Health System Performance Assessment: how equitable is the Belgian health system?

Abstract Access to and delivery of effective, high quality and affordable healthcare are fundamental objectives that have shaped health policy and the universal health insurance system in Belgium. A health system should be evaluated against these objectives. Monitoring equity within a health system - an equitable distribution of healthcare use and of payments for healthcare - is a core component of a health system performance assessment. We use the horizontal equity principle to evaluate equity in healthcare use in Belgium. Unfair inequality in healthcare use is measured by the fairness gap, comparing actual use and expected use corrected for needs. The empirical analysis was conducted using a linked dataset which contains data from the European Union Statistics on Income and Living Conditions (EU-SILC) and administrative data. Two sets of results are reported for a selected set of indicators of use: the deviation between the average fairness gap in the population and the average fairness gap in a subgroup of interest and an assessment of systematic socioeconomic inequity in the fairness gap using the absolute concentration index. We show that important socioeconomic inequities in healthcare use exist. Inequities differ by type of care, e.g., the use of hospital care and medications is more equitable than the use of GP, outpatient specialist and dental care. When accounting for healthcare needs, we find that use among high-income groups and individuals with a high educational attainment is higher compared to financially vulnerable groups (individuals at risk of poverty or with severe material deprivation, unemployed, singles). Also, individuals who are entitled to an increased reimbursement of healthcare costs, show a lower use of outpatient specialist care than expected based on their care needs. On the other hand, increased reimbursement is effective in improving accessibility to GP care, while for other financially vulnerable individuals we find a lower use of GP care.

Access to and delivery of effective, high quality and affordable healthcare are fundamental objectives that have shaped health policy and the universal health insurance system in Belgium. A health system should be evaluated against these objectives. Monitoring equity within a health system -an equitable distribution of healthcare use and of payments for healthcareis a core component of a health system performance assessment. We use the horizontal equity principle to evaluate equity in healthcare use in Belgium. Unfair inequality in healthcare use is measured by the fairness gap, comparing actual use and expected use corrected for needs. The empirical analysis was conducted using a linked dataset which contains data from the European Union Statistics on Income and Living Conditions (EU-SILC) and administrative data. Two sets of results are reported for a selected set of indicators of use: the deviation between the average fairness gap in the population and the average fairness gap in a subgroup of interest and an assessment of systematic socioeconomic inequity in the fairness gap using the absolute concentration index. We show that important socioeconomic inequities in healthcare use exist. Inequities differ by type of care, e.g., the use of hospital care and medications is more equitable than the use of GP, outpatient specialist and dental care. When accounting for healthcare needs, we find that use among high-income groups 15th European Public Health Conference 2022 and individuals with a high educational attainment is higher compared to financially vulnerable groups (individuals at risk of poverty or with severe material deprivation, unemployed, singles). Also, individuals who are entitled to an increased reimbursement of healthcare costs, show a lower use of outpatient specialist care than expected based on their care needs. On the other hand, increased reimbursement is effective in improving accessibility to GP care, while for other financially vulnerable individuals we find a lower use of GP care.
Abstract citation ID: ckac129.245 Piloting the first health system performance assessment for Germany: key results and learnings Miriam Blü mel M Blü mel 1 , M Achstetter 1 , P Hengel 1 , M Schwarzbach 1 , R Busse 1 1 Berlin University of Technology, Department of Healthcare Management, Berlin, Germany Contact: miriam.bluemel@tu-berlin.de

Background:
Health System Performance Assessment (HSPA) is a tool to monitor and evaluate the performance of health systems and to inform evidence-based policymaking. For the first time, a country specific HSPA is currently being piloted for Germany.

Methods:
The HSPA is based on a newly developed conceptual framework including nine dimensions (e.g., access, quality, efficiency, population health). Indicators were selected based on a systematic search of (inter)national studies and HSPA initiatives. Where possible, indicators were analysed in their development over time , in comparison to eight European countries (e.g., Austria, Denmark, France), and along up to seven equity dimensions (e.g., sex, age, income, education, region).

Results:
Overall, 90 indicators were included in the HSPA. Trend and equity analyses were possible for almost all and country comparisons for most indicators. A few indicators could not be analysed at all due to missing data. The overall HSPA provides an in-detail picture of Germany's health system. Access, for example, can be rated as good in Germany compared to the other countries, as insurance coverage and physician density are high, and unmet needs and waiting times for elective surgery are low. Results for quality are not as good, e.g., cancer survival rates, but most indicators show a positive trend. While population health outcomes are average in country comparison (e.g., fetal and infant mortality), resource input is comparatively high. Consequently, overall efficiency can still be improved (e.g., amenable mortality per total health expenditure).

Conclusions:
This first HSPA for Germany allows new insights to the performance of the German health system which are important for policy and research. While the pilot benefitted a lot from previous HSPA initiatives, data availability remains one of the biggest challenges.

4.K. Workshop: Promoting and enhancing health literacy through school interventions
Abstract citation ID: ckac129.246 The promotion and enhancement of health literacy in schoolaged children is an important public health and education goal. To ensure healthy behaviours and attitudes in adulthood, children and adolescents have to learn about health and wellbeing early in life. Toward this goal, schools are considered the most important setting to address health literacy. Interventions delivered in schools can reach all children regardless of their social, cultural or development background. In the education sector, health literacy interventions can address not only the skills, attitudes and knowledge of students, but that of teachers, principals, health and education staff, as well as the whole school setting. Health literacy is linked to education, while it mainly addresses how people manage health information. In this context, health literacy enables children and adolescent to find, understand and critically appraise health information and use it to guide informed health decisions and promote health behaviour. While this understanding targets personal competencies of individuals, health literacy is also directed towards the environment. For example, the concept of organizational health literacy aims at increasing health literacy capacities of the environment and within settings, such as schools. This makes health literacy an important concept at the intersection of behaviour change (agency: personal health literacy) and social change (structure: organizational health literacy). While the behavioural approach is most promising to equip students with the necessary skills to act as their own agents of health information management and improve their health agency capacities, the social approach further includes consideration of social determinants of health to provide child-and adolescent-friendly environments and conditions. Therefore, effective health literacy interventions should aim at combining behavioural and social approaches, especially in such vulnerable groups as children and adolescents. The purpose of this workshop is to present and discuss four interventions on health literacy drawing on behavioural and social sciences. (i) The first presentation will introduce the Health Literacy Toolbox for Schools (Tool-HLCA). (ii) The second presentation will introduce a school curriculum for classroom based Mental Health Literacy (HLCA-IMPRES). (iii) The third presentation will provide the organizational health literacy school intervention: Health Literate Schools (HeLit-Schools). (iv) The fourth will present applied data on mental health literacy in teachers and an instrument to measure action competencies of teachers with respect to promoting their students' mental health (MHAC). Each project will be given ten minutes to present their interventions and main findings, including time to discuss with the audiences and get feedback. The participants in turn will learn about recent empirical findings they can use in health literacy practice and policy. Key messages: Children and adolescent will benefit from early interventions to develop healthy behaviours and lifestyles in their lifecourse. Health literacy is an important school topic and should be addressed within behavioural and social approaches.