INCLUDE for #HealthForAll – If solidarity, equity and universalism are at risk, #Tallinn10 meeting brings the new hope and inspiration


“Solidarity is the red thread of the European health community”, said Hans Kluge (WHO) at the closing session of the WHO high-level meeting “Health systems for prosperity and solidarity: leaving no one behind” that took place in Tallinn last week. “The system based on solidarity is the best guarantee for freedom in the society and it’s equally important as human rights” stated earlier Clemens Auer (Ministry of Health, Austria). Those statements, from very well-known promoters of sustainable health systems in Europe, can constitute a summary of the two days of discussions that focused on three important “Is” – Include, Invest, Innovate for health for all.

Are solidarity, equity and participation obvious for all?

The European health community visibly committed to solidarity, together with equity and participation, only ten years ago, when the Tallinn Charter was signed. For the young public health professional, who graduated from the university 10 years ago, it is pretty surprising that something that we take today for granted in health systems and in health work, is in fact quite new. Even though the values of the Tallinn Charter might seem indisputable for most of us, it seems that many are still not convinced that Universal Health Coverage is the best system for health and social protection that has ever been developed. The need for social equity, support for poor and vulnerable persons, and free access to the health services, has been repeatedly questioned in many European countries over the last decade. The social and health inequalities continue to increase, populism remains strong, and several arguments are being raised against universalism:

  • “We cannot afford it”
  • “It decreases productivity!”
  • “People should take care for themselves. If they don’t, it’s their own fault, the rest should not pay for it”
  • “Health systems are like a black hole – the more you put there, the less you get”
  • “It cannot be this way, it must crash”
  • ‘’Not from MY taxes!”


We cannot afford health systems that make people poor

The meeting in Tallinn, with numerous expert lectures and presentations from different European countries from Portugal to Georgia, from Finland to Kazakhstan, beat all the arguments presented above. We knew a decade ago and now in 2018 we know it very well, that we cannot afford health systems, which impose high fees on services and medicines, so that people become poor when trying to pay for them. It’s not only about the solidarity, also the economic calculation makes a strong argument. The Tallinn Charters says: “Investing in health is investing in human development” and the numerous studies confirm that.

This is very important to remember in the moment when many countries are transforming their health systems. What could they learn from the Tallinn meeting? What is the silver bullet? What are the elements of a successful reform?

What we know

First of all, we have plenty of evidence and we know what should be done. As Josep Figueras (European Observatory) said, “we know who experiences financial hardship, we know what creates financial hardship and we know which policies work”. In his presentation at the first plenary on 13 June, Professor Charles Normand showed the numbers – the moment when the out-of-pocket expenses go beyond 15% it is dangerous for all groups of the society. However, for poor and vulnerable, older people and for young families, it means they reach the border of the ‘catastrophic expenses’. At the same time, we learned that in Poland, Estonia, Portugal and Slovakia the out-of-pocket expenses are more than 20%.

We also know that the user charges do not really discourage people from using the services because they do not know if they need them or not – they seek diagnosis, answers to the questions and they are ready to sacrifice to pay for the best possible help, even if it will endanger their budget.

Finally, we know that poorer people choose treatment and medicines over prevention. Which is disturbing in the light of the facts above. The risk of catastrophic expenses, together with the general reduced health status of the poor and their lower socio-economic status is a dangerous mix, which should be avoided.

Effective solutions are not complicated but they need bold decisions

So what can be done? Surprisingly, the effective solutions presented during those two days in Tallinn, are very simple. Impressive, because they require strong political commitment and broad strategic partnership, but simple, indeed. Slovenia decided to put healthy society as a goal central to all policies 2030. Georgia is increasing their health budget by >10% annually with the hope to double expenditure to 5-6% GDP in some 5 years. Austria put a cap on pharmaceutical spending, as did Estonia. Lithuania decided to redesign their pharmaceutical policy and Latvia introduced exemptions in the middle of the financial crisis, ensuring not only equity but also employment. That clearly paid off.

All those examples show that the European Region is rich in knowledge, experience and expertise on how to design sustainable health systems for the future. Systems that are efficient, effective and equitable. Systems that contribute not only to the social but also to economic development. Systems that we all are dependent on and it’s in our best interest to make them working for all. The meeting was attended by the high-level representatives of the health ministries of all 53 countries of WHO-EURO, which hopefully got inspired and encouraged by the stories presented on the stage. For me it is comforting to know that the Outcome statement, reaffirming the key values of Tallinn Charter was approved with no doubt and opposition. In the statement, the countries agree on, above others, “the need to revisit and strengthen coverage policies in countries by extending coverage to the whole population for all needed services”. I hope we will meet in 10 years in Tallinn not to reaffirm this commitment again, but to learn about the success of the European Region in ensuring Health for All.


This Blog was written by the Young Gasteiner Karolina Mackiewicz


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