ESI Funds for health investments Hungarian national workshop - - PowerPoint PPT Presentation

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ESI Funds for health investments

Hungarian national workshop

Budapest 30th October 2014

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Workshop agenda

I. Workshop opening (9:00 - 9:15)

• II. Introduction of the project and project output

(9:15 – 9:50)

• III. Discussion about specific EC regulation (9:50 – 10:50)

► Performance reserve and monitoring ► State aid

• IV. New concepts in health (11:00 – 11:30)
• V. Introduction of the ESIF implementation

structure in Hungary (11:30 – 11:40)

• VI. Health funding potential in 2014-2020 PP

(11:40 – 12:00)

• VII. Group activity (13:00 – 14:15)
• VIII. ESIF investment critical success factors

(14:15 – 15:30)

• IX. Discussion on effective follow up

(15:30 – 16:00)

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• I. Introduction of workshop participants

Page 4

• II. Introduction of the project and outputs

(i) Project and its context

[Project introduction and disclaimer]

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Project objectives

► The project is aimed at providing assistance in the area of

healthcare to EU Member States in the programming and implementation of European Structural and Investment Funds (ESIF) in the new programming period 2014 - 2020, more concretely:

► To support the Member States and their efforts to tap into the potential

• f ESIF 2014 - 2020 for health investments and to manage ESIF

support for health in a better and more effective way

► To promote effectively implemented actions in the health sector which

will have a major positive impact on the wider population’s access to quality and sustainable healthcare in EU Member States

► To build knowledge of the implementation of ESIF for health in the new

programming period 2014 - 2020

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Project background

► The project builds on two key documents:

► Toolbox for effective structural funds investments in health

2014-2020 as developed by Subgroup 2 of the Reflection Process

• n modern, responsive and sustainable health systems that was

conducted in the Council of the EU under the auspices of the Working Party on Public Health at Senior Level

[Electronic version in various languages available at the website of the Council of the European Union] ► Policy Guide for Health Investments by European Structural

and Investment Funds 2014-2020, developed by the European Commission (DGs SANCO, REGIO, EMPL)

[Electronic version in English available at the DG REGIO website]

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Workshop objectives

1. Inform the workshop participants about the project and outputs developed

►

Introduce the project and main outputs

2. Identify all possible health investments under Operational Programmes adopted in Hungary

►

Link specific Thematic Objectives with possible health issues/investments

►

Discuss specific possibilities to support health under specific Operational Programmes developed for 2014-2020 programming period

3. Share lessons learned from implementation of health projects under the Structural Funds from 2007 - 2013

►

Share examples of good practices and recommendations to various investment life- cycle stages

►

Discuss good practice examples and participants’ experience with selected topics

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Disclaimer

► Please be aware that the workshop (as well as the project itself) are NOT

part of the negotiations between the Commission and the Member States

►

EY has been contracted by DG SANCO, not DGs directly involved into negotiations

►

EY provides consultations based on its professional judgment, analysis of documents and analysis of situation in all Member States

►

Information provided in the project outputs and in this presentation should serve as supportive material for discussion and reflection

►

Suggestions presented further do not reflect the Commission's position, but EY’s professional opinion and good practice examples gathered during this project

The presentation does not reflect the Commission's position and the way implementation of ESIF will be finally delivered is still being negotiated with the European Commission

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• II. Introduction:

(ii) Project outputs

[EY outputs introduction]

• II. Introduction of the project and outputs

(ii) Project outputs

[Project scope]

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Project outputs

WP 1: Mapping report Implementation of SF in health in all EU Member States

► Overview of 2007 - 2013

period

► Planned implementation

• f ESIF for funding

health priorities in 2014 - 2020 based on Partnership Agreements and OPs

WP 2: Guide Guidance on effective health investment from ESIF

► Recommendations for

Ministries of Health and managing authorities on practices that lead to efficient health investment funded from ESIF

► Roles of MoH and MA and

ways of their cooperation to achieve effectiveness

► Lessons learned (Do’s and

Don’ts)

WP 3: Toolkit Set of technical and managerial tools to accompany the Guide

► ESIF instruments and

mechanisms in 2014-2020

► Calls for proposal

management

► Set of indicators ► Sustainable and efficient

models & concepts in HC

► Manual on capital

investment

► Investment appraisal

methods

WP 4: Roll out to Member States: Website, country visits, regional workshops

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• III. Discussion about specific EC regulation

(i) Performance reserve and monitoring

[Analysis of EU regulation]

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Performance framework

One of the pillars towards the result orientation of ESIF

1.

Clear articulation of the objectives of OPs with a strong intervention logic

2.

Definition of ex-ante conditionalities to ensure that the necessary prerequisites are in place for the effective implementation of ESIF

3.

Establishment of clear and measurable milestones and targets to ensure progress is made as planned (performance framework)

►

Regular monitoring by the EC and the monitoring committee for each programme:

►

MA provides information on progress in the Annual Implementation Report (AIR), beginning for the reports submitted in 2017

►

Annual review meeting for all OPs convened every year from 2016 until 2023

►

Monitoring committee reviews implementation of the OP and progress towards achieving its

• bjectives

►

Two formal reviews scheduled for 2019 and the closure of the programming period

Areas for improvement Three pillars of the result orientation of ESIF Time framework

Milestones and targets in form of:

►

Financial indicators

►

One indicator per priority in form of the total amount

• f eligible expenditure

►

Output indicators

►

Selected by Member States from among the indicators already chosen for the programme

►

Result indicators

►

Key implementation steps

►

Used to set a milestone when no measurable

• utput is expected by the end of 2018

Building blocks of performance framework

2014 2018 2019 2023 2025

►

Milestones (intermediate targets) to be achieved by 31 December 2018

►

Performance review in 2019

►

Targets set to be achieved by 31 December 2023

►

Final assessment and the closure of the programming period in 2025

Monitoring performance

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Performance reserve

6% of the allocation for successful priorities

Areas for improvement Performance reserve

►

Total amount of the performance reserve allocated by ESI Fund and category of region shall be 6%

►

Constitutes between 5 and 7% of the allocation to each priority within a programme

►

Corresponding amounts shall be set out in the OPs broken down by priority and, where appropriate, by ESI Fund and by category of region

►

Will be allocated to OPs and priorities which have achieved their milestones

Performance review

►

Carried out in 2019 on the basis of the information and the assessment presented in the annual implementation report (AIR)

►

EC adopts a decision to determine for each MS and ESI Fund, the OPs and priorities which have attained their milestones and will get the performance reserve

►

Where priorities have not achieved their milestones, the MS shall propose the reallocation of the corresponding amount to “successful” priorities

►

The number of output indicators selected for a priority should be as low as possible – increases in their number raises the risk of failing the milestone set

►

Appropriate ex-ante assessment of each programme should address the suitability of milestones and targets

• selected. The assessment should analyze:

►

Relevance of the milestones

►

Whether the milestones are realistically achievable

►

Ensure that are not unrealistically low or high

►

The key question is: “What should be achieved by the end

• f 2018?”

►

Monitoring committee may also make observations to the MAs regarding implementation and should then monitor actions taken as a result of its observations to ensure achievement of the milestones

►

MS should not fail to submit information on progress against the milestones in the AIR as the reserve will not be allocated for the priorities or programmes not supported by progress report

Steps towards successful achievement of performance reserve

Useful sources: Guidance fiche: Performance Framework Review and Reserve in 2014-2020; Version 3 – 19 July 2013 available at http://ec.europa.eu/fisheries/reform/emff/guidance- performance-framework-review_en.pdf

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Reporting system

Annual implementation report

►

The Annual Implementation Report (AIR) consists of the AIR itself and the corresponding set of Indicators

►

The AIR contains details of both the physical and financial progress that has occurred in the year

►

Including the contribution of the ESIFs to changes in the value of result indicators

►

The AIR should include the following information:

►

Key information on implementation of the programme and its priorities by reference to the financial data

►

Common and programme-specific indicators and quantified target values*

►

The data transmitted shall relate to values for indicators for fully implemented operations and also where possible for selected operations

►

A synthesis of the findings of all evaluations of the programme that have become available during the previous financial year

►

Actions taken to fulfil the ex ante conditionalities (only in the report to be submitted in 2016)

►

Any issues affecting the performance of the programme, and the corrective measures taken

►

A citizen's summary of the content of the AIRs that shall be made public

►

In addition, the AIR submitted in 2017 shall:

►

Set out and assess the previous information and the progress towards achieving the objectives of the programme

►

Set out the actions taken to fulfil the ex-ante conditionalities not fulfilled at the time of adoption of programmes

►

Assess the implementation of actions to take into account the principles of promotion of men and women equality and non-discrimination, sustainable development, and the role of the partners**

►

Report on support used for climate change targets

►

The AIR for the financial years of 2014-2022 has to be submitted to the European Commission by 31 May from 2016 until and including 2023***

►

Following this, the Commission may make observations to the MA concerning issues affecting implementation of the programme

►

Each programme’s performance is also the subject of the annual review meeting attended by the representatives of the Commission and the Member State

* And beginning from the report submitted in 2017 the milestones defined in the performance framework ** Referred to in Article 5 in the implementation of the programme *** The last AIR covering the financial year of 2023 is to be submitted by 15 February 2025

Useful sources: Guidance fiche No 5: Annual Implementation Report, Version 3 – 7 March 2014 available at http://ec.europa.eu/fisheries/reform/emff/doc/04-annual-implementation-report_en.pdf SFC2007: System for Fund management in the European Community 2007-2013 - The Annual Implementation Report FAQ available at http://ec.europa.eu/employment_social/sfc2007/quick-guides/sfc2007_ms_air_faq.pdf

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• III. Discussion about specific EC regulation

(ii) State aid

[Analysis of EU regulation]

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State Aid

EU State Aid policy framework 1/3

►

Article 107(1) of the EC Treaty on the Functioning of the European Union (hereinafter “the Treaty”) prohibits Member States from distorting competition on the Common Market by giving state aid to undertakings*

“Save as otherwise provided in the Treaties, any aid granted by a Member State or through State resources in any form whatsoever which distorts or threatens to distort competition by favouring certain undertakings or the production of certain goods shall, in so far as it affects trade between Member States, be incompatible with the internal market.”

►

To determine whether an intervention/investment represents state aid or not, Article 107 (1) of the Treaty refers to four test criteria:

►

Is the measure (i.e. form of support) being provided by the State or state resources?

►

Does the measure favor particular undertakings or the production of certain goods?

►

Does the measure affect tradable activity between Member States?

►

Will the measure distort competition, or does it have potential to distort competition?

!

The fair chance exits that interventions of Member States in health care markets may meet all criteria and fall under the Community regime of State Aid * every entity engaged in economic activities is an undertaking within the meaning of EC competition law

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State Aid

EU State Aid policy framework 2/3

EXCEPTIONS

►

Categories acknowledged by the Commission as compatible with the common market*, e.g.

►

regional aid, allocated according to the map for regional aid in the period 2007-2013

►

aid for the creation of small enterprises by women; aid in favor of SMEs, to allow them to benefit from consultancy services and participation in fairs;

►

aid for research, development and innovation, in particular concerning cooperation between research

• rganizations and enterprises, intellectual property rights costs for SMEs etc.

!

Health care is not addressed among the exempted categories

►

The Commission has also the power to approve national state aid measures

• n the basis of:

►

Article 107 (3) of the Treaty

►

e.g. according to sub para (c) of this Treaty “aid to facilitate the development of certain economic activities or of certain economic areas, where such aid does not adversely affect trading conditions to an extent contrary to the common interest” may be allowed

►

Article 106 (2) of the Treaty

►

deals with Services of General Economic Interest (SGEI) and provides an exemption from the prohibition laid down in Article 107 (1) EC

* Commission Regulation (EU) N°651/2014 of 17 June 2014 declaring certain categories of aid compatible with the internal market in application of Articles 107 and 108

• f the Treaty

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State Aid

EU State Aid policy framework 3/3

EXCEPTIONS

►

State Aid under conditions of De minimis rules* are exempted from the notification requirement

Main conditions set by the regulation:

►

De minimis aid can not exceed EUR 200 000 (EUR 100 000 in case of road freight transport) granted over a period of three years. In case of the SGEI, the interventions can not exceed EUR 500 000 over any period of three fiscal years to meet the SGEI de minimis Regulation rules.

►

De minimis aid may be granted to an undertaking that has received other State aid as long as the de minimis aid is not used to top up that other aid beyond the allowable ceiling for the same attributable costs [= the treshold of EUR 200 000 is per Member State].

►

Member State must check before providing it that a new grant will not breach the limit of EUR 200,000 per undertaking.

►

Only transparent de minimis aid, i.e. aid where the amount can be calculated precisely in advance without needing to carry out a risk assessment, could be applied.

* Regulation (EU) No 1407/2013 on the application of Articles 107 and 108 of the Treaty on the Functioning of the European Union to de minimis aid

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State Aid

The concept of undertaking in health care (analysis of case law)

“Every entity engaged in economic activities is an undertaking within the meaning of EC competition law”

►

In application of the definition of undertakings to health care cases the European Court of Justice (ECJ) and the Court of First Instance (CFI) distinct between bodies managing health care schemes and health care providers*

►

Managing bodies

►

It depends on the national design of health care schemes whether managing bodies fall within the ambit of EC competition law

►

The main argument is related to the principle of solidarity and universal coverage.



In state oriented HC systems in which the principle of solidarity is predominant, benefits granted by public authorities to managing bodies of these schemes do not fall within ambit of Article 107 (1) of the Treaty

►

Health care providers

►

In cases where health care providers, like doctors and hospitals are concerned, ECJ simply departs from the assumption that health care is (usually) provided for economic consideration

►

Concerns of universal coverage do not play a role in the ECJ’s case law on the concept of undertaking and to health care providers



Doctors and other health care providers are in general concerned to be engaged in economic activities and thus fall within ambit of Article 107 (1) of the Treaty

* Analysis of EU law approach towards health care with respect to EC competition law; THE COMPETITION LAW REVIEW, Volume 6 Issue 1 pp 5-29; Financing Health Care in EU Law: Do the European State Aid Rules Write Out an Effective Prescription for Integrating Competition Law with Health Care?

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State Aid

Concept of SGEI and it application in health care

►

SGEIs represent economic activities that public authorities identify as being of particular importance to citizens and that would not be supplied if there were no public intervention.

►

The state aid for SGEI is regulated by Commission Decision of 20 December 2011 on the application of Article 106.2 of the Treaty in the form of public service compensation granted to certain undertakings entrusted with the operation of services of general economic interest.

►

Issues of general interest built upon the concept of SGEI do not constitute state aid, provided that the following conditions are met [Altmark case]:

(1) the beneficiary must have public service obligations to discharge, and the obligations must be clearly assigned; (2) the parameters for calculating the compensation must be established in advance in an objective and transparent manner; (3) the compensation cannot exceed the relevant costs and a reasonable profit (no overcompensation); (4) the provider is either chosen through a public procurement procedure or the level of compensation is determined based on an analysis of the costs of an average "well-run“ undertaking in the sector concerned - EFFICIENCY criterion.

!

Concept of the SGEI and its exemption from the state aid rules might be applicable in many situations in health care.

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State Aid

Concept of SGEI and its application in health care (analysis of case law)

►

Some useful conclusions from the jurisdiction in relation to SGEI*:

►

Bodies managing a health care scheme based on both competition and solidarity elements may benefit from the jurisdictional approach of Altmark

►

The jurisdictional decisions reflect opinion that SGEI missions may be derived from general obligations. A consequence an open group of operators may be entrusted with a SGEI mission.

This is an important conclusion for the health care sector, as in this sector an open group of operators is supposed to realize objectives of general interest.

►

On the other hand, it has still not been enlightened, whether SGEI mission still need to be derived from explicit official acts or whether general obligations related to public interest issues suffice.

 However, based on CFI‘s judgment in a case concerning state aid granted in Italy, it can be concluded that merely claiming that the public interest is involved without putting forward any substantiated evidence will not help Member States to escape from the European state aid rules. Some countries have therefore clearly defined which tasks and services are considered of general economic interest [e.g. in Slovakia, providing healthcare in the outpatient care and inpatient care is legally defined as a service of general economic interest].

* THE COMPETITION LAW REVIEW, Volume 6 Issue 1 pp 5-29; Financing Health Care in EU Law: Do the European State Aid Rules Write Out an Effective Prescription for Integrating Competition Law with Health Care?

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• IV. New concepts in health

[EY interpretation]

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Health in the EU strategic context

► Health sector as one of the most important in public spending…

►

15 % of all government expenditure in the EU

►

8 % of the total European workforce

►

10 % of the EU’s GDP*

► …is a part of the Europe 2020 policy framework and has three main

branches:

INVESTING IN SUSTAINABLE HEALTH SYSTEM

► Health expenditure

is recognized as growth-friendly expenditure

► Potential for

efficiency gains in the health care sector

INVESTING IN PEOPLE’S HEALTH

► Precondition for

economic prosperity

► Influences

economic

• utcomes:

►

Productivity

►

Labour supply

►

Human capital

►

Public spending INVESTING IN REDUCING HEALTH INEQUALITIES

► Contributes to

social cohesion

► Allows improvement

• f average levels of

health

* Source: Commission Staff Working Document - Social Investment Package: Investing in health, February 2013

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Investing in sustainable health system

Combines innovative reforms aimed at improving cost-efficiency

►

Cost- and time-effective means of health care provision through integration of all relevant patient information and medical processes

►

Stands for electronic storage, exchange of patient data and the provision of health care by electronic means

►

Allows interaction between:

►

Patient and health care provider

►

Medical facilities (including pharmacies)

►

Patients

►

Health care professionals

►

Supported measures based on the degree of development:

►

IT infrastructure development

►

Development of systems, moduls and applications

►

Implementation of eHealth into praxis

►

Information about individuals’ lifetime health status that can be found in one place and can be shared across different medical facilities

►

Creates a more efficient, convenient and more cost-effective delivery of care:

►

Saves time of physicians, other medical personnel as well as patients

►

Improves management, coordination and administrative efficiency

►

Enhances the quality of the provided care through evidence-based tools which help to make decisions about treatment

►

Enables faster sharing of patient information with

• ther health care providers across institutions

Areas for improvement eHealth concepts 1/3 (i) Electronic health records

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Investing in sustainable health system

eHealth concepts 2/3

►

Consists of two tightly connected processes:

►

ePrescribing – prescribing using electronic software

►

eDispensing – act of electronic reception of the prescription by the pharmacy and dispensing it to the patient

►

Has a high impact on effectiveness, quality and sustainability of medical care through:

►

Patient safety as it allows easier access to medication history reduces the risk of negative drug interactions

►

Efficient prescription reducing the number of duplicate prescriptions

►

Management efficiency allowing overview and easier monitoring

Areas for improvement (ii) ePrescription

►

Reduces hospitalization and general practitioner or specialist visits

►

Reduces travel time

►

Improves access to health care particularly for elderly or disabled people

►

Telemedicine:

►

Refers to health care services at a distance, where interaction between the health care provider and the patient is needed

►

Video consultations with specialist

►

Remote medical evaluation and diagnosis

►

Digital transmission of medical images

►

Telecare:

►

Based on patient monitoring using telephones, computers, videophones, alarms and other portable or wearable systems

►

Remote physiological monitoring of a patient

►

Pill dispensers and reminders

►

Environment monitoring (floods, fire)

(iii) Telehealth

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Investing in sustainable health system

eHealth concepts 3/3

►

Medical and public health practice supported by mobile devices such as:

►

Mobile phones

►

Patient monitoring devices

►

Personal digital assistants (PDA)

►

Allows collection of medical, physiological, lifestyle, daily activity and environmental data

►

Potential to serve as a basis for evidence- driven care practice

►

Enables more accurate diagnosis and treatment

►

Saves time of health care professionals spent

• n accessing and analyzing information

►

Allows patients to do more medical and care interventions remotely by themselves, guided by monitoring and reporting systems, reducing hospitalization

Areas for improvement (iv) mHealth

►

Allows effective and sustainable knowledge and information sharing

►

Includes:

►

Health information system for citizens in order to increase health literacy

►

Health knowledge management systems for professionals and students

►

Virtual health care teams which consist of health care professionals who cooperate and share information on illnesses and patients through digital equipment

(v) Networking and knowledge sharing

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Investing in sustainable health system

Cost-effectiveness of care

►

Worldwide problem of ineffective use of medicines:

►

Prescription of overpriced medicines

►

Use of an excessive number of sometimes unnecessary medications (polypharmacy)

►

Inappropriate self-medication

►

Use of less expensive equivalent (generic) drugs

►

Set of prescription guidelines to prevent misuse and unnecessary use of medicines (e.g. antibiotics)

►

Awareness about medicines and better literacy will allow patients to better manage their medication

►

Transfer of information between the health care units participating in the care of the patient will help to lower the number of unnecessarily prescribed medicines

Areas for improvement Cost-effective use of medicines

►

Patient classification system which assumes that the treatment of patients with the same diagnosis will require a similar or identical diagnostic and therapeutic algorithm

►

Financial benefits:

►

Using DRG funding as a fixed payment per case in a specific DRG

►

Budget set up based on the measurement of production by DRG

►

Management benefits:

►

Access to provided care through clinically and economically comparable units

►

Tool for measuring the outputs

►

Tool for measuring the quality of the provided health care

►

DRG allows professionals with a different focus to better communicate (e.g. communication between economists and doctors)

►

DRG allows comparison of different HC providers on their performance activity

DRG: Diagnosis-related group

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Investing in sustainable health system

Transition from institutional care to community-based care 1/2

►

Process of gradual reduction in specialized institutional care for patients

►

Potential contribution to elimination of the increasing costs caused by the ageing population

►

Patient-centered care solutions and personalized care for chronic and long-term care needs

►

Deinstitutionalization consists of two main areas:

►

Cost-effective path of care which strengthens the primary care

►

Community based care

Areas for improvement Deinstitutionalization

►

Cost-effective path of care should always lead from primary care (advanced practice nurses, general practitioners, family doctors) to secondary care (specialists, hospitals and emergency care) and then, where appropriate, to tertiary care (highly specialized consultative health care)

►

Benefits:

►

Increases the accessibility to primary health care and reduces inequalities

►

Reduces the unnecessary use of specialist care

►

Reduces inpatient hospital care

►

Takes care of patient’s disease prevention

►

Ensures patient follow-up care after secondary care

►

Links patients to social care

►

Requires to make primary care more attractive to both patients and practitioners

Strengthening of primary care

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Investing in sustainable health system

Transition from institutional care to community-based care 2/2

►

Community-based care is especially contributive to:

►

Seniors dependent on long-term care

►

People with disabilities

►

People with mental health problems

►

Lower costs of ambulatory care and care provided to patients home compared to costly hospital / medical institution care

►

Provides better outcomes in terms of quality of life in contrast to institutional care causing long- term social exclusion and segregation of the patients

►

Community-based services include:

►

Personal assistance

►

Respite care

►

Family-based care

►

Hospital at home

►

Independent living

Areas for improvement Community-based care

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Investing in people’s health

Improves the health of the population and reinforces employability

►

Stands for the process of optimizing

• pportunities for health, participation and

security in order to enhance quality of life as people age

►

Elderly people will account for 29,5 % of the EU 28’s population by 2060 (17,5 % in 2011)

►

The health status of individuals strongly influences their labour market participation

►

Health sustaining activities prevent costly health care and lower dependency burdens

►

Activities improving the employability of older people also enable people to work longer and retire more gradually

►

Stands for the process of enabling people to increase control over, and to improve their health

►

Potential for cost savings for subsequent (secondary or tertiary) care and cure and the improvement of the individuals’ health allowing them to live a more active and independent life

►

Primary prevention aims to avoid occurrence

• f disease through:

►

Eliminating disease agents

►

Increasing resistance to disease

►

Secondary prevention aims to detect and treat a disease early on and attempts to prevent asymptomatic disease from progressing to symptomatic disease

►

Tertiary prevention attempts to reduce the damage caused by symptomatic disease by focusing on mental, physical, and social rehabilitation

Areas for improvement Active and healthy ageing Health prevention

►

Stands for the process of enabling people to increase control over, and to improve their health

►

Raises awareness of health risks and how to prevent them

Health promotion

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Investing in people’s health

Improves the health of the population and reinforces employability

►

The concept aims to enable and encourage patients to take control of their health needs through their own health decisions and self- selected changes to their lifestyle

►

An empowered patient:

►

Understands his health conditions

►

Feels able to participate in decision making with his health care professional and to make informed choices about treatment

►

Understands the need to make necessary changes to his lifestyle

►

Takes responsibility for his health and actively seeks care only when necessary

►

The concept requires patients to take responsibility for their own health through e.g.:

►

Attending regular preventive checks

►

Leading a healthy lifestyle

Areas for improvement Patient empowerment

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Investing in reducing health inequalities

Contributes to social cohesion

Areas for improvement

►

Investing in reducing health inequalities breaks the vicious spiral of poor health contributing to, and resulting from, poverty and exclusion

►

Health inequalities represent:

►

Waste of human potential

►

Huge potential economic loss

►

Reasons:

►

Barriers in access to health care

►

Social status / mental state

►

Barriers in access to health care can be removed through e.g.:

►

Use of ICT in health such as telehealth or mhealth

►

Improved health care territorial cover

►

Cross border care

►

Inequalities caused by social status / mental care can be removed through contribution towards reaching Europe 2020 poverty and social exclusion target

►

Specific activities addressing health inequalities:

►

Ensure physical activity possibilities in poorer regions / areas

►

Address risk factors that are particularly prevalent in disadvantaged population groups (e.g. tobacco consumption)

►

Set up, improve or expand local health care basic services (including infrastructure) for the rural population

►

Support to better living and housing conditions for vulnerable groups:

►

Access to acceptable standards of housing and indoor temperature

►

Access to sanitation and water which meets EU standards

►

Bring innovations to the care system to improve patients’ health literacy

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• V. Introduction of the ESIF implementation

structure in Hungary

[EY understanding]

Page 34

Implementation structure and MoH involvement

Factual background

► There are five national Operational Programmes and two regional

Operational Programmes in Hungary

► Two of them directly address health care issues, i.e.:

► Human Resources Development OP ► Economic Development and Innovation OP

Q1: What is the specific role of MoH with respect to preparation and implementation of the above mentioned OPs? Q2: Are there any health related issues reflected in the regional OPs?

Page 35

Key areas of our interest:

• 1. General introduction of ESIF implementation structure (system of MA, IBs,

Certifying Authority, Audit bodies etc.)

• 2. Introduction to existing coordination tools/mechanisms in between development &

implementation of OPs

Introduction to ESIF implementation structure in 2014-2020

Page 36

• VI. Health funding potential in 2014-2020

programming period (i) Health specifics in 2014-2020 programming period [EY interpretation]

Page 37

2014-2020 health context 1/2

ESIF level

► Health is eligible for funding under 2014 – 2020. However there is

no thematic objective exclusively dedicated to health.

► Health related issues could be identified in most of the 11 thematic

• bjectives

►

Direct investments

►

Investments directly targeted on health care (HC) issues and reforms;

►

Eligibility for funding has been formally approved;

►

within direct investments MoH is usually formally involved in implementation.

►

Indirect investments

►

Investments not directly targeted on HC, i.e. health care is not considered as the main beneficiary, but health care subjects might apply for funding from them;

►

MoH usually has no formal competencies in implementation of this group.

Page 38

2014-2020 health context

Scheme of 2014-2020 health investment framework

TO 1 National strategic framework

European strategic framework

EUROPE 2020 EU policies TO 2 TO 3 … TO 10 TO 11 TO 9 Ministry of Health Hospitals General practitioners Medical universities Providers of specialized care Emergency service Medical R&D institutions Medical staff OP 1 OP2 OP 3 OP 7 OP 8 OP 6 TO 4 TO 5 MoH

Illustrative scheme

Page 39

2014-2020 health context 2/2

ESIF level The aim of the Ministries of Health (resp. of Ministries of Social affairs where applicable) shall be to maximize utilization of ESIF

• pportunities for health care under legal conditions (EC Guidelines,

3E) and with respect to Europe 2020 as well as national strategic framework (incl. Partnership Agreement).

Page 40

• V. Principles of effective coordination:

(i) Role of MoH as a coordinator of health care

[Topic covered by the project outputs]

• VI. Health funding potential in 2014-2020

programming period (ii) Potential health issues under thematic objectives

[EY interpretation]

Page 41

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 1 Strengthening research, technological development and innovation

►

Innovation in health

►

Research in development of new detection methods and treatments

►

Collaborative research in rare diseases

►

Support research and related IT infrastructures including support to health information systems

Potential health issues under TO 1?

►

Enhancing research and innovation (R&I) infrastructure and capacities to develop R&I excellence, and promoting centers of competence, in particular those of European interest

►

Promoting business investment in R&I, developing links and synergies between enterprises, research and development centres and the higher education sector, in particular promoting investment in product and service development, technology transfer, social innovation, eco-innovation, public service applications, demand stimulation, networking, clusters and open innovation through smart specialisation, and supporting technological and applied research, pilot lines, early product validation actions, advanced manufacturing capabilities and first production, in particular in key enabling technologies and diffusion of general purpose technologies

Investment priorities under given thematic objective:

Page 42

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 2 Enhancing access to and, use and, quality of information and communication technologies

►

Strengthening ICT applications for e-Health (investment priority)

►

e-Health solutions compatible with EU standards ensuring (cross-border) interoperability of IT systems

►

Use of uniform electronic health care information system

►

Creation of legal basis for e-Health

►

Improvement of IT Tools for coordination of response to health threats

►

Development of ICT based solutions and services for needs of an ageing population

Potential health issues under TO 2?

►

Extending broadband deployment and the roll-out of high-speed networks and supporting the adoption of emerging technologies and networks for the digital economy

►

Developing ICT products and services, e-commerce, and enhancing demand for ICT

►

Strengthening ICT applications for e-government, e-learning, e-inclusion, e-culture and e-health

Investment priorities under given thematic objective:

Page 43

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 3 Enhancing the competitiveness of SMEs

►

Promote awareness among SMEs on “white sector” business opportunities and know-how

►

Support SMEs' businesses addressing the needs of old people, or 'age-friendly' businesses (e.g. providing personalised care, assisting in functional physical or cognitive decline, improving old people's health literacy), including senior start-ups and entrepreneurship

►

Encourage private and public enterprises to play a larger role in public-private partnerships in 'age- friendly' areas

Potential health issues under TO 3?

►

Promoting entrepreneurship, in particular by facilitating the economic exploitation of new ideas and fostering the creation of new firms, including through business incubators

►

Developing and implementing new business models for small and medium-sized enterprises (SMEs), in particular with regard to internationalisation

►

Supporting the creation and the extension of advanced capacities for product and service development

►

Supporting the capacity of SMEs to grow in regional, national and international markets, and to engage in innovation processes

Investment priorities under given thematic objective:

Page 44

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 4 Supporting the shift towards a low-carbon economy in all sectors

►

Support energy efficiency of health care facilities

►

Assisting low-income communities and the elderly with energy efficiency improvements

►

Support actions to help reduce the use of domestic solid fuels (coal and wood) which create indoor air pollution and negatively effects health

Potential health issues under TO 4?

►

Promoting the production and distribution of energy derived from renewable sources

►

Promoting energy efficiency and renewable energy use in enterprises

►

Supporting energy efficiency, smart energy management and renewable energy use in public infrastructure, including in public buildings, and in the housing sector

►

Developing and implementing smart distribution systems that operate at low and medium voltage levels

►

Promoting low-carbon strategies for all types of territories, in particular for urban areas, including the promotion of sustainable multimodal urban mobility and mitigation-relevant adaptation measures

►

Promoting the use of high-efficiency co-generation of heat and power based on useful heat demand

►

Promoting research in, innovation in and adoption of low-carbon technologies

Investment priorities under given thematic objective:

Page 45

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 5 Promoting climate change adaptation, risk prevention and management

►

Increase investments in risk prevention and management, including protection, preparedness, response and recovery that have positive impact on human health

►

Creation of early warning systems and health care investments for disasters and climate-related events and adaptation

►

Support water efficiency in health care buildings to reduce water scarcity

►

Investments to reduce flooding of health care facilities

Potential health issues under TO 5?

►

Supporting investment for adaptation to climate change, including ecosystem-based approaches

►

Promoting investment to address specific risks, ensuring disaster resilience and developing disaster management systems

Investment priorities under given thematic objective

Page 46

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 6 Preserving and protecting the environment and promoting resource efficiency

►

Investing in waste sector management to support protection from dangerous medical waste

►

Increase actions that reduce potential health risks of contaminated sites

Potential health issues under TO 6?

►

Investing in waste sector to meet the requirements of the Union's environmental acquis and to address needs, identified by the Member States, for investment that goes beyond those requirements

►

Investing in the water sector to meet the requirements of the Union’s environmental acquis and to address needs, identified by the Member States, for investment that goes beyond those requirements

►

Protecting and restoring biodiversity, soil protection and restoration and promoting ecosystem services, including Natura 2000 and green infrastructures

►

Taking actions to improve the urban environment, revitalisation of cities, regeneration and decontamination of brownfield sites (including conversion areas), reduction of air pollution and promotion of noise-reduction measures

►

Conserving, protecting, promoting and developing natural and cultural heritage

►

Promoting innovative technologies to improve environmental protection and resource efficiency in the waste sector, water sector and with regard to soil, or to reduce air pollution

►

Supporting industrial transition towards a resource-efficient economy, promoting green growth, eco-innovation and environmental performance management in the public and private sectors Investment priorities under given thematic objective:

Page 47

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 7 Promoting sustainable transport and removing bottlenecks in key network infrastructures

►

Improve connectivity (e.g. through infrastructure) and mobility to enhance access to health services

►

Gain health benefits through enhanced safety levels of transport networks

►

Support greener infrastructure to reduce obesity and create healthier lifestyles, particularly for the youth

Potential health issues under TO 7?

►

Supporting a multimodal Single European Transport Area by investing in the Trans-European Transport (TEN-T) Network

►

Developing and improving environmental-friendly (including low-noise) and low-carbon transport systems, including inland waterways and maritime transports, ports, multimodal links and airport infrastructure, in order to promote sustainable regional and local mobility

►

Developing and rehabilitating comprehensive, high quality and interoperable railway systems, and promoting noise-reduction measures

►

Enhancing regional mobility by connecting secondary and tertiary nodes to TEN-T infrastructure, including multimodal nodes

►

Improving energy efficiency and security of supply through the development of smart energy distribution, storage and transmission systems and through the integration of distributed generation from renewable sources

Investment priorities under given thematic objective

Page 48

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 8 Promoting employment and supporting labour mobility

►

Access to employment for job- seekers and inactive people, including the long-term unemployed and people far from the labour market, also through local employment initiatives and support for labour mobility

►

Sustainable integration into the labour market of young people, in particular those not in employment, education

• r training, including young people at risk of social exclusion and young people from marginalised communities,

including through the implementation of the Youth Guarantee

►

Self-employment, entrepreneurship and business creation including innovative micro, small and medium sized enterprises

►

Equality between men and women in all areas, including in access to employment, career progression, reconciliation

• f work and private life and promotion of equal pay for equal work

►

Adaptation of workers, enterprises and entrepreneurs to change

►

Active and healthy ageing

►

Modernisation of labour market institutions, such as public and private employment services, and improving the matching of labour market needs, including through actions that enhance transnational labour mobility as well as through mobility schemes and better cooperation between institutions and relevant stakeholders

►

Supporting the development of business incubators and investment support for self-employment, micro-enterprises and business creation

►

Supporting employment-friendly growth through the development of endogenous potential as part of a territorial strategy for specific areas, including the conversion of declining industrial regions and enhancement of accessibility to, and development of, specific natural and cultural resources

►

Supporting local development initiatives and aid for structures providing neighbourhood services to create job

►

Investing in infrastructure for employment services Investment priorities under given thematic objective:

Page 49

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 8 Promoting employment and supporting labour mobility

►

Supporting adequate and qualified health workforce in all areas through adaptation and training and promotion of labour mobility

►

Active and healthy ageing measures

►

Health and human capital - supporting employment through healthy workers

►

Promotion of healthy life style and disease prevention

►

Health at the workplace

►

Supporting healthy and safe working conditions and prevent work-related injuries Potential health issues under TO 8?

Page 50

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 9 Promoting social inclusion and combating poverty

►

Active inclusion, including with a view to promoting equal opportunities and active participation, and improving employability

►

Socio-economic integration of marginalized communities such as the Roma

►

Combating all forms of discrimination and promoting equal opportunities

►

Enhancing access to affordable, sustainable and high-quality services, including health care and social services of general interest

►

Promoting social entrepreneurship and vocational integration in social enterprises and the social and solidarity economy in order to facilitate access to employment

►

Community-led local development strategies

►

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

►

Providing support for physical, economic and social regeneration of deprived communities in urban and rural areas

►

Providing support for social enterprises

►

Undertaking investment in the context of community-led local development strategies

Investment priorities under given thematic objective:

Page 51

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

►

Active inclusion improving employability

►

Integration into the labour market of people with disabilities, mental disorders, chronic disease

►

Enhancing access to affordable, sustainable and high-quality services, including health care (reducing inequalities in terms of health status)

►

Equitable access to affordable care and medication

►

Promote active involvement of patients and their empowerment

►

Access to acceptable standards of housing and hygiene

►

Investing in health and social infrastructure

►

Contributing to cost-effectiveness and sustainability of health systems

►

Supporting specialization and concentration of hospital care

►

Transition of hospital based care to community based care

►

Strengthening of primary and ambulatory care

►

Deinstitutionalization of long-term care, after care and mental care / home care strengthening

TO 9 Promoting social inclusion and combating poverty

(Potential) Health issues under TO 9?

Page 52

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 10 Investing in education, skills and lifelong learning

►

Reducing and preventing early school-leaving and promoting equal access to good quality early-childhood, primary and secondary education including formal, non-formal and informal learning pathways for reintegrating into education and training

►

Improving the quality and efficiency of, and access to, tertiary and equivalent education with a view to increasing participation and attainment levels, especially for disadvantaged groups

►

Enhancing equal access to lifelong learning for all age groups in formal, non-formal and informal settings, upgrading the knowledge, skills and competences of the workforce, and promoting flexible learning pathways including through career guidance and validation of acquired competences

►

Improving the labour market relevance of education and training systems, facilitating the transition from education to work, and strengthening vocational education and training systems and their quality, including through mechanisms for skills anticipation, adaptation of curricula and the establishment and development of work-based learning systems, including dual learning systems and apprenticeship schemes

►

Investing in education, training and vocational training for skills and lifelong learning by developing education and training infrastructure

►

Tertiary education delivering workforce sufficient in numbers as well as in qualification, reflecting the shortages of certain specializations (i.e. General Practitioners)

►

Adjustment of education system to deliver sufficient nursing staff (sufficient numbers as well as with sufficient qualification to provide certain types of care independently)

►

Lifelong training to adjust workforce skills – eHealth, new treatment and diagnostic methods

Potential health issues under TO 10?

Investment priorities under given thematic objective

Page 53

Health funding potential under specific thematic

• bjectives in 2014 – 2020 programming period

TO 11 Enhancing institutional capacity and ensuring an efficient public administration

►

Capacity building in health administration: actions to support institutional and management capacities of health administration

►

Actions to increase efficiency of health administration in particular to design and deliver health system reforms and increase its efficiency, quality and sustainability

►

Actions to enhance cross border cooperation of MS in health area

Potential health issues under TO 11?

►

Enhancing institutional capacity of public authorities and stakeholders and efficient public administration through actions to strengthen the institutional capacity and the efficiency of public administrations and public services related to the implementation of the ERDF, and in support of actions under the ESF to strengthen the institutional capacity and the efficiency of public administration

►

Enhancing institutional capacity of public authorities and stakeholders and efficient public administration through actions to strengthen the institutional capacity and the efficiency of public administrations and public services related to the implementation of the Cohesion Fund

►

Investment in institutional capacity and in the efficiency of public administrations and public services at the national, regional and local levels with a view to reforms, better regulation and good governance

►

Capacity building for all stakeholders delivering education, lifelong learning, training and employment and social policies, including through sectoral and territorial pacts to mobilise for reform at the national, regional and local levels Investment priorities under given thematic objective

Page 54

LUNCH BREAK

12:00 – 13:00

Page 55

VII. Group activity

Page 56

►

Activity objective:

►

Complex mapping of health investments potential under ESIF and beneficiaries that can be supported through individual priority axes of the Operational Programme for Cohesion Policy Funds 2014-2020.

►

Activity description:

►

The activity is designed for two groups.

►

Each group will get selected OP/OPs with their Priority Axes names and based on the previous presentation shall develop a list of:

►

Which health activities can be supported under individual priority axes?

►

Who are potential beneficiaries of every identified activity? ►

Timing:

►

25 minutes to discuss group solutions

►

• Approx. 45 minutes for presentation & discussion

►

Based on the presentation of each group, we expect to open discussion on wide range of possible health investments that could be supported in 2014-2020 programming period.

Group activity

Page 57

Group activity - handout

Group 1

OP Economic Development and Innovation

2 5 6 7

9 10 11

4 8 3 1

PA 1 – Improving the competitiveness of enterprises and enhancing employment PA 2 – Development of the knowledge economy

Operational Programme, Priority Axis TC Health areas with funding potential Beneficiaries

PA 3 – Infocommunication developments PA 4 – Environment and energy PA 5 – Promotion of employment and business adaptability PA 6 – Development of financial instruments and services

OP Public Administration and Public Services Development

PA 1 – Improving the infrastructural conditions of public services PA 2 – Organization development and services development in public administration PA 3 – Improving the infrastructural conditions of non- profit public service providers PA 4 – Organization development and services development of non-profit public service providers PA 5 – Technical assistance

Page 58

Group activity - handout

Group 2

OP Human Resources Development

2 5 6 7

9 10 11

4 8 3 1

PA 1 – Cooperative society PA 2 – Infrastructural investments in the field of social inclusion

Operational Programme, Priority Axis TC Beneficiaries

PA 3 – Growing knowledge capital PA 4 – Infrastructural investments in favour of growing knowledge capital PA 5 – Implementation of local strategies, social innovation, and transnational cooperation

Health areas with funding potential

PA 1 – Improving the international (TEN-T) road transport PA 2 – Improving the international (TEN-T) rail and water accessibility

OP Transport-Mobility Development

PA 3 – Development of sustainable urban transportation, improving the suburban and regional rail accessibility and energy efficiency

OP Environmental and Energy Efficiency

PA 1 – Adaptation to the impacts of climate change PA 2 – Development of local water supply, discharge and cleaning of water, and treatment of wastewater PA 3 – Developments related to waste management and remediation PA 4 – Developments related to nature and wildlife protection PA 5 – Increasing energy efficiency and use of renewable energy

Page 59

Discussion on group activity results

Page 60

[Topic covered by the project outputs]

• VIII. ESIF investment critical success factors

(i) ESIF investment effective lifecycle

Page 61

ESIF investment effective lifecycle

Critical success factors

Critical success factors Strategy development Investment sustainability Capacity building Procurement management Financial planning Partnership building Monitoring & Evaluation 01 07 02 06 05 03 04

Page 62

Critical success factors

Discussion topics

Q1: Based on introduction of critical areas, where do you think are Hungarian:

• i. Strong areas, i.e. areas that could be shared with other Member States as a good

practice example?

• ii. Weak areas, i.e. areas where would Hungary appreciate support in a form of a good

practice example from other Member States? Q2: Would you name any other critical success factor that has not been mentioned here and is worth mentioning?

Page 63

[Topic covered by the project outputs]

• VIII. ESIF investment success factors

(ii) Practices and recommendations to various investment life-cycle stages

Page 64

• 01. Strategy development

►

Lack of real public health strategy

►

Absence of clearly defined priorities

►

Investments are not focused on achievement of clear objectives (duplicities and overlapping of funding)

►

Investments do not generate any tangible results (there are no health gains and no improved cost efficiency of health sector)

►

Unsustainability of the investments

►

Lack of project progress or project disruption in case of changes in political environment

►

Lack of coordination in strategy development

►

On various levels of public administration

►

For different types of health care (outpatient x hospital care; primary x specialized care)

►

On cross-regional and cross-border level

Problems

Inefficient use of public resources Obstacles to systemic changes

► Develop an overarching public health strategy

based on evidence and centered around a patient

• riented approach [Ministry of Health]

► Coordinate the strategy-making process with

stakeholders to make the strategy broadly accepted and relevant [Ministry of Health]

► Identify & involve stakeholders ► Know other existing and developing strategies ► Ensure balanced and complementary approach

to maximize investment effects [Ministry of Health]

► Infrastructure development ► Human resources development ► Prevention and health promotion campaigns ► Identify financial resources and select priorities

to be financed from ESIF [Ministry of Health, Managing Authorities]

Recommendations

Page 65

Case study from Hungary, programming period 2007 - 2013

Context

►

The implementation of ESIF for health infrastructure in Hungary in PP 2007-2013 was the largest of all EU Member States (approx. 1,3 bn. EUR allocated over the 7 years, which represents 5,5 % of whole ESIF allocation)

►

EUREGIO III case study (2011) identified:

►

Lack of strategic planning in the field of health and coordinative management of resources

►

Political instability that contributed to insufficient funding coordination

►

Rather spending driven approach to utilize available SF sources

Consequences

►

Supporting even projects lacking evidence base and well-founded sustainability measures

►

Inefficiencies in a way that projects addressing various levels of care provision were not complementary and thus loose (at least partially) potential benefits

►

Potential effects limited by insufficient coordination of Structural Funds projects and other development efforts, on regional level no strategy planning:

►

Investments into regional hospitals were not coordinated with investments in outpatient primary care

►

Infrastructure investments in specialized oncological centers were not coordinated with development of regional hospitals

Q1: What was the situation in Hungary in your point of view? Q2: What are the overall results of the 2007 – 2013 PP?

Page 66

• 02. Partnership building

►

Insufficient involvement of relevant partners in development of strategies:

►

Health care strategy

►

Partnership Agreement

►

Operational programmes

►

Insufficient involvement of all relevant partners

►

Public

►

Experts

►

Foreign partners

►

Shortcomings in management of partners in implementation of strategies, programs and projects

►

Insufficient consultation and information sharing processes set-up

►

Unclear roles and responsibilities

►

Inflexible decision-making process

► Gain wide range of relevant partners in

preparation of key strategic documents through their careful identification and invitation [Ministry of Health]

►

Introduce formalized system for cooperation among partners, which will be consensually adopted [Ministry of Health]

►

Clearly delimit the roles and responsibilities

• f individual partners

►

Decide on the decision making process, favouring flexible forms ensuring at the same time wide acceptance

►

All key decisions and changes consult with partners and try to find consensus [Ministry of Health]

► Designate a responsible for stakeholder

management [Ministry of Health]

► Learn to understand individual partners’ and group

• f stakeholders’ needs [Ministry of Health]

Problems Recommendations

High risk of delay or refusal of a program / project realization Limitation or blocking of expected outcomes

Page 67

• 03. Capacity building

►

Lack of qualified human resources for efficient programme implementation at the Ministry of Health, especially when it plays the role of intermediate body:

►

Inadequate knowledge of relevant OP(s)

►

Inadequate skills in project and financial management

►

Lack of experience with health strategies implementation

►

High fluctuation rate of employees

►

Lack of information and guidance for applicants and beneficiaries

►

Insufficient information about publishing a call for proposals among potential health sector applicants

►

Insufficient support of applicants in the phase of project preparation and implementation

► Secure qualified and skilled MoH capacities

capable to support managing authorities in the area

• f health expertise [Ministry of Health]

► More extensive use of technical assistance

resources for education [Managing Authority, Ministry of Health as an Intermediate Body]

►

Standard staff education

►

Preparation of standard educational plans for capacities of Ministry of Health, MAs, intermediate bodies in the field of: Structural Funds, health policy, project and financial management

►

Exchange of experience and cooperation with foreign partners

►

More active role of MoH in building absorption capacity among potential beneficiaries [Ministry of Health]

►

Personal contact with beneficiaries and the staff of intermediate body/managing authority [Ministry of Health]

Problems Recommendations

Insufficient absorption capacity Limited quality and value added of funded projects Possible ineligibility of projects

Page 68

• 04. Financial planning

►

Insufficient detail of a project business case

►

Inappropriate use of various techniques for financial planning and investment appraisal

►

Cost-benefit analysis, cost-effectiveness analysis

►

Health technology assessment

►

Health impact assessment

►

Incorrect evaluation of project applications for funding where even project applications with insufficient detail and low value added of investments were accepted for funding

►

Project costs overruns which might seriously threaten project sponsor’s ability even to finish the project

►

Problems with ensuring project sustainability in case the operational costs during the sustainability phase were not planned for or identified properly

►

Require use of evidence-based approach:

►

Put emphasis on detailed and evidence based needs assessment

►

Support benchmarking where possible

►

Clearly set the main principles of financial planning and investment appraisal [MA, possibly MoH as an Intermediate body]

►

Set criteria for project applications evaluation and selection to ensure only financially realistic, achievable and cost-efficient projects are supported [MA, possibly MoH as an Intermediate body]

►

Monitor the financial performance data periodically to be able to identify any possible problems in time [MA, possibly MoH as an Intermediate body]

►

Ensure capacities with adequate knowledge and expertise in the field of financial planning of health projects and health investment appraisal methods through the capacity building process [Ministry of Health]

Problems Recommendations

Failure to achieve expected benefits Support of unsustainable projects

Page 69

• 05. Procurement management

►

Too complex and frequently changed procurement laws, disparities across OP

►

Erroneous procurement (typically in case of health instrumentation / technology purchases):

►

Discriminatory conditions

►

Not enough specific conditions

►

Unsuitable scope of the tender

►

Too broadly defined contract, combining unrelated items (excludes specialized suppliers)

►

Subdivisions of contract

►

Insufficient knowledge and experience with public procurement of contracting authorities and suppliers

►

Insufficient support of beneficiaries – contracting authorities from the side of administrative capacities

• f managing authorities / intermediate bodies

►

Define clear, concise and easy-to-follow programme-specific procurement rules, coordinated across all country’s Ops [Managing Authority]

►

Provide administrative support to beneficiaries acting as a contracting authority in form of guidebooks, templates, forms, tutorials and trainings [MA, possibly MoH as an Intermediate Body]

►

Set up sufficient administrative capacity Consider ex-ante reviews of tender specifications if sufficient expert capacities are available

►

Engage health care experts (as well as IT experts, engineers etc.) in preparation and/or review of the technical specifications [MoH as beneficiary, possibly even as an Intermediate Body, MA]

►

Require estimated value in an evidence-based manner, supported by market research and involve experts to consider the usual market prices [MoH as an Intermediate Body]

►

Avoid subdivision of related items into separate tenders, but do not link large contracts with various components into one tender [MoH as an Intermediate Body]

Problems Recommendations

Delays in project implementation Ineligibility of expenses Disruption of project implementation Loss of unrecoverable funds

Page 70

Case study from Slovenia – implementation of the „eZdravje“ reform

Context of the project

►

National eHealth project has been implemented in 2007-2015

►

Procurement of technological implementation of eHealth portal funded from ESF Main problems

►

Procurement took significantly longer than expected

►

Scope of the tender defined too broadly, which excluded potential smaller and specialized suppliers

►

Scope of the tender was not specific enough, or on the contrary too discriminative with focus on a single technology to deliver services

►

Insufficient involvement of IT stakeholders in formulating procurement rules

►

Preliminary checks of tender specifications delayed significantly procurement due to insufficient capacities delayed significantly

►

Main tenders were legally challenged

Implementation of the project of major national importance is delayed with increased costs.

Page 71

• 06. Evaluation and monitoring

►

Lack of data or their insufficient quality to monitor progress made

►

Unclear definitions of indicators and resulting inconsistency in data makes it impossible to evaluate the real impact of the intervention

►

Untargeted support or support of measures, which do not lead to objective achievements

►

Inner inconsistency of supported measures

►

Inexistent identification of causes of negative consequences and of insufficient outcomes of interventions

►

Insufficient information for qualified decision- making

►

Involve Ministry of Health representatives and

• ther health care expert into the monitoring

committee [Managing Authority]

►

Select relevant and unambiguous indicators for monitoring [Managing Authority with MoH, possibly MoH as an Intermediate Body]

►

Use evaluation not only for OPs, but also for assessment of:

►

Health strategies

►

OPs’ priority axes and calls for proposal relevant for health

►

Health programs and projects [Managing Authority with MoH]

►

Improve the quality of evaluators [MA, possibly MoH as an Intermediate Body]

►

Set up the objectives of each evaluation, relevant timing and methods; evaluation should take place in all stages of the investment process [Managing Authority with MoH, possibly MoH as an IB]

►

Design measures to take in reaction to the evaluation results [Ministry of Health]

Problems Recommendations

Lack of information for projects evaluation and for better results achievement of interventions in future.

Page 72

• 07. Investment sustainability

►

Higher operational costs than expected in investment planning:

►

Too high treatment costs for using the new technologies and equipment

►

Insufficient pool of patients requiring treatment with the new thus more expensive equipment

►

Medical personnel not properly trained to use new equipment, eHealth and treatment and diagnostic methods

►

Investments do not reflect the current mid- and long- term trends in health care

►

Little attention is given to health promotion and prevention programs

►

Measure and monitor sustainability of health investment before its implementation [Managing

Authority with MoH]

►

Assess future operating costs of investment actions

►

Prioritize investment actions according to their sustainability - include “sustainability” into project selection criteria [Managing Authority

with MoH]

►

Assess sustainability in terms of availability of qualified and adequately trained human resources [Managing Authority, possibly MoH as

an Intermediate Body]

►

Promote projects aimed at:

►

Monitoring healthcare effectiveness

►

Adopting healthcare guidelines and standards (i.e. for prescriptions)

►

Reduction of unnecessary use of specialists

►

Health prevention and promotion

Problems Recommendations

Page 73

Case study from Finland – innovative and sustainable health reform

►

Finnish population over 75 years is expected to double by 2030 causing the current health system financially unsustainable

►

With the help of ERDF funding, an innovative and far reaching health reform model has been developed with following objectives:

►

Save at least 10 % in current operating costs of the acute hospital service

►

Double the numbers at present of the delivery of a ‘care for elderly’ service with no increase in

• perating (staff) costs

►

Key components of reform:

►

Integrate special / acute and primary care and some social services

►

Reorganize service structures within hospitals to improve effectiveness and efficiency

►

Rebuilding age care residential accommodation to provide better support and promote healthy ageing

►

Improve rehabilitation services

►

Invest in illness prevention wherever possible

Page 74

Recommendations

Q&A

Page 75

• IX. Feedback and conclusion

Page 76

Discussion on possible follow up

What are the possible follow up activities to the session today?

Page 77

Thank you for your participation!

Dagmar Svobodova Senior consultant, Advisory services Dagmar.Svobodova@cz.ey.com

Romana Smetankova Senior manager, Advisory services Romana.Smetankova@cz.ey.com

Page 78

Appendices

Page 79

Appendix 1: Project outputs

Page 80

WP1 Mapping report

Mapping report

WP1

►Objective:

► Give a complete picture of health investment under Structural Funds / ESIF in EU Member States for the period 2007 – 2013 and the period 2014 – 2020 (planned actions) ► Provide entry information for the Guide, the Toolkit and the Roll-out phase

►Activities:

►Collect information on health investment under SF made in 2007 – 2013 in individual Member States, including total allocations of SF for health investment and examples of concrete projects ►Interviews with MAs / Ministries of Health representatives on past investment as well as future priorities ►Analysis of draft Partnership Agreements when available ►Analysis of draft operational programmes when available

►Deliverable:

► Report summarizing areas of health investment under SF / ESIF, identifying main categories of investment in 2007 – 2013 and main priorities for 2014 – 2020 ► Country sheets describing health investment in individual Member States



The mapping report is still in a draft version and updated on an ongoing basis – based on developments in negotiations with the EC and information gathered during national workshops.



The final version shall become publically available on February 2015.

Page 81

WP2 Guide for effective ESIF investments in health

Guide

►Objective:

► Elaborate a practical Guide for Member States’ authorities that will enhance effectiveness of investment in health in the programming period 2014-2020

►Activities:

► Analysis of a set of case studies on health investment ► Interviews with managing authorities and Ministries of Health on successful and even unsuccessful projects and their experience ► Identification of critical success factors ► Summary of lessons learned (Do’s and Don’ts) ► Design of a set of recommendations

►Deliverable:

► Recommendations on practices that lead to efficient setup of actions in health area financed from ESI Funds under the new programming period 2014 - 2020

WP2



The guide is a live document updated based on expert reviews and information gathered during national workshops.



The final version shall become publically available on December 2014.

Page 82

Guide for effective ESIF investments in health

Structure

Part I: Theoretical background

► Today’s EU health systems ► Challenges ► Sustainable concepts ► Health funding

in 2014 - 2020 PP

► Funding principles ► Health actions under

thematic objectives

Part II: ESIF programming & implementation

► Models of MoH involvement in

the operational programmes

► Intermediate body ► Subject matter expert

► MoH involvement in OP

delivery:

► Calls for proposals ► Projects preparation and

delivery

► Evaluation & monitoring

Part III: Lessons learned

► Main causes of investment

inefficiency

► Recommendations in areas

considered as critical success factors based on case studies, interviews and EY’s experience

► Case studies summary WP2

Page 83

WP3 Technical toolkit

Technical toolkit

► Objective:

► Develop a set of tools supporting the national authorities in achieving sustainable and effective investments in health under ESI Funds, which accompany the Guide

► Deliverable:

► Set of documents providing a technical advice on key issues related to investments in health under ESI Funds

► Technical areas covered by the Toolkit:

► Introduction of 2014 – 2020 instruments & mechanisms and evaluation of their relevance for health area ► Reference checklist on calls for proposals for officials involved in managing 2014 – 2020 funding in health ► Useful indicators for objective evaluation of projects/actions in healthcare ► Compendium of new concepts and models in healthcare ► Capital investment management manual ► Appraisal techniques and evaluation of their relevance for health investment evaluation



The Toolkit documents are still in a draft version, open to updates based on information and MS requirements identified during national workshops.



The final version shall become publically available on December 2014.

WP3

Page 84

WP3 Technical toolkit 1/6

Categorization of instruments and mechanisms for 2014-2020 PP

WP3

Instruments

► Forms of support under ESIF

► Grants and prizes ► Financial instruments

► Specific territorial approaches to

development under ESIF

► Integrated approach to territorial

development (CLLD, ITI, Integrated Sustainable Urban Development)

► European Territorial Co-operation

► Community programmes

► Horizon 2020 ► Health Programme

Mechanisms

► Funding mechanisms

► Delivering the Europe 2020 strategy

goals

► Synergies, coordination and

complementarities

► Thematic concentration ► Strong result orientation ► Performance reserve based approach

► Cohesion policy principles

► Concentration ► Programming ► Partnership ► Additionality

Page 85

WP3 Technical toolkit 2/6

Reference checklist: Success factors for calls for proposals

WP3

Management of calls for proposals

► Preparation of an indicative timetable

for calls

►

OP Performance framework, milestones values

►

Absorption capacity

►

Synergies and complementarities ► Set-up and public announcement of

individual calls

►

Use targeting on specific health themes

►

Raise awareness among heath entities about funding possibilities ► Evaluation of calls

►

Reassessment and update of calls timetable and their focus

Project applications assessment

► Assessment process

►

administrative check

►

eligibility check

►

quality assessment ► Design of quality assessment criteria

►

Impact on cost-efficiency and sustainability

►

Capacity to reduce inefficiencies in access to care and health status

►

Need for the project (relevance)

►

“Value for money”

►

Feasibility ► Risk analysis ► Selection of projects for funding ► Award of funding

Page 86

WP3 Technical toolkit 3/6

Set of indicators for final evaluation of action

WP3

Indicators in ESIF context

► Operational Programmes indicators

►

Financial indicators

►

Output indicators

►

Result indicators ► Requirements on Output indicators

►

Common output indicators

►

Programme specific output indicators ► Requirements on Result indicators

►

Responsive to policy

►

Normative

►

Robust

►

Data collection possible in timely manner

Indicators to evaluate ESIF health action

► Indicators per main categories of health

actions eligible for ESI funding*

►

eHealth

►

Health infrastructure & community based care

►

Access to healthcare

►

Health workforce

►

Prevention, promotion and healthy aging

►

Health status

* Indicators based mainly on existing indicators monitored by:

►

Eurostat

►

DG Sanco (European Community Health Indicators - ECHI)

►

National statistical offices

Page 87

WP3 Technical toolkit

4/6

Compendium of (new) concepts and models

WP3

Use of information technologies Clinical and prescription guidelines and models Population-oriented concepts Other

► eHealth concepts

►

Electronic health records

►

ePrescription

►

Telehealth & mHealth ► Networking and

knowledge sharing

► DRG model ► Cost-effective use of

medicines

► Deinstitutionalization

►

Cost-effective path

• f care

►

Community-based care, personalized medicine and long- term care

► Active and healthy

ageing

► Health promotion

and prevention

► Patient

empowerment

► Medical tourism ► Cross border care

Page 88

WP3 Technical toolkit 5/6

Manual on capital investment

WP3

Strategic investment guide

► Capital investment planning

►

Strategy identification

►

Financial planning

►

Project definition

►

Risk management ► Capital investment implementation

►

Ministry as an Intermediate Body

► Preparing Project Requests and Call for

Proposal

► Reviewing and Prioritizing Project Requests ► Implementation

►

Ministry as a beneficiary

► Project request preparation ► Investment implementation

► Capital investment sustainability

Categorization of financial mechanisms

► Other sources of funding apart from

ESIF

►

Loans / Guarantees

►

Equity / Venture Capital

►

Initiatives of EC

► JESSICA ► JEREMIE ► JASPERS ► JASMINE

►

Combinations of the instruments

►

PPP

Page 89

WP3 Technical toolkit 6/6

Investment appraisal

WP3

General principles of economic appraisal Key process steps:

1.

Problem identification & definition

2.

Definition of alternatives for problem solution

3.

Assessment of costs and benefits

►

List all the costs and benefits

►

Quantify/describe all the costs and benefits

►

Converse data into value of resources 4.

Calculation which will strongly depend on the type of economic appraisal

5.

Decision-making

Investment appraisal techniques

► Quantitative assessment techniques

applicable to health investments

► Cost Benefit Analysis (CBA) ► Option Appraisal (OA) ► Cost Consequence Analysis (CCA) ► Cost Effectiveness Analysis (CEA)

► Qualitative assessment techniques

applicable to health investments

► Cost Utility Analysis (CUA) ► Health Impact Assessment ► Health Technology Assessment (HTA)

Page 90

WP5 Online platform

Online platform (webpage)

►Objective:

► Develop an online platform supporting the roll-out phase by allowing widespread dissemination of the deliverables and tools developed

►Deliverable:

► A single point providing all the necessary information about funding of health from ESIF in 2014-2020 and the most up-to-date versions of project outputs

www. www. .eu eu



Like other project outputs, the webpage is still customized and refined on an ongoing basis.



Official public release is expected on October 2014 giving access to the most up to date versions of outputs presented.

WP5

Page 91

WP5 Online platform

Website content & structure

►

News containing information about workshops / updates or most up-to-date issues

►

Project introduction & background information

►

General introduction of EU Cohesion Policy 2014-2020 principles & mechanisms

►

Indicative list of health actions under thematic objectives for the 2014-2020 programming period

►

Downloadable project outputs: > Guide > Toolkit > Training materials from national workshops

►

Frequently asked questions (FAQs)

►

Mapping of implementation of SF/ESIF in health across EU Member States: > areas of health investments in 2007-2013 PP > areas of health investments in 2014-2020 PP

►

Useful contacts

WP5

• I. Website content: