Assessment tool

EU Health Systems Impact Assessment tool


This webtool is designed to help produce a Health Systems Impact Assessment, which can be used as part of the European Commission's Impact Assessment.

Why is health important in EU Policies?
Health is valuable in itself, but it also leads to economic growth as a healthy population is able to contribute to society. Article 152 of the Treaty Establishing the European Community states that
"A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities"

Member States are fully responsible for health policy and the organisation of health systems, but nevertheless EU policies often have an impact on health and in particular many policies have unintended positive or negative consequences for Health Systems, due to their large and complex structures in every Member State.

How do I use this Tool?
This tool will give you information about the objectives and health system functions that your proposal may impact on, either in a positive or negative way. The tool will also direct you to information and evidence from past initiatives that can help you find out first whether your proposal will have an impact on Health Systems, and then to estimate what that impact might be in a HSIA.

Other similar tools have been developed, including the UK East Midlands Region's toolkit, where policymakers answer questions which help them scope out the impact of their proposals on the region's sustainable development objectives.
The advantage of using this kind of tool is that, without background knowledge of health systems, you are rapidly directed to the information you need to estimate the impact of your proposal.

Who can I contact for help?
You are not expected to be an expert on health or Health Systems. The HSIA team in SANCO D1 is available to give advice and help you use the tool. SANCO may also be able to offer a link to experts on national health systems when appropriate.

Health Systems

What are Health Systems?
Health systems consist of all the people and actions whose primary purpose is to improve health', according to the WHO World Health Report 2000: Health Systems: Improving Performance. Within the report, the definition of health systems is given as, "all the activities whose primary purpose is to promote, restore or maintain health.

Health systems therefore include formal settings like hospitals, primary care units and clinics, including their workforce, infrastructure, purchasing and catering. Importantly, health systems also include home care of the sick, public health activities in health promotion and disease prevention. They also encapsulate policy planning and management by government and other bodies. (NB: there is, as yet, no agreed EU definition of health systems.)

The Values and Principles of Health Systems
On 2 June 2006 the Council of the European Union agreed to a set of Common Values and Principles in EU Health Systems It invited the European Commission to ensure that the common values and principles are respected when drafting specific proposals concerning health services, and it invited the Institutions of the EU to ensure that the common values and principles are respected in their work.

The overarching values are

  • Universality
  • Access to good quality care
  • Equity
  • Solidarity

These values are shared across Europe, even though different Member States have different approaches to translating these values into reality, some have insurance systems, some require co-payments from patients, etc. Member States have agreed that all systems must be financially sustainable in a way that safeguards these values for the future.

operating principles are:

  • Quality
  • Safety
  • Care that is based on evidence and ethics
  • Patient involvement
  • Redress when things do wrong
  • Privacy and Confidentiality

Member States have agreed that these are principles which EU citizen should expect to find in a health system anywhere in the EU. It is important to keep these principles and values in mind when estimating the impact of proposals on health systems.

Health Systems Impact Assessment

What is a Health Systems Impact Assessment?
A Health Systems Impact Assessment looks at the effects of your proposal on health systems. These can be positive, so you should not start out looking only for negative impacts. The HSIA can be included as part of your general Extended Impact Assessment.

Why should I do a Health Systems Impact Assessment?
The large and complex machinery of Health Systems is clearly an area where EU policies can have a substantial and sometimes unintended or unexpected impact. Health Systems employ large percentages of EU countries' workforce, account for major public and private spending, and have extensive infrastructure. Health systems themselves have far reaching impacts on the quality of life of the population, and on workforce productivity and economic prosperity, as a healthy population means less worker absenteeism. In the past, not enough attention has been paid to the impact of policies on health systems given their vital role in supporting society and economy.

Further, from the cross-border perspective, as patient and provider mobility between Member States increases, as well as cross border trade in everything Health Systems need, from cutting edge medical devices to catering equipment, the need for scrutiny of the impact of new policies on Health Systems is vital.

What is the Difference between Health Impact Assessment and Health Systems Impact Assessment?
When you think about your proposal in relation to health, you probably think first of public health, and the health of individuals. For example, will a transport policy encourage more cycling and better fitness? Will an emissions policy mean improvements in respiratory conditions? Health Impact Assessment (HIA) is a tool to look at this kind of health impact. For more information on HIA, please contact SANCO C5.

However, policies often have a significant impact on health systems, the hospitals, primary care facilities, clinics, healthcare staff, equipment, infrastructure, communications and many other factors which support the day to day provision of health services, and their cost in terms of money and efficiency to taxpayers, insurers and the state. For example, if a policy changes the rules on lifting weights at work, this may have an effect on staffing a hospital, as more nurses may be needed to lift patients. If a policy harmonises vocational training across the EU there may be a positive effect on health systems in terms of staffing. What happens under the free movement of goods and services when patients travel to receive treatment? Many non-health policies and actions have an effect on the way that Health Systems organise and deliver their services.

Use the Cube

The Commission has developed the Health Systems Impact Cube as an online resource. The cube has three clickable ' faces'. The EU policies face of the cube stores information on how past policies have affected Health Systems.

The impacts of the policies are looked at in terms of the parameters of Access, Quality and Sustainability, as well as the four Functions of a health system, which are shown on the other faces of the cube.

The objectives include three of the key common principles and values for health systems as agreed by Member States.

The functions are four crucial functions of health systems.

Using these parameters helps to categorise the information about policies and therefore to give a structure to the analysis of the impact on health systems.

The first step in doing a HSIA is to click on the Cube below to learn more about the Objectives and Functions, and to access the EU policy areas related to your proposal. For example, if your proposal was on tobacco subsidies, you would check for policies on tobacco, or if you are working on pharmaceuticals, you would look for policies in that area.

Click on the Policy side of the cube to be taken to a choice of a number of different policy areas. Click on your policy area to see a policy assessment giving an overview of the interactions that the policy can have with health systems.

Within that policy assessment you can find 'impact news alerts' with examples of specific policies which have a relationship with health systems.

This will give you the evidence for making assumptions about what the impact of your proposal will be on Health Systems.

Click on the other faces of the cube to learn more about the Objectives 1 which should be taken into account in a HSIA, and the Functions 2 of a Health System.


1 Based on Barcelona European Council 2002, approval of these 3 values as a basis for reforming social protection systems including health systems

2 This framework is well established and was developed in connection with the World Health Report 2000 (Murray, Frenk 2000, A framework for assessing the performance of health systems, Bulletin of the World Health Organisation 78(6):717-31)

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One of the core functions of a Health Systems is collecting the money to pay for health services (by means of tax or insurance), pooling it, and distributing it to the health services. Policies can impact on this function if they affect private insurance markets, public budgets, employee contributions, reimbursement practices, or the ways in which insurers interact with patients (e.g. advertising). They can also impact it if they change the cost of something the health systems purchases, such as pharmaceuticals, technology and equipment, staff, etc. (see Sustainability)

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Resource Generation
Resource generation is a core function of a health system. New proposals may affect resources that Health Systems use, for example:

  • human resources e.g. training and mobility of health professionals
  • physical resources e.g. equipment
  • taxation
  • insurance costs
  • knowledge

New proposals may also affect the sources of these resources, for example:

  • universities and medical schools
  • research centres
  • companies producing products e.g. pharmaceutical products, medical devices

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Stewardship refers to the way Health Systems act to:

  • formulate policies
  • exert influence
  • gather and use intelligence
  • oversee the other three elements (financing, resources and service provision)

New policies may have an effect on the stewardship of Health Systems when they influence planning and allocation of resources by national and regional governments. They can have an effect when they influence the containment of costs, for example of pharmaceuticals and health care technologies or other products, or when they influence social and health insurance benefits.

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Service provision
Health Systems provide a huge range of services to patients which can potentially be affected by new proposals. The types of services include diagnostic, preventive, therapeutic, and rehabilitative services, laboratory work, pathology, blood services, ambulances and transportation and environmental health services. They also include public health services and health promotion

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EU Policies under the Treaty Establishing the European Community
Policy assessments will be eventually be added for each policy.

  1. Free Movement of Goods
  2. Agriculture
  3. Free Movement of Persons, Services and Capital
  4. Visas, asylum, immigration and other policies related to free movement of persons
  5. Transport
  6. Common Rules on Competition, Taxation and Approximation of Laws
  7. Economic and Monetary Policy
  8. Employment
  9. Common Commercial Policy
  10. Customs cooperation
  11. Social Policy, Education, Vocational Training and Youth
  12. Culture
  13. Public Health
  14. Consumer Protection
  15. Trans-European Networks
  16. Industry
  17. Economic and Social Cohesion
  18. Research and Technological Development
  19. Environment
  20. Development Cooperation
  21. Economic, financial and technical cooperation with third countries

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Accessibility of Care for All, based on solidarity and fairness, is a core principle for health systems. Health systems should not exclude those who are unable to pay for care, and should be accessible to disadvantaged groups like people on low income, immigrants, people with disabilities, minority ethnic groups, as well as taking gender differences into account. Health systems should act as a safety net against poverty or social exclusion linked to ill health, accident, and disability, as well as care at the end of life. As the population ages, providing health care for older people is a pressing issue. The interaction between providers, insurers, and patients means this is a complex issue. Inequalities between groups in terms of access to healthcare still exist and new policies should avoid increasing these gaps, and where possible help to close them. (see COM(2004)304 for more information)

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Health Systems must be of sufficient quality and safety. Health Systems must continuously be improved and updated as progress is made in health and other sectors. Practices and treatments which provide real benefit, based on scientific assessment, should be promoted. Health care workers must be given good quality training throughout their careers. New medical technologies and pharmaceuticals must be assessed for quality, safety and efficacy. Health systems must also be adaptable enough to cope with changing needs and new demands. (see COM(2004)304 for more information)

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Health systems must be financially sustainable. Offering good quality care while adapting to new needs like the ageing population and technological progress is a challenge for all health systems. Costs can come from many different fields: new technologies, pharmaceuticals, staffing and training costs, research and development, building costs, costs relating to catering etc. Many Member States have introduced reforms including varying reimbursement rates or prices for treatment, fixing budgets for the hospital sector, 'decentralising' to give responsibility to local and regional health managers, and developing steering tools based on health objectives. Working towards preventing illness and disease will save on expensive treatment later, and evaluating the cost-effectiveness of drugs and procedures can help manage finances. (see COM(2004)304 for more information)

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