Health system efficiency in Germany: results of a pilot study to assess health system performance

Abstract Background Improved efficiency is one overall goal in WHO’s Health Systems Framework. Efficiency is an important dimension of health system performance assessment (HSPA). HSPA is used as a tool to monitor and evaluate the performance of health systems and to support evidence-based policymaking. In the pilot study for a first German HSPA, efficiency was assessed as one dimension. Methods Indicators were selected based on a systematic search of established instruments in national and international HSPA initiatives. Criteria for the inclusion of indicators were data availability and international comparability. Where possible, indicators were evaluated in terms of their development over time (2000-2020), in comparison to eight European countries (e.g., Austria, Denmark, France), and regarding equity aspects (e.g., age, gender, region). Results Eight indicators to assess the efficiency of the German health system were identified and analysed accordingly. They cover the pharmaceutical sector, outpatient and inpatient care, and system-wide efficiency. Trend analyses were possible for all indicators, and most were also suitable for international comparisons. Overall, results of the chosen indicators indicate a moderate health system efficiency. The volume of generics as share of all pharmaceuticals, e.g., was 83% in Germany in 2019 (country average: 54%) and has been steadily increasing since 2000. In contrast, expenses for pharmaceuticals overall rose from 1.4% of GDP in 2004 to 1.7% in 2019, whereas it declined from 1.3% to 1.1% on average in the other countries. Conclusions Within this first pilot study, a systematic and comparative German HSPA measuring the efficiency of the German health system using eight predefined indicators was proven to be feasible. The results give insights into efficiency measurements across different sectors, e.g., pharmaceuticals, identify developments of efficiency over time, and can support evidence-based policymaking. Key messages • In the pilot study for a first German HSPA, efficiency was evaluated using eight indicators covering pharmaceuticals, outpatient and inpatient care, and system-wide efficiency. • Based on the available data, which allowed trend analyses for all indicators and comparisons to eight European countries for most indicators, Germany’s health system efficiency can still be improved.


Background:
Despite policies aiming to curtail men's violence against women (VAW) in Sweden, one in three women have experience physical/sexual VAW. Promoting anti-VAW masculinities among young men is a key intervention to reduce VAW; yet little is known about what actions could be used to effectively do so in Sweden. This study aims to: 1. Identify actions that young people (men and women), and stakeholders believe can be used to promote anti-VAW masculinities and 2. Quantify the relationship, coherence and patterns of importance and applicability between the different identified actions.

Methods:
A mixed-methods study was conducted in Stockholm in 2019. In-depth interviews with young people aged 18-24 years (men = 16, women = 12) and stakeholders (n = 12) were used to identify actions to promote anti-VAW masculinities. Then, an online survey with 83 people (77 young people) was conducted asking participants to sort the actions and rate them in terms of importance and applicability. Multidimensional scaling and hierarchical cluster analysis were used to create clusters maps. Each cluster was rated in terms of importance and applicability. Results: Six clusters were identified: 1.own self-reflection and change, 2. actions in leisure-cultural spaces, 3. mandatory education on gender-VAW, 4. positive role models in public arenas, 5. support civil society and 6. strengthen government, police, and legal response. The clusters of mandatory education on gender-VAW and own self-reflection and change were rated higher in importance (mean 5.1 and 4.8 respectively). Mandatory education on gender-VAW and actions in leisure-cultural spaces were rated higher in applicability (mean 4.6 and 4.7 respectively). Correlation between importance and applicability was low (rho = 0.16).

Conclusions:
Promoting anti-VAW masculinities to tackle VAW should be done in multiple arenas. Mandatory education on gender-VAW in schools and leisure spaces are key strategies to promote anti-VAW masculinities.

Key messages:
Preventing VAW by focusing on masculinities requires the involvement of various social spheres. Mandatory education on gender and VAW is considered key in curtailing men's VAW in Sweden.

Background:
Improved efficiency is one overall goal in WHO's Health Systems Framework. Efficiency is an important dimension of health system performance assessment (HSPA). HSPA is used as a tool to monitor and evaluate the performance of health systems and to support evidence-based policymaking. In the pilot study for a first German HSPA, efficiency was assessed as one dimension.

Methods:
Indicators were selected based on a systematic search of established instruments in national and international HSPA initiatives. Criteria for the inclusion of indicators were data availability and international comparability. Where possible, indicators were evaluated in terms of their development over time , in comparison to eight European countries (e.g., Austria, Denmark, France), and regarding equity aspects (e.g., age, gender, region).

Results:
Eight indicators to assess the efficiency of the German health system were identified and analysed accordingly. They cover the pharmaceutical sector, outpatient and inpatient care, and system-wide efficiency. Trend analyses were possible for all indicators, and most were also suitable for international comparisons. Overall, results of the chosen indicators indicate a moderate health system efficiency. The volume of generics as share of all pharmaceuticals, e.g., was 83% in Germany in 2019 (country average: 54%) and has been steadily increasing since 2000. In contrast, expenses for pharmaceuticals overall rose from 1.4% of GDP in 2004 to 1.7% in 2019, whereas it declined from 1.3% to 1.1% on average in the other countries.

Conclusions:
Within this first pilot study, a systematic and comparative German HSPA measuring the efficiency of the German health system using eight predefined indicators was proven to be

Background:
Health System Performance Assessment (HSPA) is used as a tool to monitor and evaluate the performance of health systems and to inform evidence-based policymaking. For the first time, a systematic HSPA was piloted for Germany. The conceptual framework includes different dimensions, e.g., access, population health, efficiency, and quality of care. In the following, Germany's performance is analysed in terms of quality of care.

Methods:
Indicators to assess the dimension of quality of care were selected based on a systematic search of established instruments in national and international HSPA initiatives. Other criteria for the inclusion of indicators were data availability and international comparability. The indicators were evaluated in terms of their time trend  and in international comparison (e.g., Austria, Denmark, France).

Results:
Overall, 17 indicators were selected to assess quality of care, of which two could not be analysed due to missing data. Indicators include, e.g., emergency readmissions after hospital stays, patient-reported medical errors, coercive measures in psychiatric wards, and in-hospital mortality. Trend analyses were possible for 14 indicators and most of them showed positive developments. In country comparisons, which were feasible for seven indicators, Germany mostly ranked below average. In-hospital mortality for acute myocardial infarction, e.g., was 8% in 2019 in Germany (other countries: 4%-7%) and has been stable since 2014. For stroke, Germany performs better and ranks three of five (6%; range: 5%-9%) in 2019.

Conclusions:
Measuring quality of care for a systematic and comparative German HSPA was proven to be feasible. However, some indicators could not be mapped so far due to lack of data. The results give insights into quality measurements across different sectors and can support evidence-based policymaking.

Key messages:
In the first health system performance assessment (HSPA) for Germany, quality of care was evaluated over time  and compared to eight European countries using 17 indicators. Measurement of quality was feasible, but data availability should be strengthened in the future as country comparisons were possible for only half the indicators and two could not be analysed at all.

Background:
Although largely preventable, tooth decay (dental caries) is among the most common health conditions worldwide and contributes to substantial dental treatment expenditures. While Fluoride Toothpaste (FT) is considered an essential strategy for oral health prevention, its market price has been shown to vary substantially across various settings. Against this background, the present study aimed to develop a decision analytical model to evaluate the cost-effectiveness of FT in various settings.

Methods:
Leaning on WHO CHOICE methodology, evidence scoping and an expert consensus were facilitated to extract model input parameters which were then fed into cost-effectivenessanalyses (CEA) for FT. The cost-effectiveness of the interventions was expressed as cost per Disability-Adjusted Life Year (DALY) averted.

Results:
The CEA identified a high likelihood for FT to be a costefficient treatment strategy in settings with comparably low market prices for FT. FT was less likely to be a cost-efficient treatment strategy in settings with comparably high market prices for FT.

Conclusions:
The developed decision analytical model is suitable to inform policymakers about the extent to which FT represents good value-for-money under different market prices. Community pharmacies deliver high-quality health care and are responsible for medication safety. During the pandemic, accessibility to the nearest pharmacy became more essential to get vaccinated against Covid-19 and to get medical aid. The government's goal is to ensure nationwide, reachable, and affordable medical health care services by pharmacies. Therefore, the density of community pharmacies matters.
Overall, the density of community pharmacies is fluctuating, with slightly decreasing tendencies in some countries. The research question is: upon which conditions depends the variance in the density of community pharmacies in Europe? So far, the literature has shown that changes in the system affect prices and density. However, a European overview of the development of the density of community pharmacies and its triggers is still missing. This research is essential to counteract against decreasing density consulting in a lack of professional 15th European Public Health Conference 2022