A European Cancer Plan: Make it disruptive! (F12)

There were many take home messages from this session at the EHFG 2019, but to just state one would be very unfair. What was apparent, however, was that the development of a European cancer plan is desired, but we probably won’t see such a document anytime soon. Peter O’Donnell kicked off the session by outlining the agenda vocalising that a European cancer plan is European and not national. He outlined the need for key performance indicators (KPIs) in this area. Nils Wilking, Associate Professor, Institute of Health Economics, Karolinska Institutet, quickly followed presenting his comparison report on “Cancer in Europe 2019 – Disease Burden, Costs and Access to Medicines”. This will be available on the Karolinska Institutet website in November 2019 for those of you who are interested. Surprisingly, Nils reported that 42 – 45% of all cancers are preventable and that all EU countries roughly spend the same percentage of their healthcare budget expenditure on cancer medicines.

Tit Albreht, Lead, IPAAC Joint Action & Senior Health Services and Health Systems Researcher, Institute of Public Health, Slovenia, made a very important point that patient involvement was high in the design phase of cancer services, but decreased in the implementation and evaluation phases. This is contrary to public opinion in this field. We need to invest more in monitoring systems like France has.

Barbara Wilson, Founder of Working with Cancer, emphasised the importance of the survivorship still being on the agenda for discussion. However, she argued that cancer should be recognised as a disability and this is why disability adjusted life years (DALYs) are the most accurate health metric in economic evaluations which analyse cancer patients. Martin Seychell, Deputy Director-General, European Commission Directorate-General for Health and Food Safety (DG SANTE), scared us by saying that all projections show that cancer is the leading cause of death in Europe. He also talked about how Human Papilloma Virus (HPV) prevention in males can be overlooked in some European countries. Recently, in Ireland, the Health Information Quality Authority (HIQA) has recommended that a more effective version of the HPV vaccine be given to girls and extended to boys beginning in September 2019. Sometimes, as Ireland is not on the mainland, we can feel a bit disconnected from Brussels. However, we are implementing recommended EU health polices before other EU countries.

Mike Morrissey, Chief Executive Officer, ECCO and Kathi Apostolidis, President, ECPC engaged in panel discussions where it was stated that for a European Cancer plan to really work, EU member states must agree on and implement certain key universal rules in their own National Cancer Control Programmes (NCCP) and build on that. In Ireland, our NCCP was established in 2007 to ensure that all elements of cancer policy are delivered to the maximum possible extent. Our NCCP continues to reorganise cancer services to achieve better outcomes for patients. In fact, I was recently involved in a study where I argued that the subcutaneous trastuzumab formulation for the treatment of HER-2 positive breast cancer should be taken out of the secondary care setting and supplied to patients via their local pharmacy for self-injection at home. (1) This would reduce the loss of productivity for all involved as patients can avoid going to hospital. I believe it is this patient-centric rationale that should be entwined throughout the development of our future European Cancer plan.

This workshop was organised by European Cancer Organisation (ECCO), European Federation of Pharmaceutical Industries & Associations (EFPIA), European Cancer Patient Coalition (ECPC) and The Organisation of European Cancer Institutes (OECI) and moderated by Peter O’Donnell, Brussels correspondent, APM Health Europe.

References

  • O’Brien GL, O’Mahony C, Cooke K, Kinneally A, Sinnott SJ, Walshe V, Mulcahy M, Byrne S. Cost Minimization Analysis of Intravenous or Subcutaneous Trastuzumab Treatment in Patients With HER2-Positive Breast Cancer in Ireland. Clinical breast cancer. 2019. https://doi.org/10.1016/j.clbc.2019.01.011

This blog was written by the Young Gasteiner Gary L O’Brien.

Can People Afford to Pay for Healthcare? New Evidence on Financial Protection in Europe (F7)

“No one should have to choose between healthcare and other basic needs” – this essential message was delivered by Tamás Evetovits, Head of the WHO Barcelona Office for Health Systems Strengthening, WHO Regional Office for Europe, in this afternoon workshop organised by World Health Organisation (WHO) Regional Office for Europe and moderated by the witty Prof. Charles Normand.

Tamás engaged the audience by using the metaphor of an umbrella and its strength in different weather conditions to illustrate the durability of universal health coverage (UHC). He enforced that UHC means that no one should experience financial hardship and unmet need. An evocative video showed the real life examples of people like Lisa, a patient who had to choose between paying either for her electricity bill or prescription medicines.

Jonathan Cylus, Economist and London Hub Coordinator, European Observatory on Health Systems and Policies, discussed two metrics used to capture financial hardship: catastrophic out of pocket (OOP) payments and impoverishing OOP payments. Catastrophic OOP payments are those greater than 40% of a household’s capacity to pay after deducting standard needs, while impoverishing OOP payments are those that, once paid, cause a household to fall below the poverty line. Johnathan discussed the bespoke WHO methodology used in the “Can people afford to pay for health care? New evidence on financial protection in Europe (2019)” regional report. (1)

Sarah Thomson, Senior Health Financing Specialist, WHO Barcelona Office for Health Systems Strengthening, WHO Regional Office for Europe elaborated on how we can we improve financial protection especially for the poor.

Triin Habicht, WHO consultant & former Head of the Department of Health System Development, Ministry of Social Affairs, Estonia, discussed the reform of Estonia’s pharmaceutical co-payment system. Post reform, 134,000 people per year now benefit from additional coverage. Triin also alluded to the electronic health insurance fund (EHIF): when a patient goes into the pharmacy to acquire prescription medicines, their specific co-payment value owed adjusts automatically because of the EHIF. As a practising pharmacist, I would love to see this reformed system implemented in my home country of Ireland, as it would mean patients would not overpay as is sometimes the case.

Kaisa Immonen, Director of Policy, European Patients’ Forum argued that we all need to “look behind the figures” and increase public patient involvement (PPI) in the area of healthcare access. Stefan Eichwalder, Cabinet of the Minister, Federal Ministry of Labour, Social Affairs, Health and Consumer Protection, Austria gave an overview of his country’s complex healthcare system. Martin Seychell, Deputy Director-General, European Commission Directorate-General for Health and Food Safety (DG SANTE) told the audience “not to rely too much on the headline figures of just how many people are covered “ and “look at what services actually are covered/offered“. He added that if we not cover a lot of services then we have a lot of unmet need.

After an animated panel discussion, Charles Normand concluded the session by elaborating on equity in healthcare saying access can be disease-specific, so choosing the right disease for yourself can be crucial. The audience burst into laughter.

References

  • Can people afford to pay for health care? New evidence on financial protection in Europe (2019), By Sarah Thomson, Jonathan Cylus and Tamás Evetovits, 2019, xv + 116 pages, ISBN 978 92 890 5405 8, https://apps.who.int/iris/bitstream/handle/10665/311654/9789289054058-eng.pdf?sequence=1&isAllowed=y

This Blog was written by the Young Gasteiner Gary L O’Brien

Food for thought: We are what we eat (L6)

After an indulgent jampacked and fruitful three days absorbing all things related tohealth policy at the European Health Forum in Gastein, this session allowed conference attendees to ingest the current issues regarding food policy in Europe and digest what this means for our public health and wellbeing.

Food is a fundamental part of human society that impacts every facet of our lives. What we eat has huge effects on how we look, how we feel, and most importantly our own health. We use food to sustain ourselves but increases in food availability has indirectly led to increasing disease prevalence across EU countries. We are seeing more and more diseases such as irritable bowel syndrome (IBS), food allergies, liver disease and bowl disease in our populations. Huge societal issues around food and health sustainability are brewing and we need to act now for the health of our populations!

As food supply and delivery has developed in recent history, we have created an obesity monster that is devouring health system resources and people’s quality of life. During this session it became obvious to me there is a lack of awareness of the impact food issues have across society at both the micro and macro level.  The damage being caused to our lives by actions of the food industry is exceptionally serious. We need to start to ask hard questions of food industry practises now and introduce disruptive policy inventions to bring down the disease burden of obesity.

During this session, we found out that not only are we what we eat but that we are not alone and our own friendly microorganism’s health is also dependent on what they eat. To keep our fellow bacterial buddies healthy and happy, we need to realise core benefits of healthy eating and change supply chains and food delivery systems.

We heard about steps some countries are taking such as Israel to improve their populations health from the massive negative effects to rising obesity. It was emphasized that we need to empower people through market interventions to have the choice of changing their own eating habits.

As far as Public health in concerned we need to focus creating environments where people can eat well. We need to more to a space where we engage many areas not just health but other areas of government at all levels to design policies to change behaviour and improve life’s of our citizens. At an EU level, we need to strive to make ensure different actors in the system are involved and are aware of the importance of food in citizen’s lives.

Healthy eating choices need to be considered a basic human right, Food for thought indeed.

This Blog was written by Young Gasteiner Ronan O’Kelly.

European alcohol policy: The elephant in the room (F10)

In terms of heath, alcohol-related harms have long been a sensitive topic. However, we must understand that whenever one raises the topic of alcohol, one will inevitably get into all sorts of quagmires. Still, the harm alcohol causes is undeniable. Compared to other major non-communicable disease risk factors, such as tobacco-use, a relatively high proportion of alcohol-related harm occurs early in the life course. The WHO European region struggles with one of the highest levels of alcohol-related deaths: alcohol kills approximately 2345 people per day and that is an inevitable fact. How can we tackle this? What are the potential solutions we can take?

Carina Ferreira-Borges, who is the Programme Manager Alcohol and Illicit Drugs at the WHO European Office for Prevention and Control of NCDs, reminded us that we need to rethink and re-challenge our current direction with alcohol. The European Union region have the highest level of alcohol consumption. The WHO identified three ‘Best Buys’, actions for alcohol policy. The first Best Buy deals with increasing the price of alcohol through taxation. The second focuses on limiting alcohol availability though for example restrictions on the time alcohol is available in stores. Lastly, Best Buy suggests restrictions on marketing, either by reducing or banning it all together. Unfortunately, it has been very troublesome in getting European countries on board of these Best Buys.

Alcohol-related harm does not happen in a vacuum. Alcohol alone affects 13 of the Sustainable Development Goals and 52 targets. There is a relationship between the harmful use of alcohol and heart diseases, cancer, liver diseases, mental health disorders and other non-communicable diseases. Alcohol-related harm brings direct costs to the household in terms of poverty, loss of job or unemployment. The European Union is faced with massive costs, approximately €156 billion yearly, by alcohol alone.

Rethinking and strengthening implementation may take more than just regulations and laws. We need to rethink the concepts we take for granted. For example, more than half of the male drinkers between 15-64 years have engaged in heavy episodic drinking in 2016. We need to think about the social aspect of alcohol. During the group work sessions, one point seemed to come across in most of the tables: we need to change how people think of alcohol in terms of socializing. How can we disrupt the norm of drinking when going out with friends, when we find ourselves thinking we need that glass of wine in our hand to be a part of a group? How do we strip our minds from the social norm of alcohol being present in sports events? The groups tried to come up with solutions such as incentivizing alcohol-free events to cover their losses. It was also recognized that alcohol policies should be Europe-wide, because if it is possible, people will travel for alcohol. This is not true only in terms of bordering countries, but for example, in Scandinavia young high schoolers go on cruises to Estonia or Sweden with the sole purpose of drinking.

Coming from Finland, I cannot help but to mirror experiences in other countries to my own status quo. Even though restrictions on advertising alcohol, selling alcohol during certain hours and tax on alcohol are in place in Finland, according to the Finnish Institute for Health and Welfare, 78% of alcohol consumption in 2016 can be classified under the category of harmful use of alcohol. Personally, I do not consume alcohol for religious reasons. However, I do sense a slight change in drinking culture nowadays. Non-alcoholic drinks seem to be more available. This change would not have come if enough people were not demanding alcohol-free beverages. In other words, there is power in masses, we are the keys to the changes we need to see.

In order to reduce and eventually eliminate alcohol-related problems, we need to change not only individuals and societies, but also companies. During the panel discussion, we heard how Heineken bought Slovenian breweries, and in no less than two weeks Heineken suggested a legislation change in Slovenia. Furthermore, there is a dire need to put Best Buys in the agendas of governments. NGOs might be more willing to adopt these actions, but they need assistance from each one of us since changing how we view alcohol is certainly not an easy task.

If you, or anyone you know is struggling with alcoholism or drug addiction you can ask for help in Ohio and start getting your life back.

This Blog was written by Young Gasteiner Idil Hussein

Shortage of essential decisions Shortage of essential medicines (L5)

Can patients expect short-term, effective actions to ensure availability of their medication? This was one of the last questions asked during the lunch session on shortage of essential medicines. I believe it actually was the most important question which remained largely unanswered.

In the last decade, delivery problems of medicine have increased. In Estonia and France, for example, medicine shortages for respectively 118 and 116 human medical products have been reported. During the session, all relevant stakeholders sat together in a panel to discuss this growing problem, from politicians regulators, practitioners to the industry. Euro Commissioner of Health and Food Safety, Vytenis Andriukaitis set the scene. It is important to distinguish unintentional from intentional reasons for medicine delivery shortages. Unintentional reasons relate to the global pharmaceutical supply chains. Disruptions at raw material manufacturers, quality problems or packaging issues may cause delayed delivery. Yet, it increasingly happens that pharmaceutical companies intentionally lower production of certain medicine brands because of too low profit margins or small market sizes.

Listening to the different panellists convinced me that the solutions are abundant. According EMA regulator Kristin Raudsepp, there needs to be a stronger network for governments and regulators to prevent and respond to potential medicine delivery issues. The pharmaceutical industry itself also has to do it’s homework according to Raudsepp: pharma needs to improve on manufacturing capacity planning, logistics, regional forecasting demand, multilingual packages, and importantly, transparency. Richard Bergström, having worked in the pharma sector, largely confirms this: the responsiveness and traceability within supply chains can improve a lot. Everybody from the panel and audience seemed to agree on the fact that much needs to be done and that this requires action from policy makers, the industry and above all collaboration between them.

Thinking back about the mentioned most important question, asked by a patient representative, I had an uncomfortable feeling after the session. Are all these problem analyses and solutions going to prevent patients from missing essential treatments? I am afraid not. During the Gastein Forum one issue has frequently been raised: the current way in which healthcare in general and pharma in particular is organized and financed is unsustainable. Can we expect from large pharmaceutical companies, owned by shareholders who seek a maximum short-term profit, that they will do everything to assure delivery of not so profitable medicine? Recent years seems to show the contrary as both production of old and development of new medicine is falling behind. Importantly, the regulators and practitioners are caught in the middle and are only able to manage quick fixes. Politicians on the other hand, do not have the vision or capabilities to drive real change, as expressed by soon-to retire Commissioner Andriukaitis.

Maybe after 1 November we will find out if quick fixes are enough, or that the Brexit leads to a healthcare crisis that calls for essential decisions.

This Blog was written by Young Gasteiner Bart Noort.