
laboratories. LIS provides obtaining, processing and storage of data, as well
as the technological process, automating of administration and
communication. DataMed represents LIS producers XT2-LIS and ANK - the
most popular LIS systems in Latvia. These systems are functioning already
for several years and they are constantly improved, following the
development of the industry. LIS provides integration with the systems
Doctor Office, SmartMedical and DATAMED IS.
The system was developed by SIA „Datamed”. Datamed is in Latvia since
2007, and its office is located in Aluksnes Str. 5-18, Riga. Datemed is
developing Radiology Information System (RIS), which is meant for
automating of radiology department, Laboratory Information System (LIS)
and DATAMED medicine diagnostic IS, which is a data archive providing all
diagnostic equipment (Radiology (Visual diagnostic), Functional diagnostic,
Cardiology diagnostic, Laboratory and other equipment system) centralized
data storage and accessibility form every hospital department or external
computer which has internet access. LIS provides:

Information about patient’s registry
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
Information about order, material registry and labelling

Work journals

Referral and material registry

Sending tasks to analyser and working places

Work process monitoring

Getting results, approval

Test report creating

Test report hand out

Results Report Archive

Quality control

Statistic summary

Integration with external information systems, messaging gateway,
and data import and export

System and user documentation

Microcomputer connections – possible to connect 3 analysers, no
need for separate computers for each analyser

Micro-terminals – for formula counting and reading bar codes
All described systems are used in Northern Kurzeme regional hospital.
These systems are functionally different from INCA. INCA provides an
integrated virtual platform to engage both, the patient and the patient's
doctor, in disease prevention, treatment and monitoring in and providing
quality home care. Such functionality none of the existing systems can
provide and INCA is a good additional tool to existing solutions.
6.6
Latvian Market Participants
Key market participants could be divided in the following categories:

Ministry of Health of the Republic of Latvia. Ministry of Health is
the leading government authority in the health sector and it is
responsible for public health, health care and pharmacy.

Ministry of Welfare. This is the leading institution of the state
administration in the areas of labour, social security, children's and
family rights as well as equal rights for people with disability and
gender equality.

The National Health Service – the operating direct administrative
institution subordinate to Ministry of Health, took over the functions
formerly carried out by The Centre of Health Economics and Health
Payment Center. National Health Service enters into contracts with
medical staff and organizations for medical services and state
funding.
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
Heathcare
providers,
including
staff
(doctors,
nurses,
administrative personnel) and organizations – public and private
health centres.

Suppliers. Business organizations that provide various goods and
services for healthcare organizations.

Social care providers, including public and private social centres,
personnel, social care givers.

Patients.
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7 CONCLUSIONS
Some of the biggest difficulties health systems are facing today are
financial, and despite disparities, all the countries are meeting the same
problems. Aging societies drive the costs of maintaining health and social
systems. Additionally, the financial crisis puts pressure on health and social
systems budgets.
Proactive integrated socio-sanitary care is seen as a means to lower costs
while improving service quality and the exploiting savings potentials. For all
Europe, savings could amount to 100 billion Euros annually. However,
healthcare is provided by a plurality of islands and despite having strong
institutions, good hospitals, and primary care getting better organised, they
do not work in a coherent system.
Having studied the market for integrated socio-sanitary care, Integration of
Care is currently more a concept than a reality. The integration task is not
straight forward, and there are a number of bottlenecks and systemic
barriers (mainly legal and organisational) at the interface between social
and health care settings, such as:

Fragmentation of Care and Budgeting,

Lack of Coordination (political inflight)

and Collaboration.
The virtual integration option provided by INCA, can help to overcome mask
some of these issues for end users. Nevertheless, fore smaller players, the
in-homogenity of the different health and social care systems, as reflected
in the country sections of Spain, Cyprus, Croatia and Latvia constitutes a
particular entry barrier, leading to the initial impression that a EU wide
role-out can only be achieved with the support of strong local players that
know their health and social system extremely well and can collaborate with
the INCA Consortium to adapt the INCA solution to the local clients’ needs.
Concluding, it can be remarked, that the need for INCA is there. INCA
provides a solution to the pressing problem of health and social system
streamlining to keep finances on track, while at the same time delivering
high quality and timely socio-sanitary services. The entry barriers detected
are diverse and strong, but with the help of the EU pilot funding, the
consortium is on the right track to device a sustainability strategy to
overcome these barriers. This Sustainability Strategies will be part of
Deliverable D5.2 to be presented in June 2015.
8 APPENDIX - DATABASES AND OTHER RESOURCES
8.1
Background Reading and Web Portal List
Much can be learned from recent reports and studies in the field. The
following table lists documents that are identified by partners as particularly
relevant.
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Table 8-1: Important Background Reading.
Cover
Citation
Title
(Valeri, et al., 2010)
Business models for eHealth
(Rand, Ernst & Young, 2012)
National Evaluation of the Department of
Health’s Integrated Care Pilots
(Øvretveit, 2011)
Does Clinical Coordination Improve Quality
and Save Money? Volume 1 and 2 (Council EU, 2013)
Reflection process on modern, responsive and
sustainable health systems
(Goodwin, et al., 2014)
The King´s Fund. Ideas that change health
care. Providing integrated care for older
people with complex needs. Lessons from
seven international case studies
(Ernst
& Young
and Danish Study on business and financing models
Technological Institute, 2013)
related to ICT for ageing well
(NWL/NHS, 2014)
North West London Integrated Care Pilot:
Business Case
(EIP AHA B3, 2012)
(EIP AHA B3, 2013)
A compilation of good paractices ‐ Replicating
and tutoring integrated care for chronic
diseases, including remote monitoring at
regional level
(Valentijn, et al., 2013)
Understanding
integrated
care:
a
comprehensive conceptual framework based
on the integrative functions of primary care
(Björnber, 2013)
Euro Health Consumer Index 2013
(Deusto Business School, 2014)
El papel de los gobiernos en la Alianza
Sociosanitaria
eHealth Task Force Report
Redesigning health in Europe for 2020
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The references mentioned in Table 8-1 are made available to the
consortium
partners
via
the
WP5
shared
folder
references_must_read_literature_socio_sanitary_health_and_social_systems.
Similarly it is useful to keep track of the most important websites with
respect to WP 5 activities. Some hyperlinks to interesting webpages are
given below:
http://ec.europa.eu/research/innovationunion/index_en.cfm?section=active-healthy-ageing&pg=documents
http://integration.healthiernorthwestlondon.nhs.uk/chapters
http://www.esifforhealth.eu/Project_outputs.htm
http://ec.europa.eu/health/index_en.htm
http://ec.europa.eu/health/ehealth/key_documents/index_en.htm
http://www.esn-eu.org/home/index.html
8.2
Bibliographic Resources

The National Center for Biotechnology Information advances science
and health provides access to biomedical and genomic information
http://www.ncbi.nlm.nih.gov/

Embase from Elsevier Life Science Solutions is the most
comprehensive international biomedical database for biomedical
researchers http://www.elsevier.com/online-tools/embase

The Cochrane Library provides access to high quality, independent
reviews, abstracts, clinical trials etc. www.wiley.com/cohcrane With
reviews under www.cochrane.org/reviews.

The Database of Abstracts of Reviews of Effects (DARE) provides
abstracts of systematic reviews focused on the effects of
interventions used in health and social care. It is owned by the
Centre of Reviews and Dissemination of the National Research
Institute
of
Health
Research
of
the
NHS
of
the
UK
http://www.crd.york.ac.uk

CINAHL Journals database was originally an index to nursing
literature but has now developed into a comprehensive bibliographic
index and includes abstracts and full text materials from selected
journals.
http://www.cinahl.com/library/journals.htm
and
http://www.ebsco.com

Medscape
features
peer-reviewed
articleshttp://www.medscape.com/
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original
medical
journal
8.3
23/12/2014
Online Statistics Databases

World Health Organization (WHO), European health for all database
(HFA-DB), http://data.euro.who.int/hfadb/

Eurostat:
o
http://epp.eurostat.ec.europa.eu/portal/page/portal/eurostat/h
ome/
o
Population structure and ageing (statistics of population
projections of Eurostat for persons >65 years and for years
2020-2030)
http://epp.eurostat.ec.europa.eu/portal/page/portal/eurostat/h
ome/

OECD: http://stats.oecd.org/index.aspx?DataSetCode=SHA)

Open
Data
Portals
(overview):
agenda/en/open-data-portals
8.4
http://ec.europa.eu/digital-
Online Project Databases

CORDIS Search Service:
http://cordis.europa.eu/newsearch/index.cfm?page=simpleSearch&js
=1
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D5.1 Market Overview - inclusive introduction of integrated care

Transcription

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