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Remarks by Angel Gurría, OECD Secretary-General, at the OECD-Austria Symposium on the Austrian Health System
Vienna, 24 June 2008
Chancellor, Minister, Ladies and Gentlemen,
I am very pleased to participate in this seminar today which comes at a crucial moment in the debate on health reforms in Austria. We have just heard Minister Kdolsky outline the main challenges and proposed solutions currently under discussion.
Austria is not alone in its objective to improve the health care sector performance. The great demand for our work on health at the OECD shows us that many countries are grappling with similar problems and are seeking to learn from each other’s experiences. At the same time, crafting the right policy responses depends strongly on the individual country’s context and set-up of the health sector.
This is why we have been conducting in-depth reviews of the health sector in OECD countries. These studies provide an assessment of the strengths and weaknesses of each national system, and an evaluation of policy alternatives. They have provided useful input to national reform debates. We would welcome the Austrian government’s decision to join the group of countries being reviewed.
There are, however, a number of challenges that we have found to be common to all countries and that is why we also conduct international comparisons of health systems (for example “Health at a Glance”). In my remarks, I would like to focus on the following three key areas: inequalities in health and in health care; shortfalls in the quality and safety of health care; and the pressures of population ageing.
The great health gains achieved in recent decades have not been equally shared among all population groups. Inequalities in health status exist along many socio-economic dimensions: age, gender, race, income and occupation to name just a few. They exist in all OECD countries regardless of wealth, politics or social systems.
Let me give you just a few examples:
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In Spain, excess mortality in the more deprived areas compared with richer ones amounts to 35,000 deaths per year.
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In England, if all men aged 20–64 years had the same mortality rates as professionals and managers, there would be 17,000 fewer deaths each year.
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In Austria, we find significant differences in health between highly educated and least educated women. In the Netherlands, the difference in health between less-educated men and those with a university education is so great that morbidity and mortality in the population as a whole could be reduced by up to 50% by closing the gap.
These inequalities are unfair and reducing them is a moral imperative. But it is also good economics. Across the European Union, for example, removing health inequalities could save an estimated 15% of social security systems’ expenditures, and up to 20% of the costs of health-care systems.
There is growing recognition that health reflects the social conditions in which people grow, live and work and that inequalities in health can be addressed, in part, by addressing the social determinants. Inequalities also reflect outstanding gaps in access to and use of health services. And here, many governments are already working to reduce the gaps, following the principle that health care should be based on need, and not on the ability to pay or where you live. The OECD aims to support governments in meeting this policy objective with our new work to develop indicators of inequalities in health and health care to use in regular tracking and international comparisons.
A second challenge for OECD countries is to improve the quality of health care services. As we begin to measure performance in this area we learn that health care very often falls short in terms of responsiveness to patient preferences, effectiveness and even safety. A number of studies have been published revealing quite shocking results. A report for the UK Department of Health [in the year 2000] indicated that so-called "adverse events" -- that is, injuries resulting from medical intervention, not the underlying condition of the patient -- were costing more than 2 billion pounds per year. Another study [2006] found that unnecessary medical tests cost the U.S. health care system close to a billion US dollars per year in addition to producing unnecessary patient stress from false positive results.
Governments are now actively pursuing policies to monitor and improve the quality and safety of their health services and are increasingly looking to the international arena for best practices. At the OECD, we have developed standards for measuring health care quality that permit cross-country benchmarking.
Last November, we released our flagship “Health at a Glance”, where we adressed this issue. It reveals large differences across countries and raises important questions on factors explaining performance. Why do countries such as Austria and Germany have in-hospital fatality rates after admission for a heart attack that are 50% higher than the rates in France? Why do Austrian victims of hemmorhagic stroke appear 30% less likely to die while in hospital than those in the Netherlands? Are these differences entirely due to differences in patient risk or age structure across countries, or are there changes in policies or practice that, if adopted, could save lives?
A final challenge I would like to highlight is population ageing. Austria has seen one of the biggest improvements in life expectancy at age 65 in the OECD area, following Japan, Finland and Australia. The gains in life expectancy have been proportionally greater for older age groups. On average across the OECD, a woman aged 65 today can expect to live a full 20 more years, a 27% gain in life expectancy compared to 1970. For life expectancy at birth, there has been a 12% gain, meaning 9 extra years.
Contrary to common belief, population ageing has not been a very significant contributor to the dramatic growth in health expenditure. Health expenditure in the OECD has grown by almost 50% as a share of GDP since 1980 [rising from 6.6% to 9.4%, on average], largely reflecting advances in the capability of medicine to detect and treat conditions.
Ageing societies are however responsible for a surging demand for long-term care of the frail elderly. Spending on long-term care as a share of GDP rises with the percentage of the population aged 80 and older. In 2005, long-term care expenditure accounted for just over 1% of GDP across OECD countries. We project that such spending will reach between 2% and 4% of GDP by 2050.
How ageing will affect the demand for long-term care services depends strongly on disability trends among older people. Here, the pattern is mixed. Several countries have seen steady improvement in the health and functional status of the elderly, while others report stable or even increasing trends of disability. These differences are not well understood and cry out for further research.
A number of OECD countries are focusing on so-called “healthy ageing” policies to avert or delay the onset of disability and dependency. Indeed, the OECD projects that public spending could be slowed by ½ of a percentage point of GDP (between 2005 and 2050) if half of the additional lifetimes of the elderly could be spent in independent living. But beyond the attempts to calculate the exact magnitude, there is widespread consensus that the impact of population ageing on overall health-care costs can be mitigated by keeping people in good health, out of hospitals and doctors’ offices.
Responsibility for caregiving traditionally rested with the families of dependent elderly persons. Today, such responsibilities are more broadly shared across society, partly as a consequence of higher labour market participation by women. The supply of long-term care workers responds to wages and working conditions. Poor working conditions, burnout and low pay make it hard to attract and retain caregivers.
In many OECD countries, especially in the EU, a large number of foreign workers supply care to elderly people. In turn dependency on migrant workers raises another set of policy challenges, such as the integration and recognition of foreign qualifications and credentials, education and recruitment, quality of care and migration policies to address the question of illegal employment.
This fall, we will launch a series of country-focused, thematic reviews, specifically on long-term care -- and I hope very much that Austria will participate in this project. We are also strengthening our data base on care recipients and caregivers.
Health systems are different from country to country, with different strengths and weaknesses, and our work at the OECD shows that there is no one “best” system. National preferences and priorities shape the policies and, despite common goals, policy makers make different trade-offs between competing objectives, when required. There is no ready mix of reforms to meet the needs of all. Instead, reforms must be tailored to the national context, concerns and values. Given the speed of developments in medicine and the evolution of health-care goals, reform of health systems is necessarily an ongoing, iterative process.
Increasing value for money in health systems requires experimentation and performance measurement, using actionable and accurate indicators. Benchmarking within and across countries, and information sharing can surely help. Bringing experience, evidence and new ideas together, will help policy makers meet the challenges they face. You are not alone, and you are certainly not the first nor the last Country to attempt an ambitious healthcare reform. Let’s make sure that you succeed.
The OECD stands ready to help Austria address its health policy challenges by sharing other countries’ experiences and working together to find the most appropriate solutions for Austria.
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