PROBLEMY EKOROZWOJU – PROBLEMS OF SUSTAINABLE DEVELOPMENT

The COVID-19 pandemic has revealed the insufficient capacities and capabilities of countries around the world to deal with global infectious diseases and stressed the need to improve the international health security framework. An efficient and comprehensive health system that is able to cope with public health emergencies is an essential prerequisite for strengthening health security. The paper analyzes the efficiency of health systems in the European Union (EU) countries and their responsiveness to the COVID-19 pandemic. The research covers 27 EU countries and it is based on the secondary data contained in the 2019 Global Health Security Index Report. The aim of the paper is to identify key determinants for improving the efficiency of health systems in the EU, as well as to examine the interdependence between health expenditures and the efficiency of health system in this sample of countries. The research is conducted through descriptive statistics and correlation and regression analysis. The conclusions can be useful for the EU policy makers in formulating a strategy to improve the efficiency of Member States’ health systems and preparedness for possible new pandemics.


Introduction
Human health and ways to protect and improve it can be interpreted as the basic goals of humanity and as central issues in the research of theorists and practitioners in various fields.According to the World Health Organization, health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.There is no doubt that humanity has significantly improved the quality of health in previous centuries.Today, most of the world's population has access to the water, sanitation, and hygiene.Numerous countries have built complex health care systems with the modern procedures and equipment that enable a healthy lifestyle of people.Global knowledge and experience in the field of health is expanding constantly and today is greater than ever before.However, health improvement is extremely unequal in a global perspective.For example, a child born in Hong Kong can expect to live more than 84 years, while life expectancy of his peer in Ukraine is 72 years, and less than 54 years if child is born in Central African Republic (United Nations, 2020).Such huge inequalities in life expectancy across countries cannot be clarified through biology.Differences in health conditions between (and within) countries are a consequence of the economic and social policies that determine the environment in which people are born, grow, live, and work (Council of Europe, n.d.).Namely, the life expectancy and health care quality of population largely depend on the level of economic and social development.The COVID-19 pandemic exposed the differences in the efficiency of health systems around the world, but also revealed the lack of global readiness to face public health emergencies.This pandemic has forced national economies across the globe to analyze their capacities and capabilities to prevent, detect, and quickly respond to the occurrence of infectious diseases and other acute forms of endangering the public health.Health systems that are able to respond effectively to such health threats have a significant advantage in reducing their negative health, social, and economic consequences.The paper evaluates the efficiency of health systems in the 27 European Union (EU) countries in terms of prevention, detection, and rapid response to the pandemics on the example of COVID-19.The goal is to determine key factors in improving the efficiency of health systems in EU countries and, thus, enhance the health security of their citizens for possible new pandemics.Also, the paper considers the impact of health expenditures in EU countries on the efficiency of their health systems.The research findings can serve as guidelines for health policy makers in all EU countries.The paper contains five separate segments.The first segment deals with the theoretical background and review of the literature on health security and effi-ciency of the health system.The analysis of determinants of health system efficiency in the EU countries is presented in the second segment of the paper.Research methodology and hypotheses are defined in the third segment.The empirical results of the research are presented and discussed in the fourth segment.The last segment provides the concluding remarks and recommendations for improving the efficiency of health systems in the observed countries.

Theoretical background and literature review
Despite the fact that statistics show that the rate of infectious diseases in the EU countries has been declining in recent decades, sudden health shocks in the previous period have confirmed that threats to public health in the EU and the rest of the world exist permanently.Theoretical and empirical studies in the field of health system efficiency and health security of national economies demonstrate that this topic has attracted special attention of researchers at a time when the world was facing global challenges to public health.The occurrence of these studies in the last two decades can be attributed to efforts to explore and learn lessons from the consequences of the aforementioned infectious diseases.However, due to its global population coverage and duration, but also extremely pessimistic predictions about its social and economic consequences, it seems that the COVID-19 pandemic has caused the greatest attention of the professional and scientific public in recent history.There is a broad consensus between researchers that the COVID-19 pandemic amplifies several problems of national economies and societies, which were serious and obvious even before (Anand et al., 2020;Ferrannini et al., 2021).A large number of studies published in the previous period (Jones et al., 2008;Morens et al., 2004;Morse et al., 2012;Webster, 1997) pointed to the catastrophic consequences that a possible global pandemic would have on international supply chains and cross-border economic cooperation, but also on individuals, welfare, and polices.Apparently, the COVID-19 pandemic threatens to exceed such predictions (Acemoglu et  ).The general conclusion of all mentioned studies is that the current health crisis will leave a deep mark in economic and social welfare on a global level, and that increasing the efficiency of health systems, which is reflected in the degree of resistance to such health shocks in the future, will be a necessary precondition for recovery and functioning in an international environment.
The concept of health system efficiency is quite controversial in practice and is very difficult to apply in a comparative analysis across countries (  & Hakkinen, 2009).Nonetheless, the health system efficiency is important as it seeks to capture the extent to which the inputs to the health system, in the form of expenditures and other resources, are used to secure valued health system goals (Cylus et al., 2017b: 7).It is the growing concern for policy makers and managers especially in the times of crises.

The analysis of determinants of health system efficiency in the EU countries
A) The analysis of financial support to the health system in the EU countries Financial support to the health system is an important prerequisite for its building and development.The level of health expenditures in a national economy depends on numerous demographic, social, and economic factors, as well as the financial concept and organizational structure of the health sys-tem itself.This clearly suggests that there are significant disparities in the level of health expenditures among countries in the EU.OECD and EU (2020) found that there is a strong correlation between national income and health expenditures, so high-income EU countries are typically those that spent the most on health.The same conclusion emerges from this paper through an analysis of health expenditures per capita in EU countries in the period 2014-2018 (Table 1 With average spending at $ 5,677 per person, Luxembourg was the largest spending country in the EU, followed by Germany ($ 5,517), Sweden ($ 5,410), Austria ($ 5,377), Netherlands ($ 5,342), Ireland ($ 5,311), and Denmark ($ 5,227).Spending levels in the seven mentioned EU countries were at least 50% above the EU average ($ 3,344).At the opposite end of the scale, Romania ($ 1,210), Bulgaria ($ 1,428), Latvia ($ 1,525), and Croatia ($ 1,628) were the lowest spenders in the EU region, with less than 50% of health expenditures compared to the EU average.Comparing the average annual investment in the health system of Luxembourg (as the leading EU country in terms of health expenditures) and Romania (as the country with the lowest health expenditures in the EU) shows a huge difference in financial support to health systems between EU member states.Namely, Luxembourg invested 4.7 times more in its health system in the observed period than Romania.Such large disparities in financial support to the health system over time necessarily lead to significant differences in health security conditions between countries.

B) The analysis of EU health systems responses to COVID-19
The COVID-19 pandemic is an unprecedented health, social, and economic shock that has surprised the world and the global economy.Countries across the EU region applied numerous and comprehensive responses to the virus, such as closing borders and total lockdown, but also providing masks, ventilators, and vaccines.However, coronavirus mortality and morbidity rates exist within the context of a national healthcare system and a population (World Bank, 2020).Out of 180 countries in the world for which the above statistics are monitored, Hungary took the 2nd place, Czech Republic 4th place, Bulgaria 8th place, Slovak Republic 11th place, Belgium 12th, Slovenia 13th, and Italy 14th place in terms of deaths per 100,000 population.Therefore, even seven EU member states are in the top 14 countries in the world according to the number of deaths per 100,000 population.These data clearly confirm that the COVID-19 pandemic has exposed the insufficient preparation and efficiency of some health systems in EU region to deal with major public health emergencies.

Methodology and hypotheses
The efficiency of health systems in the EU countries is observed through the prism of

H2.2. Health expenditure per capita has positive impact on the category Prevention of GHS index. H3: Investments in health system have positive influence on the category Health system of GHS Index. H3.1. Health expenditure as % of GDP has positive impact on the category Health system of GHS Index. H3.2. Health expenditure per capita has positive impact on the category Health system of GHS Index. H4: The level of detection of health system increases the number of confirmed COVID-19 cases. H5: The number of deaths from COVID-19 is influenced by the level of rapid response of health system and the number of confirmed COVID-19 cases.
For testing defined hypothesis regression and correlation analysis are performed.The list of used variables is presented in Table 3. tically significant (0.4958).Additionally, the positive strong statistically significant correlation exists between prevention and current health expenditure either as percent of GDP (0.6774) or per capita (0.5001).The correlation between Health System and current health expenditure as percent of GDP is positive, strong, and statistically significant (0.5957), while between Health System and current health expenditure per capita is positive, moderate, and statistically significant (0.4674).The correlation between current health expenditure as percent of GDP and confirmed cases is positive, moderate, and statistically significant (0.4373), while between current health expenditure per capita and deaths per 100,000 population exists negative, moderate, and statistically significant correlation (-0.4029).The regression results are presented in Table 6.First two models explain the effects of current health expenditures on GHS index.Model 1 analyses the impact of current health expenditure as percent of GDP (CHEgdp) on GHS index in 27 EU countries and confirms the positive and statistically significant impact as we expected.If the current health expenditure as percent of GDP increases by 1 percent, the GHS index will increase by 0.58 percent.The estimated model explains 37.43 percent change in GHS index and this model is statistically significant as confirmed by the F test (p<0.01).Model 2 explains the effects of current health expenditure per capita (CHEpc) on GHS index and also confirms the positive and statistically significant impact.If the current health expenditure per capita increases by 1 percent, the GHS index will increase by 0.16 percent.The estimated model explains 21.42 percent change in GHS index and this model is statistically significant as confirmed by the F test (p<0.05).The results of these models suggest towards accepting the H1.1.and H1.2.hypotheses, and hence towards overall accepting the H1 hypothesis.Following two models explain the effects of current health expenditures on Prevention.Model 3 analyses the impact of current health expenditure as percent of GDP (CHEgdp) on Prevention and confirms the positive and statistically significant impact as we expected.If the current health expenditure as percent of GDP increases by 1 percent, the Prevention will increase by 7.94 percent.The estimated model explains 40.95 percent change in Prevention and this model is statistically significant as confirmed by the F test (p<0.01).Model 4 explains the effects of current health expenditure per capita (CHEpc) on Prevention and also confirms the positive and statistically significant impact.If the current health expenditure per capita increases by 1 percent, the Prevention will increase by 0.19 percent.The estimated model explains 16.91 percent change in Prevention and this model is statistically significant as confirmed by the F test (p<0.05).Therefore, we can accept the hypotheses H2.1.and H2.2., and overall, the H2 hypothesis.
Next two models explain the effects of current health expenditures on Health System.Model 5 analyses the impact of current health expenditure as percent of GDP (CHEgdp) on Health System and confirms the positive and statistically significant impact as we expected.If the current health expenditure as percent of GDP increases by 1 percent, the Health System will increase by 8.42 percent.The estimated model explains 29.58 percent change in Health System and this model is statistically significant as confirmed by the F test (p<0.01).Model 4 explains the effects of current health expenditure per capita (CHEpc) on Health System and also confirms the positive and statistically significant impact.If the current health expenditure per capita increases by 1 percent, the Health System will increase by 0.23 percent.The estimated model explains 16.79 percent change in Health System and this model is statistically significant as confirmed by the F test (p<0.05).These results point towards acceptance of hypotheses H3.1.and H3.2. and hence, the H3 is confirmed as well.Model 7 analyses the impact of Detection on Confirmed cases of COVID-19.The results confirm that 1 percent increase in Detection leads to the increase in Confirmed cases by 1.85%.The estimated model explains 14 percent change in Confirmed cases and it is statistically significant as confirmed by the F test (p<0.10).Finally, Model 8 investigates the effects of Rapid Response and Confirmed cases on the Deaths per 100,000 population.The results show that 1 percent increase in Rapid Response leads to the 0.80 percent decrease in the Deaths per 100,000 population, while the 1 percent increase in Confirmed cases results in the increase of the Deaths per 100,000 population by 0.32 percent.The estimated model explains 40.89 percent change in Deaths per 100,000 population and this model is statistically significant as confirmed by the F test (p<0.01).These results enable us to verify the hypotheses H4 and H5.The results obtained in this study undoubtedly confirmed that investments in health systems are important in determining their overall efficiency and responsiveness to the pandemics.Higher investments in health systems improve the capacities and capabilities of the health systems to prevent, detect and rapidly response to the pandemics, thus strengthening the heath security of all citizens and reducing the number of deaths.These results correspond to the conclusions drawn by Dyakova et al. (2017: x) that investments for health and well-being are priority for strengthening public health systems, capacities and services to ensure national and global health security.Furthermore, the OECD (2020) study stresses the need to pursue the health system strengthening in parallel with the health security efforts for prevention, detection, and rapid response to pandemics in order to develop resilient health systems.Health systems resilience implies the capacities of the health institutions and stuff to effectively respond and manage crisis, without jeopardizing their core operations (Lal et al., 2021).The COVID-19 pandemic more than ever raised the question of aligning all health system capacities and capabilities towards preventing pandemics, while continuing principal health services at satisfactory level.

Conclusion
Global COVID-19 pandemic has raised the question of the efficiency of health systems around the world and their preparedness to deal with unforeseen events and circumstances.These issues have become even more important for policy makers and managers due to the financial concerns regarding the continuing economic sustainability and resilience of health systems.The countries' responses to COVID-19 have been diverse, mainly dependent on the resilience of their health systems, and are still contextual and ongoing issues.Considering all this, our intention was to contribute to the existing discussion and give insights regarding efficiency of health systems.We investigated the efficiency of the health systems in the EU countries, as well as their responsiveness to the COVID-19 pandemic.The efficiency of the health system is assessed based on the Global Health Security Index, as the overall measure, and its main categoriesprevention, detection, rapid response, and health system, showing the countries' readiness for prevention and mitigation of pandemics and other health threats.The key determinants impacting the overall efficiency of the health system, as well as prevention and health system capacity are investments in health system.The correlation analysis results determined positive, statistically significant correlation between health expenditures, either as percent of GDP or per capita, and GHS index, Prevention and Health System.The results of the regression analysis revealed positive, statistically significant impact of health expenditures on these efficiency measures.Hence, the first three hypotheses of this study were confirmed.Further, the results of the study determined the positive impact of detection capacity of health system on the confirmed cases of COVID-19 pandemics, as well as the impact of rapid response capability of the health system on reducing the number of deaths per 100,000 population.Thus, the last two hypotheses were also verified.As the level of health expenditures in an economy depends on diverse demographic, social, economic, and organizational factors, there are significant disparities among countries regarding the level of health expenditure.The analysis revealed that, although the health expenditures exhibit positive trend at an average rate of 3.7% per year for the period 2013-2018, the high-income EU countries invest more in their health systems, than the low-income EU countries.The comparison between the leading EU country in terms of health expenditures (Luxembourg) and the country with the lowest health ex-penditures (Romania) showed that investments in health system in Luxembourg are 4.7 times bigger than in Romania.Based on all the above mention, it is evident that empirical findings in this study could be valuable for policy makers in the EU countries in drafting strategies and defining measures and activities aimed at increasing the efficiency and responsiveness of their health systems.Significant attention should be given to the health systems funding, as it is proven that investments in health systems lead to their increased efficiency and resilience.Therefore, it is clear that building comprehensive health systems, with stable public financing and embedded core capacities, will provide the stronger resilience and defense against the future unpredictable pandemics.

Ancklowedgement.
The paper presents the results of research supported by the Ministry of Education, Science and Technological Development of the Republic of Serbia (Agreement No. 451-03-9/2021-14/200148).
Severe acute respiratory syndrome (SARS) in 2002, Swine flu pandemic (H1N1) in 2009, Escherichia Coli outbreak in Germany in 2011, Ebola virus disease in 2014, Zika in 2016, and, finally, COVID-19 in 2019 show that global threats through new infectious diseases can arise at any time and in any place.

Table 2 .
Table 2 presents data of John Hopkins University (2021) on confirmed cases and deaths due to the COVID-19 virus in EU countries.Confirmed cases and deaths due to the COVID-19 in the EU countries, source: John Hopkins University 2021

Table 3 .
List of used variables, source: authors' own work a

Table 6 .
Regression results