A bit about me: I am in my final year of my PhD at ScHARR, which is funded by a University scholarship I won in 2017. Prior to this, I had been working in the public sector for over 15 years leading commissioning and strategy for community safety, alcohol and drugs; a job I left to complete this PhD. Why? There are two main reasons. First is my passion for the subject. My study focusses on the impact of budget cuts from alcohol and drug treatment services and due to my professional experiences, I wanted to help better understand the effects to support treatment policy. Second, after completing my Masters part-time alongside a demanding job, I decided complete my PhD on a full-time basis. When I’m not studying, you can usually find me walking my rescue dogs or running in the hills.
A bit of background to my study: In England, an estimated 900,000 adults need specialist treatment for alcohol or drug dependence. Whilst this is only about 2% of the adult population, the associated harms are substantial and far-reaching. Alcohol and drug dependence can negatively affect an individual’s physical and mental health, their wellbeing, working lives, and local communities. It can affect their relationships, quality of life and life expectancy and create pressure on publicly funded services, including hospitals, social care and the police. Specialist treatment forms an important part of national policy to reduce this harm as it is evidenced to improve health and social outcomes for individuals, their families and broader society. Local authorities are responsible for funding and monitoring treatment services in England; with most of the funding being made available by the Public Health Grant. This is money given to local authorities by national Government to fund public health services, including alcohol and drug treatment. Since 2013/14, there have been reports of substantial budget cuts to Public Health Grant funding and the money allocated to alcohol and drug treatment. Whist there have been no declines in the estimated number of people who would benefit from treatment, there have been reductions in the number of people engaging in treatment but we do not know if this is connected to the budget cuts. Fewer people engaging in treatment may contribute to increased health and social harms and, in recent years, there have been increases in related hospital admissions and deaths.
Study design: This blog focuses on the results from phase one (of three) of a mixed method study (Figure 1); designed after completing a systematic review of the available evidence. Phase one matched routine quantitative data from the Ministry of Housing and Local Government, the National Health Service, the Office for National Statistics and the National Drug Treatment Monitoring System. Phases two and three build upon this by interviewing, and then surveying, people responsible for funding treatment services to understand their views and experiences of the effects of budget cuts.
What did I do? In phase one, I matched readily available data from administrative reports on each local authority. I then looked at whether local authorities that had experienced larger changes in public health grant spending had also experienced larger changes in the following outcomes: treatment engagement, successful completions, alcohol-specific hospital admissions, alcohol-specific mortality, and drug-related deaths.
What did I find? Treatment services in England have lost more than £212.21 million (-27%) of Public Health Grant funding between 2013/14 and 2018/19. By 2018/19, 34,000 fewer (-11%) people were engaging in treatment and 44,000 fewer were successfully completing (-21%) alcohol and drug treatment despite overall increases in the estimated number of people who would benefit from treatment. During the same time period, there were increases in alcohol-specific hospital admissions (+9%), alcohol-specific mortality (+4%) and drug-related deaths (+24%). Areas that had experienced bigger cuts in treatment spending saw fewer people accessing and successfully completing treatment. However, areas that had experienced bigger cuts did not experience bigger increases in admissions or deaths. In my published paper, I encourage caution in interpreting these results for several reasons. For example, most people who would benefit from alcohol or drug treatment do not access treatment, so any relationships may be more identifiable by matching patient data. Also, the study focuses on a six-year period but it may take much longer for the full effects to be seen.
These results might help policy makers make decisions about treatment funding. Fewer people engaging in, and successfully completing, treatment might increase relating harm and increase cost pressures elsewhere, including health and social care and criminal justice services.
The Sheffield World Health Assembly Simulation, or #SheffWHO is a student-led annual conference simulating the process of the annual World Health Assembly, the World Health Organization’s supreme governing body. During this immersive simulation, participants role play with specific roles such as Member State representatives or Non-State Actors such as NGOs, pharmaceutical companies or media organisations. Delegates then debate throughout the three-day event, drafting resolution papers to propose innovative solutions to major health challenges. Keynote speakers, including senior representatives from WHO and academics from around the world, are also invited to help stimulate discussion and advance real-world learning.
Attending the conference is a unique experiential learning opportunity and highly recommended for anyone interested in Public Health or Global Health.In its fourth year running, #SheffWHO2021 was held virtually from 19 to 21 March 2021. This year, over 100 participants joined from 34 countries around the world, including Europe, Africa, Australasia and the Americas.
Prior to the event, delegates submit position papers highlighting the views of the country they represent, on the conference theme, which this year was “Building Back Better: Strengthening Health Systems”. Ms. Magali Collonnaz participated as the delegate of Germany and won the ‘Best position paper’ award. Her paper is published below.
We are living in extraordinary times: 2021 brings the COVID-19 mortality to >2 million deaths worldwide (1) and to >70,000 deaths in Germany (2).The COVID-19 pandemic has been exerting enormous pressure on health systems around the world, highlighting the sub-optimal resilience of health systems, even those renowned for their high performance (3). Building back after the COVID-19 pandemic is intrinsically linked to health systems strenthening. Health systems strengthening is key to limit the adverse consequences of epidemics, and to treat cases while maintaining essential health and non-health services (4). Moreover, access to affordable and quality healthcare is a fundamental human right and a prerequisite for sustainable social and economic development (5). The question now is what can we do to strengthen health systems?
Germany : Country profile & health system
In 1883, Germany was the first country in the world to establish a nationwide Social Health Insurance (SHI)(6). The German health system has a complex governance structure: Germany is a federal republic and decision-making powers are shared between national and state levels (7). Governance of the German health system relies strongly on self-governing structures and there is limited state control. Health insurance is mandatory in Germany since 2009 and coverage by the SHI is nearly universal, with 88% of the population covered by the SHI in 2017 (7–9). Private health insurances (PHI) cover 10% of the population, while the last 2% are covered by special schemes (7–9). Employees earning less than 54 900€ per year are automatically insured by SHI. Other people can opt for PHI or stay in SHI on a voluntary basis (6,8). Everyone has an equal right to health care regardless of their income (9).
Healthcare is mostly financed with the premiums paid by employees and employers (9). These premiums are based on income. SHI revenues are pooled together with some tax subsidies in the central health fund and reallocated to sickness funds. Physicians are paid fee-for-service, and hospital care is reimbursed through diagnosis-related group based payment (6,8). Germany invests a substantial amount of its resources on healthcare, with 3 996€ per capita spent in 2015, the second highest amount in the EU (6). A total of 84.5% of health spending is publicly funded (the highest share in the EU ) and out-of-pocket spending only amounts to 12.5%, which is below most EU countries (6).
Life expectancy at birth in Germany was 80.7 years in 2015, slightly above the EU average of 80.6 (6). Access to health in Germany is good, with very few citizens reporting unmet needs for medical care (0.5% of the population reported having forgone needed care in 2015). However, unmet need is higher in lower income groups of the population (6).
Health system strengthening: Germany’s current response
Germany is strongly committed to strengthening its health system through actions on the six health system building blocks identified by the WHO (5,10). Germany has a strong and resilient health system, resulting in relatively good health for the population. This is the result of several measures taken by the government over the past few years. First, the Institute for Quality Assurance and Transparency in Health Care (IQTiG) was founded in 2015 to develop quality indicators and make medical care quality more transparent for patients (6). Second, several reforms have addressed the shortage of physicians, in rural areas. For example, the 2015 Healthcare Strengthening Act promoted the establishment of integrated care programs, enabled municipalities to set up health centres and allowed hospitals in rural areas to provide outpatient care (11). In addition, physicians working in rural areas now receive financial incentives (6). Third, the recent Long-Term Care Strengthening Acts have considerably expanded the benefits package. This was coupled with an increase in insurance contribution rates by 0.5%. Part of this increase is used to create a long-term care precaution fund (6). Lastly, Germany has a very large hospital inpatient sector, with 813 beds per 100 000 inhabitants, which is the highest ratio in the EU and 58% above the EU average (6). Bed capacity has only been reduced by 11% since 2000, whereas some European countries have reduced capacity by more than 40% over the same period. Germany also has high numbers of physicians and nurses, with per population rates above the EU average (6).This is partly explaining why Germany’s health system was so successful in managing the Covid-19 pandemic.
However, the health system still has room for efficiency improvement: Given the high number of hospital beds, the physician to bed ratio is relatively low, and the nurse to bed ratio is one of the lowest in the EU. Moreover, amenable mortality in Germany is below the EU average, but 10% of all deaths were still considered to be avoidable through higher quality and more timely care in 2014.
Health systems strengthening: the solutions
Germany strongly believes that health systems strengthening must be a priority if we want to achieve the sustainable development goals by 2030 (12) and avoid service disruption during future outbreaks. Several actions at the national and international level must urgently be considered.
At the national level
Ensuring access to healthcare for all through universal health coverage is one of the key strategies to
strengthen health systems, as well as to achieve the Sustainable Developing Goal 3. In addition, out-of-pocket payment must be reduced to a strict minimum.
Vulnerable and isolated groups of the population must be ensured access to healthcare, and measures must be taken to remove any barriers jeopardising access to healthcare for these groups.
All countries should increase the healthcare workforce and number of hospital beds, including beds in intensive care units. This is essential to increase health systems resilience. In addition, the mental health needs of the health workforce must be protected and they should be offered fairer wages.
Public health services must be strengthened in order to ensure a timely detection and notification of epidemics or other health-related threats. This includes investing more money into public health services, developing reliable monitoring systems and drafting clear frameworks for emergency public health response.
At the international level
As planetary, animal and human health are intrinsically aligned, one health must be given a high priority in the WHO’s agenda to ensure a better preparedness to emerging infectious diseases outbreaks.
We need to use the appropriate metrics in evaluating health systems. Standardized methods for data collection are required to allow for cross-country comparison of the burden of disease caused by an outbreak. We also need internationally comparable measures of precariousness that go beyond GNP and life expectancy to highlight health inequalities.
We need to emphasise global solidarity: high income countries must support low-and-middle income countries in post-Covid recovery. Global and national health should be considered together, and there should not be any disparity between countries’ local and global response to tackling a global health treat.
1. WHO Coronavirus Disease (COVID-19) Dashboard [Internet]. [cited 2021 Feb 19]. Available from: https://covid19.who.int
2. Germany: WHO Coronavirus Disease (COVID-19) Dashboard [Internet]. [cited 2021 Mar 9]. Available from: https://covid19.who.int
3. El Bcheraoui C, Weishaar H, Pozo-Martin F, Hanefeld J. Assessing COVID-19 through the lens of health systems’ preparedness: time for a change. Glob Health. 2020 Nov 19;16(1):112.
4. Strengthening the health system response to COVID-19 – Recommendations for the WHO European Region: policy brief, 1 April 2020 (produced by WHO/Europe) [Internet]. [cited 2021 Mar 11]. Available from: https://www.euro.who.int/en/health-topics/Health-systems/pages/strengthening-the-health-system-response-to-covid-19/strengthening-the-health-system-response-to-covid-19-policy-brief/strengthening-the-health-system-response-to-covid-19-recommendations-for-the-who-european-region-policy-brief,-1-april-2020-produced-by-whoeurope
5. Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). Health systems strengthening [Internet]. GIZ. [cited 2021 Mar 9]. Available from: https://www.giz.de/en/worldwide/40525.html
6. State of Health in the EU Germany Country Health Profile 2017 [Internet]. 2017. Available from: https://www.euro.who.int/__data/assets/pdf_file/0004/355981/Health-Profile-Germany-Eng.pdf
7. Germany: health system review [Internet]. WHO Regional Office for Europe; 2014 [cited 2021 Mar 9]. Available from: https://apps.who.int/iris/handle/10665/130246
8. Düllings J. Overview of the German Healthcare System. HealthManagement [Internet]. 2010 [cited 2021 Mar 9]; Available from: https://healthmanagement.org/c/imgfr/issuearticle/overview-of-the-german-healthcare-system
9. Health care in Germany: The German health care system [Internet]. Institute for Quality and Efficiency in Health Care (IQWiG); 2018 Feb [cited 2021 Mar 9]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK298834/
10. Strengthening health systems to improve health outcomes : WHO’s framework for action [Internet]. World Health Organization; 2007 [cited 2021 Mar 13]. Available from: https://www.who.int/healthsystems/strategy/everybodys_business.pdf?ua=1
11. Munir K, Worm I. Health systems strengthening in German development cooperation: making the case for a comprehensive strategy. Glob Health. 2016 Dec 3;12(1):81.
12. THE 17 GOALS | Sustainable Development [Internet]. United Nations. [cited 2021 Mar 13]. Available from: https://sdgs.un.org/goals