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The study, titled “European Public Health: a single system for healthy populations following COVID-19 pandemic experience”, is a comprehensive socio-economic analysis of the healthcare systems of nine EU countries.

Telehealth, data collection, communication and EU co-operation are at the centre of the analytical report, which provides a structured, international overview of the situation vis-à-vis the Covid-19 crisis and its transformative impacts on the world of healthcare.

Milan, 5th December 2022 – BFF Banking Group – the leading name in Europe for the management and non-recourse factoring of trade receivables due from public-sector administrative bodies and national healthcare systems – is today publishing the fourth edition of its Healthcare Report: “European Public Health: a single system for healthy populations following COVID-19 pandemic experience.”

This edition of the Report, which BFF has been commissioning from the Farmafactoring Foundation since 2019, was compiled by Professor Vincenzo Atella and Dr. Joanna Kopinska. It compares and contrasts the healthcare systems of the EU countries where BFF has a presence: Italy, Croatia, the Czech Republic, France, Greece, Poland, Portugal, Slovakia and Spain.

Thanks to data obtained from official sources and a custom survey of professionals and experts, the analysis offers an overview of these countries’ healthcare systems, in an endeavour to highlight common challenges and country-specific issues that may be crucial from the perspectives of both practitioners and policymakers.

“This Report has what it takes to serve as a trustworthy monitoring tool, with a view to understanding the variables at play prior to the Covid-19 crisis, during it, and in this post-Covid phase. Countries that spend more on health found themselves at an advantage,” commented Livia Piermattei, President of the Farmafactoring Foundation. “The importance of innovation and research, which require long-term investment and planning, was thrown into even sharper relief. We explored the usefulness of creating synergies and of co-operation between the healthcare systems of the various countries, as well as the effectiveness of ensuring rapid, comprehensive, timely communication between healthcare systems, workforces, patients, and families. The report enables us to explore opportunities for the overhaul of our societies and our way of managing health, creating systems that respond more effectively to the needs of all stakeholders.”

Alessia Barrera, Director of Communications and institutional Relations, BFF Banking Group, added: “BFF has always put its weight behind research geared towards addressing trending topics that could affect the relationship between companies and public-sector administrative bodies, in order to foster positive debates and encourage improvements. This edition of the Healthcare Report raises issues that are particularly crucial today, such as the delicate role of communication in building trust between governments and citizens, so as to enable mutual understanding and avoid risks being underestimated. We sincerely hope that this tool may contribute to the development of more effective approaches to the management of critical situations in healthcare by all those involved”.

Key Highlights from the Report

Almost three years after the pandemic emerged, the virus still threatens the world. As of the end of November 2022, around 2 million people have died with COVID-19 across Europe. In terms of excess mortality, the elderly (aged >65) accounted for 91% of all excess deaths in 2020 and 84% in 2021. Long-term care patients accounted for 40% of COVID-19 deaths and remain particularly vulnerable today.

• State and backlogs of our healthcare systems

Our healthcare systems were (and remain) unprepared to deal with the twofold burden of communicable and non-communicable diseases. On the one hand, they have had to rapidly reorganize to provide more hospital beds and equipment. They have also had to hire new health workers, and the dearth of medical and nursing staff is one of the most important problems according to experts. Moreover, the financial constraints have been binding, and so the solution has often involved reviewing capital expenditure projects and/or blocking or delaying non-critical projects and purchase orders for non-critical items.
These changes have put all levels of care delivery at risk. Rising healthcare expenditure is not sustainable, and governments will need to cut their deficits to manageable levels once the pandemic is over. If they fail to do so, they will not be able to face the usual challenges such as an ageing population and rising social welfare costs (first and foremost, pensions and healthcare). Even under the most favourable scenario, countries will have to deal with significant debt, the repayment of which will pose formidable issues, especially in terms of intergenerational fairness.

• Telehealth, cyber security and data

Telemedicine has become a valuable and widely available tool in many countries, designed to ensure patient care and reduce the risk of exposure to COVID-19 for patients, healthcare professionals and the public. However, while telemedicine can help overcome certain barriers to entry faced by people living in remote communities, the adoption of digital services during the pandemic may also have exacerbated some of the inequalities that preceded the pandemic. A number of obstacles to telehealth have been identified: liability, reimbursement and cyber-security concerns – all of which must be addressed by policymakers.

The Covid-19 epidemic has made it clear that the EU lacks a coherent health data infrastructure in terms of health data availability and comparability. There is a patent need for a central organization providing permanent (rather than temporary) health data at EU level, including public health data interpreted in the broadest sense. To drive population health improvement and public health preparedness in the EU, said organization should encompass multiple forms of health data and assist numerous EU-level actors/agencies.

• In search of more comprehensive and inclusive EU co-operation

Health systems are unlikely to converge under an international integration paradigm because the costs to national budgets would be too high. Rather than an integration paradigm, member states favour co-operation.

Nevertheless, given the common threats, several common strategies at EU level seem highly desirable. First, the EU should develop a shared understanding of the performance of health systems and define how to measure that performance, setting common minimum standards for the robustness of the systems. Moreover, it should use economies of scale in terms of research and knowledge concerning non-communicable diseases, and should implement mechanisms for disease surveillance and the consolidation of scientific knowledge. Member states should put a great deal of effort into building health partnerships that are open to everyone, ensuring consistency and avoiding duplication across different, disjointed small projects and programmes, with a special focus on measuring disparities of access to healthcare. Inter-disciplinary health research is crucial to addressing the impact of ageing on overall demand, as well as the matters of access to health in Europe and the fast-growing number of people with mental health conditions. Additionally, as indicated above, there is a crucial requirement to enhance systems for monitoring and collecting forward-looking and disaggregated data that can help identify emerging health needs and gaps. This could be accomplished by expanding the scope of the European Centre for Disease Prevention and Control to include non-communicable diseases, with a view to ensuring the success of the European Health Data Space initiative, which will serve as a vital foundation for future health research, legislation and policymaking. To achieve this goal, the EU should also promote the digital transformation of health systems and set ambitious goals in this regard.

• Communication

Collectively, all the EU countries must focus on rebuilding trust in scientific research and public health policy through inclusive and adaptable health communication policies. Free access to information and pluralistic discussion is vital to allay public concerns. Outreach and persuasion have been shown to be more successful than vaccine mandates in obtaining higher vaccination rates.

Overall, the report did not rate crisis communication highly. The inability to communicate properly in an effective and timely manner was particularly marked in the early phases of the pandemic, but also when new waves and new variants hit the population.

A large part of the responsibility for the schizophrenic drift in information provision should be attributed to the failure of institutional communication to take centre stage, where it should have been offering consistent and reliable messages and preventing policy communications from spreading conflicting messages, given that instrumental use of information can engender a lack of trust between governments and citizens.

The public health sector should build its capacity to respond in a timely manner in order to rebut misinformation in a credible fashion by monitoring, evaluating and mitigating scientific scepticism. Various groups of organizations and media outlets should come together, consistently addressing misinformation and disinformation in a co-ordinated manner, while public health officials, bodies and academic institutions should raise awareness and communicate with the public in ways that build public trust before a crisis occurs. Moreover, public health practitioners should monitor how people with varying beliefs interpret information, providing the necessary insights to develop a shared language that can resonate with vulnerable audiences.

• Health as an EU and Global public good

Last but not least, the commitment to leave no one behind should not end at the borders of the Council of Europe countries. A single response to a common global threat and increased support for COVAX and other efforts aimed at global health risk-sharing mechanisms should characterize Europe's commitment to universal solidarity, alongside a recognition that testing, treatment and vaccines must be available everywhere if everyone is to be kept safe.

The economic slump and inflationary pressure will likely worsen the financing issues pertaining to public and out-of-pocket spending. This implies that the EU should allocate a higher level of funding to promote the health of disadvantaged and vulnerable individuals, and should create interventional health and social support teams at the local or central level to fight inequalities. Given that international competition worsens health inequalities and risks, Europe’s member states should focus on building health partnerships that are open to all.

The recent crisis caused by the war has profoundly accentuated inequality issues both within and across member states. Refugees have added further stress to European healthcare, and integration is often ineffective, especially for underfunded health systems. A clear example is provided by Poland, which welcomes more Ukrainian refugees than any other EU country, meaning that the financial burden on its already underfinanced healthcare system will inevitably increase. Should the emergency continue in the coming years, this situation will require systemic measures by the EU, particularly in the financing and relocation of patients.

The recent events are an inevitable reminder that we live in an interconnected world. As a global community, we have all learned that we need a "One Health" approach based on multilateral leadership, co-operation, and the sharing of science and technology. One Health is still in its infancy in operational terms. Now more than ever, we need to acknowledge that health is a common public good, and if we lack a holistic approach, we pay a much higher price economically and socially.

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BFF Banking Group
BFF Banking Group is the largest independent speciality finance provider in Italy and a leading player in Europe for the management and non-recourse factoring of trade receivables owed to suppliers by public-sector organizations; BFF also provides securities, banking and corporate payment services. In 2022 BFF launched BFF Insights, the group’s study area, which drives forward and consolidates the commitment to researching and sharing the analyses that have always marked out BFF’s relationship with its clients and stakeholders. The group operates in Italy, Croatia, the Czech Republic, France, Greece, Poland, Portugal, Slovakia and Spain. BFF is listed on the Italian Stock Exchange. In 2021 it reported a consolidated Adjusted Net Income of €125.3 million, with a 13.8 % Group CET1 ratio at the end of September 2022. www.bff.com

Farmafactoring Foundation
The foundation is a private, non-profit organization whose main objective is to promote and develop research activities in the field of public-sector administrative bodies and the healthcare sector. Founded in 2004, it has carried out numerous studies, and has also sponsored important independent projects by young researchers in the fields of economics and healthcare systems in Italy and in Europe. The foundation habitually supports and contributes to numerous cultural and social initiatives. www.fondazionefarmafactoring.it/en

About the authors:
Vincenzo Atella is Professor of Economics at the University of Rome Tor Vergata, where he heads up the Department of Economics and Finance. He is also an adjunct associate of the Center for Health Policy at Stanford University, where he has been visiting professor several times, former Scientific Director of the Farmafactoring Foundation, and past President of the Italian Health Economics Association (AIES). He has co-ordinated several European projects and received financial support from the European Science Foundation. His research focuses pro-actively on applied economics, with a special emphasis on the healthcare sector. The results of his research have been published in several international refereed journals and numerous books.

Joanna Kopinska is an Assistant Professor (RTDB) of Economics at La Sapienza University in Rome and a fellow of the Centre for Economic and International Studies at the University of Rome Tor Vergata, where she was awarded her PhD in Economic Theory and Institutions. Her research interests focus on health economics, labour economics, public economics and economic demography. Her most relevant research has been published in the Journal of Health Economics, Demography, Labour Economics, Health Policy and other journals.





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