Health system reform: Integration for quality, equity and effectiveness, by Victoria Cox, Riitta-Maija Hamalainen

24 September 2015

The challenge of realising effective health services

The Informal Meeting of Ministers of Health, 24-25 September 2015 is discussing today health in the context of the European Semester. In that context we look to see how quality, equity and effectiveness can be fostered through health system reform.

European health systems are undergoing considerable reform so that they can address changing health demands. As a consequence of the economic crisis, ageing populations, increasing prevalence of chronic disease, multi-morbidity and rising costs of delivering care, health systems must adapt to tackle these challenges. In order to address these issues, a shift in the way services are delivered is required through health system reform. One means of doing so is to strengthen primary care and foster collaboration between sectors. This has the potential to help deliver change by shifting care from hospitals to settings that are closer to the community, allowing for a greater focus on disease prevention and health promotion.

OECD suggests that countries should improve primary care to reduce costly hospital admissions for chronic conditions[1]. Vice President Valdis Dombrovskis recently stressed that healthcare reform is essential to ensure that health systems provide accessible quality care in an efficient and economically sustainable manner[2].  However, the analysis by EuroHealthNet of the 2015 Country-Specific Recommendations (CSRs) found that the CSRs failed to adequately address health care reform. Only six CRS’s were related to primary care, quality of care, community care and accessibility. EuroHeathNet argues that efficient use of resources is not possible without focusing on health promotion, disease prevention, the importance of mental health and the need to address health inequalities[3].

There is ample evidence that the level of spending on health care is not linear to better health outcomes. It is actually spending in areas other than healthcare that would reap health outcomes[4]. As we move towards a holistic approach to the person and accept that ill health is very much determined by social determinants, we must recognise that these determinants are not the sole responsibility of health provider alone but involve social services, education, housing and the third sector. Most healthcare systems are currently organised along organisational boundaries, which may hinder ability to cooperate across sectors.

Equity in health relates to the preventable inequalities experienced with regards to health and health outcomes between different groups in society. It is well known that these inequalities follow a social gradient and it is often the most vulnerable people who experience inequalities as a result of their socio-economic situation, environment, and lifestyles. On top of this, vulnerable people often face the greatest difficulties accessing healthcare, leading to worsened health outcomes and reinforcing existing inequalities in health. The fragmented nature of health services and limited coordination with other public services exacerbates these challenges.

In order to improve equity in health, integration fosters collaboration between sectors. Integration not only cultivates person-centered care[5], but co-production also occurs through community engagement. Local planning allows health systems to consider the needs of the population at local level and therefore use resources to tackle the social determinants of health in the most effective manner. Localized planning between healthcare, social care and other sectors also reduces organizational barriers. This creates a more transparent system, whereby patients can flow more smoothly along their healthcare journey, accessing the services they require in a simplified manner. This can help to reach those who may otherwise not have been able to navigate each individual service.  

The European Commission advocates integrated practices to reduce the social determinants of health and ultimately to keep people healthier, reducing dependence of the health system, encouraging people to work for longer and contributing to the economy[6]. It therefore follows that when looking at health system reform the CSR’s should take a more holistic approach. The WHO defines quality of care as “care that is safe, effective, people-centred, timely, efficient, equitable and integrated[7]. Disjointed health systems do not live up to these aspirations, and by applying principles of integrative practice there is more potential to re-align health systems to be person centred, improve the social determinants of health, increase accessibility and, as a result of this combination, increase their effectiveness.


[1] OECD. “Health at a Glance”. (2014).

[2] European Parliament Plenary, Strasbourg. “Sustainability of healthcare systems in Europe: future challenges – Commission statement”.  (2015).

[3] EuroHealthNet. “Will the 2015 Country Specific Recommendations contribute to health equity?” (2015).

[4] João Medeiros & Christoph Schwierz. “Efficiency estimates of health care systems”. (2015)

[5] World Health Organisation. “WHO global strategy on people-centered and integrated health services.“(2015).

[6] European Commission. “Social investment Package: Investing in Health” (2013).

[7]World Health Organisation. “WHO global strategy on people-centered and integrated health services.“(2015).