“Ministry of Finance needs to be a good listener” – Interview with Corina Pop, former Romanian State Secretary for Health

Corina Pop

Corina Pop (CP) served as Romanian State Secretary for Health from 2015 to October 2018. She coordinated the Project Implementation and Coordination Unit. At the EHFG plenary, she gave her perspective on “making the case for investment in health”. This interview is a follow-up on the heated plenary debate.

NP: During the plenary, you talked about the issue of ‘silo thinking’ and how to better understand the dialogue between health and finance decision-makers. We, as public health professionals, are sometimes in the position of having plans for a health project which we need to pitch to the finance ministry to convince them to allocate a budget for it. We would be interested to hear your take on such situations from the health perspective – how do you approach this challenge?

CP: First of all, I am a doctor, and I am not political. I am rather strictly a doctor in the position of the Ministry of Health. When I arrived at the MoH, one of the most important problems that I faced, and which is of particular interest to me, was that the doctors didn’t want to be involved in the projects. They are not interested in projects because running a project is very difficult. It is not like clinical or surgical medicine, or dentistry. It requires a type of work done by a civil servant. This means that you need to have a team, ideas, and you to spend a lot of time writing mails and talking about money and administration – this is why doctors do not want to be involved. I called everyone I know asking to help me run these projects because we had a reasonable amount of money at our disposal. For me, as a health system policy-maker, it means that you have to find both the resources and the beneficiaries. In order to promote your interests and projects, you need to convince not only the Ministry of Finance, but also the promoters who are the doctors, the managers of the hospitals etc. The promoters are especially interested in research and not in public health-related projects.

For example, I have an important project for Romania that I care about a lot. It is about health economics. As there is no specialist for health economics in Romania, I said ‘look we have to prepare a project: first, we need a curriculum and a methodology, then we need to find the professors, the teachers, the speakers, the experts, and finally we need to train and pilot the first 20-30 doctors or economists’. Even though I have written the guidelines and the programme, no one wants to run the project. And this is not only about the funding, it is also about the interest in public health.

BF: How do you think you could adjust this and make public health a more attractive specialty for doctors in Romania?

CP: It has to be specifically promoted during the undergraduate studies. What we need is for students to start learning about the importance of public health and health of the population as soon as they start studying medicine. It is important to talk about public health when talking about epidemiology in the first year. This way, the students have more options before they go the common way of choosing the surgical specialty which is associated with fame and lots of money. However, no one wants to talk about epidemiology, you know (laughs).

NP: Mr Hetemäki from Finland mentioned the issue of trust being a key factor for collaboration, which can only be based on a common understanding. Now adding that you also have to convince the promoters, how do you actually achieve this? 

CP: There are two dimensions. First, the evidence. Just saying ‘look I have a lot of evidence here, please give me the money’ is not enough to gain trust. Rather, you need to approach it by providing the evidence, i.e. number of saved women’s lives with cervical cancer. It is not like in a Disney cartoon in which you can achieve anything by repeating ‘please trust in me, trust in me’ (laughs). The second dimension is the team that will implement what you promise to do. However, I recently had a case of a very difficult and complex project in which the professionals were simply not able to promise to deliver a certain number of services. That is why the budgeting official said ‘OK, if you are not able to, you will not get the money’. It is very difficult to fight with the Ministry of Finance for trust. It is about the capacity-building and it is about the health workforce. That is why I said, ‘my wish for the Ministry of Finance is to be a good listener’, to have patience to explain that there is so much we can do, and this is not at all because we are unable. It is because health services are too complex. We have to be very patient and listen to the process. It should not be like in a marketplace: ‘how much do you want?’ ‘health spending is this much’, ‘which are the metrics?’, ‘OK, I won’t give any money’. This is impossible.

NP: Are there any tools to support you in convincing them?

CP: Yes, there are two partners you need. One of them is a very good journalist, always capable of presenting the problem. The second is the civil society, especially patient associations. Together with journalists and patient societies/associations, we can convince the Ministry of Finance. Not only with evidence, but with real life examples.

NP: I understand. We frequently hear the financial sustainability of healthcare systems being questioned due to challenges such as the aging population, unhealthy lifestyles and high prices of new medicines and technologies. In your view, what needs to be done to successfully address these challenges?

CP: The problems that require a lot of attention are related to innovation, ageing and costs of healthcare delivery. It should be taken case by case, though. Depending on the country, I can provide you with different answers. Regarding Romania, and the low-income countries, I have told you that it’s always about choosing between either prevention or treatment and diagnosis because all of these fall under the same budget. It is up to you to keep explaining the importance of keeping prevention high, because prevention will decrease the spending in the next 10 years. But the Ministry of Finance does not care about the next 10 years, especially if the elections are in 2 years. At the same time, you have to explain that it is impossible to spend only on prevention, because you have cases of cervical cancer that are happening right now, and need radiotherapy.

The problem is that they are not interested in prevention of lifestyle-associated diseases, because they do not understand the process from smoking and cancer to spending and expenditure. This is the process that we, as specialists, know all too well.

The budgeting officials are interested in taxing alcohol and smoking, but this money does not go to health. It means that you have to explain that we raise the taxes not only to gain more money, but also to prevent people form buying and consuming tobacco products, as well as to use that money to cure the already existing cancer. There needs to be a communication, one needs a lot of time to explain things that seem so trivial for us in public health.

BF: You were mentioning that these things are sometimes hard to explain. Do you think that the direct benefits that the health system has, such as contributing to people having longer lives and healthier lives, are measured enough in the current system? And do we communicate these benefits enough?

CP: Surely it is not communicated enough. And I think that everybody talks about aging, but everybody talks about what problems you have when you are elderly. No one talks about how beautiful it is to have your grandchildren and to be healthy at the same time. It means to explain that good health gives you the gift to be healthy when you are elderly. It means that you are healthy enough to help your family and community. We have to live well and have a high quality of life.

BF: This leads me on to the next question. Public health is actively working on well-being and safety of the entire population. Do you think that the entire health system takes this into account? Sometimes I feel we have a system that is geared around the financial aspect and doesn’t take into account the things which we cannot quantify.

CP: Yes, it’s interesting, we just discussed this one two hours ago. I think that the Sustainable Development Goals address exactly these ‘uncountable’ aspects. If we talk about any of the SDGs, none of them is only about numbers: they talk about quality, well-being, air, nutrition, communicable diseases, safety, patient safety, water, transport… So, yes, it’s exactly about the SDGs.

BF: So you see the SDGs as a useful tool to help you?

CP: Very useful, but they are not promoted enough by the policymakers. They understood they would need to take care about the SDGs, to fulfil the targets, but they don’t really care. If the policymakers were to read, but really read the SDGs, they would understand they are faced with a complete political programme, and a very beneficial one. It is so complete, it is so about people, it’s so social, at the same time addressing health, economy and inequalities.

BF: Is there any way that the SDGs have influenced or inspired you in the way you’re tackling certain health issues in Romania?

CP: Yes, we had a lot of meetings. We had a meeting with Zsuzsanna Jakab in July about SDGs, it was very important for Romania, because she has the power to bring the politicians to the same table.

NP: Who participated, only health policymakers?

CP: No, the president of the country, the directors of the whole university, the rectors of the universities.

BF: Did she help you to get other people on board?

CP: Yes, certainly, she has the power to do that. She’s wonderful in doing something to get all the policymakers on the same table, and without punishing any, she convinced them that was important to work for health.

This interview was conducted by the Young Gasteiners Beatrice Farrugia (BF) and Nataša Peric (NP).

Is the EU reaching SDG 3.3.? An interview with Andrew J. Amato-Gauci

“Tuberculosis is our shame; Elimination of viral hepatitis C is very possible and HIV/AIDS is more complicated.”

I have met Dr Andrew Amato at the main conference venue of the European Health Forum Gastein, which he attended for the first time. During an hour-long interview, we had an interesting and fairly open discussion on where European Union is now in reaching SDG 3.3, as well as what are the key reasons for that. I hope you would enjoy reading this article as much as I enjoyed talking to this passionate health care professional while drinking a coffee on a sunny terrace of a small café surrounded by the Alps.  

AT: The motto of this year EHFG opening plenary was “Let’s think big for Public Health in Europe”. What does it mean for you to think big?

AA: For me, it means that we should be more ambitious in our aims and our goals. Even if we know that we are being too ambitious, this is important as the political commitment to public health today is rather weak, so politicians do need aspirational goals. I don’t see a lot of public health champions among the politicians today. There is also a tendency towards adopting more populist policies. Unfortunately, this usually means the politicians will tend to only focus on policies and make promises that will provide short-term satisfaction. So, we, the public health activists, need to look at the big picture and set ourselves bigger goals that could inspire the politicians to follow suit and plan greater policies, rather than going for immediate and short-term outcomes.

For example, hepatitis C elimination in Europe is ‘easily’ achievable from a policy aspect – the only thing that needs to be done is testing of the at-risk populations and providing curative treatment, as simple as that. Of course, it would cost a lot of money initially, but the benefit such a plan is that it will have to be done only once on large scale.Obviously, I am oversimplifying to make a point, but it really can be done with the help of motivated and strong-willed politicians behind it.

Vaccination is a similar topic: we could do so much better with just a little bit more emphasis on the right legislation, a bit stricter enforcement and stronger advocacy strategies. By now, we were supposed to have eliminated measles in the EU: we have the tools, we have the money, and yet, for the lack of interest and political will, the campaigns have mostly faltered. I am convinced that a major campaign – and by “major”, I mean a suitably funded campaign with inspired leadership, which is run over 3 to 5 years,focusing only on measles –, would easily manage to eliminate measles in the EU. The USA had managed to come very close to achieving this, and then faltered for various reasons, which unfortunately include recurrent imported infections from the EU. That’s the kind of high-level policies we need, with countries coming together and agreeing that we need to work on this particular priority and putting sufficient resources there. The problem with this is that the health mandate of the EU Commission is still rather limited. Namely, there have been brave attempts in starting up major partnerships (e.g. against tobacco or cancer) and becoming more involved in public health, but it is still a work in progress. The organization of health services is still the mandate of Member States, so we have different health care services across the EU. For me, this is in a way against the spirit of the EU, which is all about crossing borders without any obstacles or differences. So, as long as health care services,disease prevention and health promotion services are different in every country, a citizen moving from one country to another will face differing services. We still have a long way to go for the EU to fix that. From the public health perspective, the DG SANTE is probably not the most influential sector of the Commission – it is nowhere near the Economics, the Finance, or the Foreign Affairs sectors, just to name a few. I think we should all work on raising the profile of health to a satisfying level.

AT: Turning to one of the SDGs, precisely to SDG 3.3 – what are the key priorities for Europe?

AA: Yes, the famous SDG 3.3…. It is unlikely that we will be able to achieve TB elimination in the EU within the target. This is a disease which is almost 100% curable with antibiotics, and yet, despite all the medical advances that we have made, we can’t seem to “fix” it in the EU. I don’t understand how we have found ourselves in this situation. It’s true that the numbers are decreasing, but the decline is very slow. We need to focus on the latent TB, especially because we have never given it the attention it deserves. MD RTB shouldn’t remain the problem it is now, there are new tools coming online quite soon which hopefully should make it less of an issue.

The SDG 3.3. refers to combating hepatitis.What does that mean? The UN has come up with numbers, planning a reduction of 90%, but I think that total elimination of HCV is what we should aim for at the EU. As I said before, we already have all the necessary tools in the EU, and we have good health care services, so why can’t we achieve that?

For HIV/AIDS, the SDG target is more complicated. We have at last begun to see a true reduction of incidence in the EU/EEA, first seen in the surveillance data of the last year, mainly in new cases of infection among men who have sex with men. This is largely thanks to the adoption of Test and Treat policies and the roll out of PrEP for at-risk populations. I think people began to realize that the more we adopt these ‘fast-track’ policies, the more we will see HIV coming down rapidly. Also, AIDS rates are dropping very fast because the treatment is working so well. On the other hand, we see epidemics of gonorrhea and syphilis in the EU. With further roll out of PrEP, we can expect to see more of these. Still, it will be hard to know whether this is due to more new infections actually happening, or because at-risk people are tested more often and thus are found to be infected. However, I think if PrEP is implemented properly, the highest-risk groups will likely attend services more often, both for their prescriptions and screening tests. This way, they will be tested and treated for syphilis and gonorrhea as well, possibly bringing these down in the longer term. So, there is a possibility of using PrEP to reach out to the most at-risk group and reduce their overall infection risks and exposure. The current rates of increase of STIs are concerning, and we are expecting to find out more about the rising rates of congenital syphilis in the USA. We haven’t seen it yet, but we can expect that this is going to happen in one- or two-year time. 

Of course, malaria is not that relevant in the EU for now, but if the rates of other vector-borne diseases are anything to go by, it is just a question of time. 

So, I believe HCV is where we could achieve the most. For TB we are not doing as well as we should, especially in the east of Europe. And as a side effect of PrEP we might be also combating STIs.

AT: I also wanted to talk about SDG 3.3. and migration. You have published several papers related to the issues of migration. Every now and then, something happens in the world and we have a new wave of migrants arriving to the EU, bringing new culture, traditions, languages, as well as new health-related problems. What do you think of that?

AA: Our work with migrants is limited, because ECDC’s focus lies within infectious diseases, which might not be the major public health problem for migrants. TB and, to a lesser extent, hepatitis may pose some problems, especially among irregular migrants coming from high-prevalence areas, but for HIV/AIDS this is much less of an issue. The problems for migrants go beyond infectious disease, and we don’t have a mandate there.  

A specific problem with migrants that I have is the word itself. We use “migrant” for a very broad phenomenon, and mostly synonymous with migration from outside of EU: there are people who are economic migrants, for example the North Africans, who are trying to get across in order to get work; there are war refugees like Syrians, and there are whole mix of central Asians, who are looking for a better life. Still, we tend to put all of them in one basket of “migrants”. They all have very different problems, very different issues, very different health needs. It’s such a complex issue, and our work has been very limited. Some policy advisers asked ECDC to define whether we should be testing “migrants” for certain diseases, for example. In response, we developed guidelines that specify what should be asked if a test is offered, and of course, stating that those tests should be provided only on voluntary basis. Also, if a test is provided, the treatment has to be made available, otherwise it is simply not ethical to test. TB in migrants is something that we focus more on, as many migrants come from high-prevalence areas, but hepatitis and HIV/AIDS are among the least health problems migrants face. HIV/AIDS, as we have found out, becomes a problem for the migrants after moving to the EU. There is good data showing they get infected more often after they had moved to the EU. It is quite the opposite to what right-wing politicians like to preach – that the migrants bring HIV/AIDS to the EU. Finally, as already mentioned, we use the term mostly synonymous with migration from outside of the EU, but we should also consider the impact of migrations within the EU, from Eastern European to Western European countries.

AT: To sum up, this is your first time at EHFG – what does it feel like?

AA: Yes, it is. So far, I have only seen the village (laughing) and the village is very cute and I love the mountains! So, I am very happy to be here. I am here with my director, we will have ECDC session tomorrow, and I am looking forward to our session, we will see how it goes.

This interview was conducted by a Young Gasteiner Anna Tokar

A new approach to NCD control in Europe

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Interview with Marianne Takki, Policy Coordinator, DG Sante, European Commission

“I’m here to tell everyone about the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases, and explain to organisations and other health stakeholders how the approach works.”

At the European Health Forum Gastein 2018, Marianne Takki was present to discuss the activities and role of the European Commission in non-communicable diseases (NCDs) prevention and control.

MD: You mentioned that the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases[i], which the European Commission established this summer (2018), is a totally new approach. What is so different about this approach compared to how the Commission worked on NCDs earlier?

MT: Previously, there were several disease-specific expert groups at the Commission, such as on rare diseases, cancer control, and mental health. The outputs of these groups were not effectively taken forward. We [the Commission] realised that, for plans and recommendations to be useful to someone, implementation needs to be the focus of all planning. Now, with the new steering group that officially started in July 2018, the member states are involved from the beginning. The aim of the steering group is not to create aspirational statements, nor develop new policies: instead, the steering group will address what we already have. This approach puts health in all policies into practice.

“The Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases, which is established by the European Commission in July 2018, is a new approach to non-communicable disease control in Europe. This approach is about health in all policies being integrated into practice.”

Through the best-practices portal – which is a part of this new approach – we make sure that the member states know which NCD interventions are available and which can be implemented. Preferably, these practices are already implemented in a country or region and, with some adaptation, can be implemented in other places. The best practice portal is more than just a collection of best practices, it also includes an evaluation, for which the assessment criteria are established by the steering group. Finally, the Commission provides funding to member states for the implementation of best practices

MD: NCDs are now on the political agenda, but winds might change. How can we keep NCDs on the national and European agendas?

MT: Commitment of member states is realised by having regular prioritisation exercises, where member states prioritise their own needs. There are already many agendas out there, such as the sustainable development goals (SDGs), so the steering group aims to support member states in achieving the targets and goals that are most challenging for them.

MD: What can we expect from the steering group in the future?

MT: Until today, the Health Programme was the main funding for health projects. But now, while we are moving towards the next multi-annual financial framework of the EU (2021-2027), this will change. The steering group will be the main mechanism. I’m here [at the European Health Forum Gastein] to tell everyone about the steering group and to bring forward our approach, so that it becomes clearer to organisations and other health stakeholders. It is a new approach and we are taking baby steps in the beginning. The positive feedback that we have received from the member states since the launch of the steering group is a clear indicator that we are using the right approach.

In the next multi-annual financial framework, health is incorporated in the ESF+ programme, within the so-called health ‘strand’ or ‘cluster’. As stated in the proposal for the ESF + programme, article 29 in particular, the steering group would mainly be responsible for the health strand, including the work plans, prioritisation, strategy and implementation of the public health activities in the EU.[i] We are aiming for a more upstream decision-making process in the future. This would mean that the steering group can steer financial resources based on member states’ health objectives.

By the way, 7.7 billion euros are set for health research in Horizon Europe [the new research cluster]. I don’t think people see the opportunities here.

The first formal meeting of the steering group – chaired by Martin Seychell – was held on 6th of November 2018. We also plan a joint meeting between the steering group and the current Horizon 2020 research programme committee in Brussels in early spring 2019. This is to facilitate discussions between the stakeholders from research and health on ministerial level and the different Commission services on where the synergies are. This is one concrete future step in making sure that our policies are aligned, and our objectives are in synergy.

This interview was conducted by a Young Gasteiner Maaike Droogers

[i] Article 29 of ‘Proposal for a Regulation of the European Parliament and of the Council on the European Social Fund Plus (ESF+) COM/2018/382’ suggests that the steering group could have an important role in the future ESF+ health strand. Available here, https://eur-lex.europa.eu/resource.html?uri=cellar:a39e5630-640f-11e8-ab9c-01aa75ed71a1.0003.02/DOC_1&format=PDF.  

[i] Webpage of the Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases is available here: https://ec.europa.eu/health/non_communicable_diseases/steeringgroup_promotionprevention_en

EHFG 2018 Hackathon

“I really felt the hackathon was incredibly well organised and enjoyable. We were surrounded by positive people looking after us and helping us the whole time and even before the results were known, the experience definitely made me want to take part in more of these kinds of hackathons in future.”

(J.H., Hackathon participant)

This year, the European Health Forum Gastein (EHFG) hosted its first hackathon, jointly organised with EIT Health and with the organisational support of PROIDEA. A hackathon nurtures competition built upon collaboration and aims for an acquisition of knowledge, which is expected to bring forward new ideas. The application call was open to anyone interested in developing innovative solutions for health-related problems. Continue reading

Commercial determinants of health and the global financial markets (P3)

Think bigger and think smarter!

Let´s make informed decisions and learn and change the market the healthier way! 

The final day in Gastein is coming to an end and we are at the Closing Plenary, where the focus is on the commercial determinants of health and the global financial markets.

In his opening speech, the EHFG President Clemens Martin Auer reminded us to think bigger, think smarter and be bold and bright, and with this good reminder we dived into the plenary. Martin McKee, the moderator, took over and gave us an insight into the plenary where the focus was on MONEY, investments, markets and of course health.

I have to use some of the space in this short blog to share the story of Dr. Bronwyn King (founder and CEO of Tobacco Free Portfolios) and her amazing journey. She started her talk by showing a short video about a Dutch patient who is suing a tobacco company for attempted murder and grievous bodily harm, and then explained her personal story, that started only about 8 years ago when she found out that her pension fund was being invested in tobacco stocks, and as a radiation oncologist who was trying to save the lives of patients often suffering from lung cancer that was usually related to tobacco use, she could not believe it and had to take action. Now, to cut a long story short, she took on the tobacco industry: this has lead to stocks dropping as well as to many pension funds, banks and other commercial organisations divesting from tobacco stocks. It truly was amazing to hear from a person who is so personally involved and it really made you sympathise with her cause. I think it is important for all the Young Gasteiners like myself, as well as for other figures in public health, to see and hear that there are individuals out there making a difference. But this is only the start, there is more to do and we need to move forward.

Continue reading