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The Ljubljana Charter on Reforming Health Care, 1996

The purpose of this Charter is to articulate a set of principles which are an integral part of current health care systems or which could improve health care in all the Member States of the World Health Organization in the European Region. These principles emerge from the experience of countries implementing health care reforms and from the European health for all targets, especially those related to health care systems.


1. The purpose of this Charter is to articulate a set of principles which are an integral part of current health care systems or which could improve health care in all the Member States of the World Health Organization in the European Region. These principles emerge from the experience of countries implementing health care reforms and from the European health for all targets, especially those related to health care systems.

2. This Charter addresses health care reforms in the specific context of Europe and is centred on the principle that health care should first and foremost lead to better health and quality of life for people.

3. The improvements in the health status of the population are an indicator of development in the society. Health services are important, but they are not the only sector influencing peoples’ wellbeing: other sectors also have a contribution to make and responsibility to bear in health, and intersectorality must therefore be an essential feature of health care reform.

4. In cognizance of this, we the Ministers of Health or their representatives from the European Member States of WHO (participants in the Ljubljana Conference) hereby pledge ourselves to promote the following principles and call upon all citizens and urge all governments, institutions and communities to join us in this endeavour. We further request the WHO Regional Office for Europe to take the necessary action to support Member States in giving effect to these principles.

Fundamental principles 5.

Within the European context, health care systems need to be:

5.1 Driven by values

Health care reforms must be governed by principles of human dignity, equity, solidarity and professional ethics.

5.2 Targeted on health

Any major health care reform should relate to clear targets for health gain. The protection and promotion of health must be a prime concern of all society.

5.3 Centred on people

Health care reforms must address citizens’ needs taking into account, through the democratic process, their expectations about health and health care. They should ensure that the citizen’s voice and choice decisively influence the way in which health services are designed and operate. Citizens must also share responsibility for their own health.

5.4 Focused on quality

Any health care reform must have as its aim - and include a clear strategy for - continuous improvement in the quality of the health care delivered, including its cost-effectiveness.

5.5 Based on sound financing

The financing of health care systems should enable such care to be delivered to all citizens in a sustainable way. This entails universal coverage and equitable access by all people to the necessary care. That, in turn, requires the efficient use of health resources. To guarantee solidarity, governments must play a crucial role in regulating the financing of health care systems.

5.6 Oriented towards primary health care

Reforms, with primary health care as a philosophy, should ensure that health services at all levels protect and promote health, improve the quality of life, prevent and treat diseases, rehabilitate patients and care for the suffering and terminally ill. They should reinforce joint decision-making by the patient and care provider and promote the comprehensiveness and continuity of care within their specific cultural environments.

Principles for managing change 6.

The following principles are keys to managing change effectively:

6.1 Develop health policy

6.1.1 Health care reform should take place as a coherent part of an overall policy for health for all which is consonant with the socioeconomic conditions of each country. This policy development process needs to be based on a broad consensus involving as many relevant social actors as possible.

6.1.2 Major policy, managerial and technical decisions on development of the health care system should be based on evidence where available. Reforms must be continuously monitored and evaluated in a way that is transparent to the public.

6.1.3 Governments must raise value-related issues for public debate and ensure equitable distribution of resources and access of the entire population to health services. They should also take facilitating legislative and regulatory initiatives. Whenever market mechanisms are appropriate, they should favour competition in ensuring quality and in using scarce resources.

6.2 Listen to the citizen’s voice and choice

6.2.1 The citizen’s voice and choice should make as significant a contribution to shaping health care services as the decisions taken at other levels of economic, managerial and professional decision-making.

6.2.2 The citizen’s voice should be heard on issues such as the content of health care, contracting, quality of services in the provider/patient relationship, the management of waiting lists and the handling of complaints.

6.2.3 The exercise of choice and of other patients’ rights, requires extensive, accurate and timely information and education. This entails access to publicly verified information on health services’ performance.

6.3 Reshape health care delivery

6.3.1 Self-care, family care and other informal care, as well as the work of a variety of social institutions, need to be brought closer together with the formal health care services. This requires continuous communication and appropriate referral and information systems.

6.3.2 Well designed strategies are needed to shift working capacity from acute hospital care to primary health care, community care, day care and home care, whenever necessary.

6.3.3 Regional health service networks need to be reinforced insofar as they are more cost-effective, allow for a better organization of the response to medical emergencies and facilitate cooperation between hospitals and with primary health care.

6.3.4 Continuous quality development in health care requires information systems based on selected quality indicators that can be abstracted from routine work and fed back to individual physicians, nurses and other health care providers.

6.4 Reorient human resources for health care

6.4.1 In the health services, greater attention needs to be paid to identifying and stimulating appropriate professional profiles that can be part of the multi-professional teams of tomorrow’s health care systems.

6.4.2 There is a need for a broader vision than that of traditional curative care in the basic training, specialization and continuing education of health care personnel. Quality of care, disease prevention and health promotion should be an integral part of training.

6.4.3 Proper incentives should be introduced to encourage health personnel to be more conscious of quality, cost and outcomes of care. Professional and payment organizations should cooperate actively with health authorities to promote such a development.

6.5 Strengthen management

6.5.1 There is a need to develop a set of managerial functions and public health infrastructures entrusted with the tasks of guiding or influencing the overall system to achieve the desired improvements in the population’s health.

6.5.2 Individual health care institutions should enjoy the maximum possible autonomy in management of their resources consistent with the principles of an equitable and efficient health care system.

6.5.3 Management development needs to be strongly promoted by strengthening individual capacities to lead, negotiate and communicate and by developing institutional tools to deliver health care more effectively and efficiently.

6.6 Learn from experience

6.6.1 There is a need to promote the national and international exchange of experience with implementing health care reform and supporting reform initiatives.

6.6.2 This support must be founded on a well validated knowledge base with regard to health care reforms, with cross-cultural differences in health care being properly understood and appropriately valued.

Note: This document does not confer legal rights.


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