EU Health Forum

This paradigm shift was central to discussions at the EU Health Forum, where experts from healthcare, public policy, and industry addressed how to make systems both efficient, accessible, and financially sustainable. The key message: healthcare systems must stop being evaluated by how much they spend and start being assessed by the value they create for patients—above all, by treatment outcomes.

“Croatia ranks near the bottom of the European scale in life expectancy. Cardiovascular diseases and cancer together account for three out of five deaths, while the prevalence of diabetes stands at 7.7%, further highlighting the need for prevention, early diagnosis, and long-term disease management. Rates of preventable mortality are high, and Croatia performs below the EU average in smoking, obesity, and alcohol consumption. However, significant improvements in population health are achievable through targeted action in three areas: reducing smoking, preventing air pollution, and strengthening vaccination as one of the most cost-effective public health measures,” warned dr. Bernd Rechel, co-author of the State of Health in Croatia report, a joint publication of the European Observatory on Health Systems and Policies, the OECD, and the European Commission.

“Healthcare is no longer just a social system - it is part of national security infrastructure. The question is not how much we spend, but how the system is organized. A shift is needed from treating disease to managing health - integrating data, coordinating care, and measuring outcomes rather than activities,” emphasized State Secretary at the Ministry of Health, Marija Bubaš. She added: “There is no sustainable healthcare without fiscal logic, and no sustainable fiscal policy without a healthy population. Fiscal policies must therefore include prevention, regulation of risky behaviors, and incentives for healthy choices.”

No Data, No Management

Systematic measurement of treatment outcomes was highlighted as a key prerequisite for transforming the system. It is essential to develop outcome-based payment models, where therapies are financed according to their real effectiveness for patients. The establishment of a national oncology network represents a major step forward: by connecting hospitals, standardizing treatment, and transparently monitoring outcomes, conditions are created for higher-quality care and more accountable management of public funds, emphasized Igor Lerman, Director of IQVIA Adriatic, noting that implementation of the oncology network could be completed by the end of June.

Commenting on the impact of the High-Cost Medicines Fund, whose budget now stands at €400 million, Lerman warned: “Spending does not correlate with treatment outcomes. Croatia ranks among the highest in terms of doses consumed, yet we are the second worst in the EU in survival rates. This indicates inefficiency. The issue lies in system design and management - not in funding or workforce.”

Urban Wastewater Treatment Directive – A Risk to Medicine Availability

One of the EU Health Forum topics was the EU Urban Wastewater Treatment Directive. While the Directive has a legitimate goal of protecting the environment and public health, there is growing concern that its implementation could have serious unintended consequences for medicine availability and the sustainability of healthcare systems. Under the Directive, pharmaceutical and cosmetics manufacturers would be required to cover at least 80% of the total cost of quaternary treatment, with the greatest burden falling on generic medicine producers.

The key issue lies in the assumptions behind the Extended Producer Responsibility (EPR) model and the European Commission’s calculations. While EPR typically assumes that producers can reduce environmental impact by altering products or processes, this is not feasible for medicines. Furthermore, the vast majority of pharmaceutical residues in wastewater result from patient use, not manufacturing processes.

This is supported by data: European Commission estimates suggest pharmaceutical residues may account for up to 66% of micropollutants, while some models indicate that a small number of medicines account for most of the estimated “toxic load.” However, available laboratory data suggest their actual share is significantly lower - in some cases below 1%. At the same time, cost estimates for implementing the Directive vary widely. In the Netherlands, for example, annual costs are estimated at around €400 million - up to six times higher than initial European Commission estimates. Additionally, calculations suggest that some medicines could increase in price by up to 900%.

Generic medicines, which account for around 70% of all therapies in Europe but less than 20% of total expenditure - often priced below €3 per month - are particularly vulnerable.

“Manufacturers are committed to environmental responsibility and already invest in advanced treatment systems. However, unlike other industries, they cannot significantly alter product composition or manufacturing processes without compromising safety and efficacy. This is not an industry seeking exemptions, but one that provides the majority of therapies in Europe - cost increases of this magnitude simply cannot be absorbed,” stated Ana Gongola, President of the Croatian Employers’ Association – Pharmaceutical Industry Association.

It was emphasized that Europe must not be forced to choose between environmental protection and a stable supply of medicines. A solution must be found that enables both, but it must be proportionate, feasible, and based on real data.

“If additional costs become too high, some medicines could become economically unsustainable, with risks of product withdrawals, shortages, closure of production lines in Europe, and relocation of manufacturing to third countries,” warned Nikolina Dizdar Čehulić, CEO of Pliva, noting that smaller markets like Croatia are particularly vulnerable, where access to certain therapies is already under pressure due to low pricing.

In light of increasing global risks, ensuring the stability, resilience, and sustainability of Croatian and European healthcare systems - and the reliable supply of medicines to patients - requires maintaining, modernizing, and strengthening pharmaceutical production as a strategic industry and critical infrastructure within the European Union. The upcoming Critical Medicines Act (CMA) aims to achieve this. Key tools under the CMA will include the use of non-price criteria in public procurement that value a significant share of medicine production within the EU, the adoption of multi-winner procurement models for the same tender, and preferential co-financing of strategic pharmaceutical manufacturing investments from national and EU funds. The Urban Wastewater Treatment Directive should therefore actively support the achievement of these objectives.