title: Policy challenges and reforms in small EU member state health systems: a narrative literature review.
abstract: The EU directive on patients' rights and cross-border care is of particular interest to small states as it reinforces the concept of health system cooperation. An analysis of the challenges faced by small states, as well as a deep evaluation of their health system reform characteristics is timely and justified. This paper identifies areas in which EU level cooperation may bring added value to these countries' health systems.
  
  
  
  Literature search is based primarily on PUBMED and is limited to English-language papers published between January 2000 and September 2014. Results of 76 original research papers appearing in peer-reviewed journals are summarised in a literature map and narrative review.
  
  
  
  Primary care, health workforce and medicines emerge as the salient themes in the review. Lack of capacity and small market size are found to be the frequently encountered challenges in governance and delivery of services. These constraints appear to also impinge on the ability of small states to effectively implement health system reforms. The EU appears to play a marginal role in supporting small state health systems, albeit the stimulus for reform associated with EU accession.
  
  
  
  Small states face common health system challenges which could potentially be addressed through enhanced health system cooperation at EU level. The lessons learned from research on small states may be of relevance to health systems organized at regional level in larger European states.
authors.affiliation: Department of Health Services Management, Faculty of Health Sciences, University of Malta c/o/Mater Dei Hospital MSD 2080 Msida, Malta natasha.azzopardi-muscat@um.edu.mt.|Department of International Health, CAPHRI School for Public Health and Primary Care, Maastricht University, 30 Duboisdomein Maastricht, The Netherlands.|Directorate for Health Information and Research, Ministry for Energy and Health, 95 G'Mangia Hill Pieta', Malta.
authors.forename: Natasha
authors.initials: N
authors.lastname: Azzopardi-Muscat
authors.affiliation: Department of International Health, CAPHRI School for Public Health and Primary Care, Maastricht University, 30 Duboisdomein Maastricht, The Netherlands.|Directorate for Health Information and Research, Ministry for Energy and Health, 95 G'Mangia Hill Pieta', Malta.
authors.forename: Tjede
authors.initials: T
authors.lastname: Funk
authors.affiliation: Department of Health Services Management, Faculty of Health Sciences, University of Malta c/o/Mater Dei Hospital MSD 2080 Msida, Malta.
authors.forename: Sandra C
authors.initials: SC
authors.lastname: Buttigieg
authors.affiliation: Department of Health Services Management, Faculty of Health Sciences, University of Malta c/o/Mater Dei Hospital MSD 2080 Msida, Malta.
authors.forename: Kenneth E
authors.initials: KE
authors.lastname: Grech
authors.affiliation: Department of International Health, CAPHRI School for Public Health and Primary Care, Maastricht University, 30 Duboisdomein Maastricht, The Netherlands.
authors.forename: Helmut
authors.initials: H
authors.lastname: Brand
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D005062:European Union / Q000458:organization & administration*; D018166:Health Care Reform / Q000458:organization & administration*; D006282:Health Personnel / Q000458:organization & administration; D006291:Health Policy; D006302:Health Services Research; D006801:Humans; D011320:Primary Health Care / Q000458:organization & administration; D013222:State Medicine / Q000458:organization & administration*