Investing in health systems is one of the cornerstones of the Tallinn Charter – but how do we make it work?

Last week’s 10th anniversary meeting for the signing of the Tallinn Charter, which back in 2008 put a commitment to investing in sustainable health systems that are inextricably embedded in overall policy formation and responsive to people’s needs firmly on the international agenda, strongly and enthusiastically reinforced the importance of investing in a healthy society by ensuring that health systems have enough resources to achieve their goals (a short overview of selected related passages from the Charter and the Outcomes Statement of the anniversary meeting is in the table, below).

Tallinn Charter, 2008 Tallinn10 Outcome statement
Therefore we, the Member States and partners, believe that

  • Investing in health is investing in human development, social well-being and wealth; (…)
  • Heath systems are more than health care and include disease prevention, health promotion and efforts to influence other sectors to address health concerns in their policies; (…)
  • Health systems need to demonstrate good performance.

We, the Member States commit ourselves to:

  • (…) invest in health systems and foster investment across sectors that influence health, using evidence on the links between socioeconomic development and health; (…)
  • Engage stakeholders in policy development and health; (…)

Countries shall pursue (…) performance goals to the greatest extent possible given their means. This requires efficiency: making the best use of available resources. (…)

The overall allocation of resources should strike an appropriate balance between health care, disease prevention and health promotion to address current and future health needs. (…)

In a rapidly globalizing world, generation of knowledge, infrastructure, technologies, and, above all, human resources with the appropriate skills and competence mix requires long-range planning and investment to respond to changing health care needs and service delivery models.

(…) We will thus:

i.        continue to strive to secure and sustain adequate resources through greater public investment, make use of efficiency gains and ensure a redistribution of resources to meet health need, especially towards poorer people and regular users of health care, for whom the economic gain is most evident;

ii.      intensify efforts to bring health and finance decision-makers together around shared goals by taking note of public finance objectives and correspondingly demonstrating the economic and social returns of investing in health systems; and

iii.     elevate our efforts to enact cost-effective and evidence-based public health approaches, services and interventions by improving cooperation with key stakeholders inside and outside the health system; by improving human resource policies through training and broadening the range of professionals and skills; by introducing financial mechanisms to increase the share of resources to public health; and by adapting the organization of public health services with better population-based health needs assessment and coordination with primary health-care services.

(…)We (…) further commit to scaling up work on health system transformation, and will invest in mechanisms and processes to manage the transformational change required of our health systems. (…)

We, the participants of this high-level meeting, call upon European leaders to recognize the centrality of strong health systems based on the need to include, invest and innovate, where healthy populations are the bedrock of delivering on governmental and social commitments, and to pursue these policy directions.


During the meeting, discussions often focused on the fact that despite a wide recognition of the importance of safeguarding and improving the health of populations, health policy-makers often find it difficult to ensure funding for reforms, additional initiatives or ad-hoc responses to short-term needs. Prepared specifically for the meeting, a video starring Geert van Maanen, who has served as the Secretary General of both the Ministries of Health and Finance in the Netherlands (and who should definitely consider an acting career in subtle comedy) aptly put the issue in context. Finance Ministers, and, in consequence, governments, need to see that existing funds are used wisely before they will consider committing even more to the health system. Beyond ideological conviction, they do not necessarily always see how health systems can be of value to the overall economy.


Indeed, while statutory health spending per capita shows shallow upwards trends in the majority of EU countries since the signing of the Tallinn Charter (see OECD data for 2008-2016), the breakdown of contributor to the phenomenon (e.g. high-priced innovations and inefficiencies) requires more granular analysis. Having said that, there seems to be sufficient data to suggest that higher per capita spending corresponds to lower amenable mortality rates – if only Health Ministers readily had such evidence at hand when speaking with their counterparts in Finance!

This is the gap a new policy brief by the European Observatory on Health Systems and Policies ( aims to bridge. Authors Jonathan Cylus, Govin Permanand and Peter Smith systematically examine the barriers health policy-makers can face when trying to “make the case” for (further) investing in the health system. They identify the reasons for resistance on behalf of governments to prioritize health as a sector for investment (e.g. the major role of factors outside the influence of the health care system in determining overall health outcomes, perception of widespread inefficiency, low prospects of productivity growth etc.) and provide hands-on advice for health policy-makers to overcome them.

So what could matter to Ministers of Finance? The authors organize the main messages of the brief around four key areas of interest in resource allocation:

  • Is spending on health systems a good use of government resources and how can health systems demonstrate that they use public resources responsibly?
  • Are health systems an important driver of macroeconomic growth?
  • Do health systems support societal well-being?
  • How does the health system influence overall fiscal sustainability?

The brief will be available online soon, but here’s a sneak peek into what we can argue to convince those with the power to act on it that sufficiently funding the health care system is a sound investment: there is good evidence that spending on the health systems contributes to better health outcomes (not to mention, out of potential contributors, it’s the one we can control the easiest) and, while we may not be able to fully eliminate inefficiencies, we can show that we are committed to value for money by monitoring performance and acting on identified waste and misuse. From the macroeconomic perspective, health systems are not only major employers but also very important for the productivity of the labor force overall. Health systems´ contribution to societal well-being is increasingly discussed in the context of “morbidity compression”, which can be directly influenced by concerted efforts. Finally, by adjusting to epidemiologic trends and focusing on keeping older people active and able to contribute to society, health systems can be a boost and not a threat to fiscal sustainability. [For the types and sources of evidence to support these assertions, seek out the full text of the brief soon!]

As Hans Kluge, the Director of the Division of Health Systems and Public Health at WHO Europe, clearly and resoundingly reiterated in his inspiring summation speech on June 14th, if we are going to stay true to the investment goal of the Tallinn Charter “we need to show that we know what we want and that we have our house in order”. [Slovenian Health Minister Milojka Kolar Celarc added another important tenet for health policy-makers when addressing those deciding on funding: persistence. “You throw me out the door, I come in the window!” is the attitude that has proven the most successful in her experience (fellow policy-makers at the meeting agreed)]. An important point to remember here: as the Tallinn Charter explicitly described (and the name of Hans’ Division fittingly reminds us), “what we want” should not limit itself to investment for the provision of health care services – public health with all its facets equally merits a place on the agenda of health policy-makers. However, securing funding for public health initiatives can be even more challenging – making sure that sufficient evidence is generated and organized in a way that is conducive to “making the case” for public health investments is another imperative. [A separate Observatory policy brief, this one by David McDaid, takes a closer look at how this can be addressed, drawing on a number of successful initiatives from a number of countries. Both policy briefs will be appearing soon on the WHO and Observatory websites. Stay tuned!]


This Blog was written by the Young Gasteiner  Dimitra Panteli


Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.