Congress report - European Health Forum Gastein

Transcription

Organiser:
International Forum Gastein
Co-organisers:
Federal Ministry for social Security and Generations
Austrian Broadcasting Corporation (ORF)
EU Committee of the Regions
With the support of:
European Commission, DG for Health and Consumer Protection
European Commission, DG Information Society
World Health Organisation, Regional Office for Europe
Federal Ministry for Economy and Labour
Land Salzburg
Programme co-ordinator:
Paul Lincoln, National Heart Forum, UK
Programme organisers:
Philip C. Berman and Paul Belcher, European Health Management
Association (EHMA)
Maggie Davies, NHS Health Development Agency (HDA), England
Michael Hübel, European Commission, DG for Health and
Consumer Protection
Genon Jensen, European Public Health Alliance (EPHA)
Monika Kaiser, Gesellschaft für Versicherungswissenschaft und
gestaltung (GVG) Cologne, Germany
Jerry O’Dwyer, Haughton Institute, Ireland
Matthias Schuppe, International Forum Gastein (IFG)
Publisher:
Günther Leiner
Tauernplatz 1,
A-5630 Bad Hofgastein
Austria
www.ehfg.org
Editors:
Günther Leiner
Matthias Schuppe
Christoph Köstinger
Co-editor:
ISBN-N° 3 – 9500989 – 3 - 3
Printed in Austria 2002
Congress report
European Health Forum Gastein
2001 (EHFG)
Bad Gastein / Austria
26 to 29 September 2001
Integrating Health across Policies
Creating a better Future for Health in Europe
www.ehfg.org
Organiser: International Forum Gastein
Co-organisers: Federal Ministry for social Security and
Generations
Austrian Broadcasting Corporation (ORF)
with support of:
European Commission, DG Health and Consumer Protection
European Commission, DG Information Society
World Health Organisation, Regional Office for Europe
Federal Ministry for Economy and Labour
Land Salzburg
The International Forum Gastein gratefully acknowledges the vital contributions, efforts and
achievements of our co-organisers and members of the advisory committee of experts which
have been instrumental in planning and organising the 4th European Health Forum Gastein
2001.
We would like to thank the following institutions, organisations and companies for their
expertise, generous support, sponsorship and fruitful co-operation which makes the
European Health Forum such a successful event and without whom we would not have been
able to realise our goals. We are looking forward to continue this partnership on our way
towards
Creating a better Future for Health in Europe.
Supporters:
European Commission
WHO – Regional Office for Europe
Austrian Ministry for social Security and Generations
Austrian Broadcasting Corporation
Austrian Ministry for Economic Affairs
Land Salzburg
Communities Bad Hofgastein and Bad Gastein
Sponsors & Hosts:
Austrian Airlines
BSMG Worldwide
Bundesverband der Pharmazeutischen Industrie, Deutschland
Casinos Austria AG
CEPCO Holding AG
Department of Health (England)
Engelhorn Foundation for Rare Diseases
Gasteiner Bergbahnen AG
Gasteiner Quellversand
Gasteinertal Tourismus GmbH
GlaxoSmithKline
Hauptverband der Sozialversicherungsträger Österreichs
Interpharma
Kur- und Tourismusverband Bad Gastein
Kur- und Tourismusverband Bad Hofgastein
Kur- und Vitalzentrum Bad Hofgastein
Lauda Air
Merck, Sharp & Dohme (MSD)
Mobilkom Austria
Österreichische Ärztekammer
Österreichische Lotterien
Pharmig
Salzburger Nachrichten
Serono International S.A.
Telekom Austria
Tyrolean Airways
Supporting & Associated Organisations:
Boehringer Ingelheim, Österreich
Deutsche Krankenversicherung AG
European Federation of Medical Informatics
Fachverband der chemischen Industrie Österreichs, Gruppe Pharmazeutika
Hilfswerk Austria
Oesterreichische Nationalbank
Wirtschaftskammer Österreich
Thank you very much for your confidence and for taking the chance of working with us
towards the realisation of the European Health Forum Gastein
Co-organisers
Sponsors
7
Table of Contents
Table of Contents
TABLE OF CONTENTS
PREFACE
7
12
David Byrne
Herbert Haupt
Reinhart Waneck
Günther Leiner
12
13
15
16
GASTEIN HEALTH DECLARATION
18
OPENING CEREMONY
25
Words of Welcome
Herbert Haupt
Gyula Pulay
James Walsh
Günther Leiner
PLENARY SESSION I + II
25
26
28
29
33
The Work of WHO in Championing Health in Development
David B. Evans
33
Investing in Better Health in Wales
Jane Hutt
34
The Potential and Limitations of Health Impact Assessment
Roscam Abbing
39
Progress and prospects for promoting and protecting health across EU policies and actions
Bernard Merkel
Establishing Health as a Key Component of Economic Policy
Sarah Burns
The WHO Investment for Health Project and the Verona Initiative (*)
Erio Ziglio
Introduction to Parallel Forum Sessions
Paul Lincoln
FORUM I: HEALTH IN OTHER POLICIES AND SECTORS
Bridging the Gap from Policy to Practice and Awareness
John Bowis
Does the media have a role in promoting health policy and bridging the gap between
policy and implementation? PR or “ER”?
Shirin Wheeler
International Forum Gastein, Tauernplatz 1, A-5630 Bad Hofgastein
Tel.: +43 (6432) 7110-70, Fax: Ext. 71, e-mail: [email protected], website: www.ehfg.org
39
39
48
66
67
67
71
8
European Health Forum Gastein 2001
Carlos Ribeiro
71
The Swedish Experience
Bosse Pettersson
71
The Experience in Wales
Mike Ponton
72
Measuring Progress and Impact
Mojca Grunter Cinc
Luigi Bertinato
73
74
Summary Report of Forum I
Cecily Kelleher
75
FORUM II: GLOBALISATION, WORLD TRADE AND HEALTH 81
Introduction - Health and Free Trade Conflict or Synergy
Julius Weinberg
81
The stakeholders - Statements on organisational and professional interests
Nina Hvid
Mehtab Currey
Mihaly Kökeny
Ron Labonte
Maurice Mittelmark
84
84
84
85
87
The expert witnesses: European Trade policies and their impact upon health
Paul Strickland
88
The role of international agencies in health protection and in developing health positive
trade policies
Robert Beaglehole
The role of health issues in multilateral trade agreements
Rolf Adlung
The role of commercial enterprises in health
Petra Laux
Summary Report of Forum II
Julius Weinberg
FORUM III: HEALTH AND THE SINGLE EUROPEAN
MARKET
91
93
96
97
101
Introduction: The European Union and health care
Philip Berman
The labour market for doctors and nurses
Bie Nio Ong
Annette Kennedy
Public procurement of goods and services: a legal analysis of the Spanish case:
Fernando Silio
Soren Berg
101
101
112
121
141
The free movement of patients
Matthias Wismar
Alain Coheur
The SEM and health care – policy conclusions from the EHMA project
Reinhard Busse
Summary Report of Forum III
Philip Berman
142
143
158
161
9
Table of Contents
FORUM IV: BUILDING A HEALTHY COMMON
AGRICULTURAL POLICY (CAP)
166
Shifting CAP's objectives to the provision of healthy, sustainable food production and
safeguarding the health and vitality of rural communities and landscapes
Aileen Robertson
166
Local level: Using urban agriculture and local sustainable food production to safeguard
food security, reduce health inequalities and preserve cohesion in rural communities
Jeannette Longfield
172
National level: Austrian farmers call for a radical change in CAP to provide healthy food
Elisabeth Baumhoefer
EU level: Interpreting the multifunctional role of agriculture and rural development
across Europe
Elisabeth Guttenstein
The EU farmers’ views on the development of the CAP
Anton Reinl
173
174
177
European level: European supermarkets set standards for their suppliers in response to
growing consumer demand for environmentally sustainable and pesticide free products
Nigel Garbutt
Summary Report of Forum IV
Mike Rayner
FORUM V: THE INFORMED PATIENT / CITIZEN: A NEW
PARTNER IN THE POLITICAL HEALTH ARENA
What are the information needs of citizens? Results from research & academia
Angela Coulter
The Right to Health and Patients’Rights: Population-based assessment
Anne Brunner & Manfred Wildner
Information needs: Results from a Spanish study
Albert Jovell
The advocacy work of the Italian Tribunal
Theresa Petrangolini
The European Experience with examples from the UK
Rodney Elgie
The US-Experience
David Lansky
How to involve citizens in health policy development and implementation? Current
activities of the European Community
Walter Baer
180
181
184
184
184
193
194
201
204
206
Summary Report of Forum V
Stipe Oreskovic
FORUM VI: HEALTH IN THE INFORMATION AGE –
HEALTH TECHNOLOGY AND POLICY DEVELOPMENT
Visions of eHealth – revisited
Ricky Richardson
Providing eHealth Services in Europe : A case study
Carl Brandt
214
225
225
226
10
Online information system for rare diseases in Europe
Michael Schubert
237
NHS Direct
Bob Gann
239
Legal aspects of eHealth
Petra Wilson
239
Quality of health information on the Internet - Moderated Panel Discussion:
Statements of professional interest
Albert van der Zeijden
Charlotte de Roo
Michèle Thonnet
Petra Wilson
243
243
243
244
The French experience
Michèle Thonnet
244
The German experience
Otmar Kloiber
244
Summary Report of Forum VI
Rolf Engelbrecht
PLENARY SESSION III
245
251
Marc Danzon
251
Reinhart Waneck
251
Health across other policies
David BYRNE
SPECIAL INTEREST SESSIONS
257
263
Public Health Research and the Proposal for a new Framework Programme on Research
Kevin McCarthy
Summary Report of Workshop II: EUEnlargement: Implications for Health Systems
Laura MacLehose
263
265
FINAL PROGRAMME 2001
276
LIST OF AUTHORS, WHO IS WHO
287
LIST OF PARTICIPANTS
297
Table of Contents
11
The views presented in this publication are those of the authors and not necessarily those of
the organizations for which they work!
12
Preface
David Byrne
In 2001, the European Health Forum Gastein drew our attention to
one of the crucial challenges of health policy making in Europe: the
need to integrate health issues across different areas of policy. This
volume brings together the different presentations and contributions into a useful
background document on this important topic.
It is important to recognise that the health of our citizens is not only – and perhaps not even
primarily – influenced by decisions taken in the health policy sphere. This is why we have to
understand how decisions in other policy areas – such as economic and social policy or
environmental and agricultural policy – impact on public health and how conversely, these
policies can contribute towards achieving a high level of health protection in Europe.
The 2001 Gastein Forum focussed on a number of key areas of policy which are particularly
important in this respect: trade and health, the Single European Market, the Common
Agricultural Policy and health and information technology. The message is encouraging and
deserves to be spread: there is considerable scope for health gain if health considerations
are systematically taken into account when taking decisions on policy orientations.
Implementing this conclusion must be a clear priority for policy makers at all level of
government.
Within the European Community, we have made considerable progress in this respect. Health
plays a central role in most of the Commission’s cross-cutting policy initiatives. Let me give
three examples. First, the Community’s sustainable development project, where health is
mentioned as one of four major challenges our societies are facing. Second, e-Europe, which
promotes the use of IT in different areas of European societies, includes a large health
chapter; and third, in the Community’s enlargement process, health issues are being actively
taken into consideration.
But much more needs to be done, and the proceedings of the 2001 EHFGH published in this
volume provide ample illustration of some of the problems we have to address. There is still
a lack of awareness about the relevance of other policies to health, and much too little cooperation across government services to address shortcoming. Often, health enters the
political agenda too late, and with a limited focus on specific health threats. Protecting and
improving health is a vast challenge which requires intensive political commitment. The EHFG
provides ammunition needed to secure the necessary support.
The Gastein conference has again proven its worth in providing a platform for discussions,
reflections and encounters between different partners interested in health across Europe. Its
real value lies in providing opportunities for an all-European dialogue across the boundaries
of day to day work. This book captures some of this unique Gastein spirit, and should be
required reading for policy makers across Europe
David Byrne
European Commisioner for Health and Consumer Protection
Preface
13
Herbert Haupt
The “European Health Forum Gastein” is a conference that goes beyond the confines of the
European Union and the barriers of societal sectors and sets health political accents for the
21st century. Since 1998 international health experts from politics, science, industry and
patients’ organisation have found an interdisciplinary platform for a responsible dialogue on
an integrated health policy in Europe in Bad Gastein.
The question of responsibility for health has, in the course of political history, found many
different responses. Nevertheless we see that today in all European states, health is
understood as a task for the whole of society.
The debate has taken on renewed topicality, regarding personal and social responsibility for
health, through the intensification of attempts for reforming the health system over the last
ten years. Aims such as securing quality, increasing efficiency and keeping costs down in the
health system are seen in the context of the participation of the individual for their own
health. Through a discussion on sustainable strategies which consider health and social
aspects, the aim of health policy on an European level begins to take shape and reach a
wider audience.
The question of the importance of market mechanisms or state driven initiatives in health
policy does not only have an economic component. It reflects also the different positions in
responsibility for health. On the road to the future therefore we need a social policy which
promotes health so that different parts in society can become conscious of their
responsibility for health and accept this challenge.
In Austria even in the 19th century, medics did not only work on cures for the day but also
sought long-term improvements in living conditions and hygiene. The “Public Health”
movement of the last decade is new, however, since it sees health as an increasingly
complex system that is understood as requiring its own interdisciplinary multiprofessionalism. The interrelationship between the origins of illness and of environmentlinked and chronic sickness are more complex than the field of illnesses concerned with
infections. This means that the public responsibility for health in some areas must be newly
defined.
Our aim is to give people through the promotion of health optimal forms of therapy and to
provide the maximum orientation in the health system for patients. We also want to
strengthen an awareness of issues related to health in areas such as work, economy, the
environment, transport, education and environmental protection.
14
Only if we work together we will succeed in securing a healthy quality of life for ourselves
and in the future for our children. In this way we can make the promotion of health a
political issue for the whole of society. This year the “European Health Forum Gastein” is
once again concerned with finding trans-national solutions for the important questions in
European health policies. In the European Union much has been done in recent years to
strengthen awareness in the interest of the needs of health requirements. I am optimistic
that through joint efforts we will succeed in overcoming regional obstacles to make health
policy truly healthy politics.
Herbert Haupt
Federal Minister for social Security and Generations
Preface
15
Reinhart Waneck
For some years now, Health Ministers from EU-states have shown the
political determination to gain more influence concerning healthrelated decisions which are being made in other political areas. It is a
positive development that the topic “Integrating Health across
Policies“ was debated in such an open, professional and futureoriented way during the European Health Forum, Gastein 2001.
But the question has to be raised, if Health Ministers have been successful in their efforts in
the past years? To a certain degree the answer is “yes“. As is well known, the legal basis has
been extended in the Amsterdam Treaty and topics have become much broader with regard
to the content, but an the other hand it has not been possible on an EU-level to gain
decisive influence an decisions being made by other departmental cabinet councils; not to
mention the securing of a right of say.
Now as ever, Health Policy is primarily a national competence, and on a European level more
intensive co-operation, as well as the handing over of competences only takes place on
certain conditions. Quite symptomatic of the hard struggle to reach a joint basis for a
European Health Policy is the long-drawn-out history (of origin) of joint European Health
Policy Strategies with the addendum Public Health.
Substantiated by the fact that health is an important economic and employment factor, too the trend has emerged that health-questions especially the ones concerning financing and
Health Insurance are being discussed also under the visual angle of the European (domestic)
market. Regarding the dissolution of national structures and the “growing-together“ of
member states, these discussions are certainly not insubstantial, but they should not remain
the sole “pan-European“ aspect of Health Policy.
“Integrating Health across Policies“ is a topic that deserves to be continued at the next
European Health Fora in Gastein, especial in regard to the fact that at the EHFG 2001 only
parts of the relevant policies were being discussed.
Reinhart Waneck
State Secretary for Health
Ministry for social Security and Generations
16
Günther Leiner
Environmental factors, lifestyle, nutrition or the workplace are
fundamental determinants of the health status of an individual. For this
reason health policy can not be seen in isolation, but has to be
recognised in its social and economic environment. If we believe that
health protection and promotion ought to be the aim of health policy
then “healthy” policies also have to be implemented across other
policy areas.
By choosing the general theme of "Integrating Health across Policies", this year we have
addressed one of the key issues of European health policy. This concept of health as a
multisectoral issue is proof of a new awareness that successful health policy requires
approaches reaching across disciplines and sectors. Therefore, just as in other areas,
networked thinking and acting is becoming increasingly important.
Only an interdisciplinary and intersectoral approach can lead to successful solutions. This
does not only apply to the delimitation of policy areas but also to the fact that many
problems can no longer be regarded from a strictly national perspective. A crisis like, for
instance, BSE, requires actions reaching beyond individual policy areas and national borders.
The principles of the four freedoms as implemented in the Single European Market are
becoming more and more relevant in the health field. As a result, the borders between EU
level and national policies are becoming increasingly permeable.
At the 4th European Health Forum Gastein many speakers, amongst them Commissioner
David Byrne have critically assessed the role the European Court of Justice plays in defining
the application of single market legislation to health issues. The Court has moved to fill the
vacuum Member States have left by neglecting the possible effects of single market
interventions on health systems. By doing so the Court has de facto assumed the position of
a policy maker in the health field.
As a politician I am clearly not very comfortable with a situation in which the judiciary
defines policy goals on a regular basis. Therefore I warmly welcome the increased attention
given to health policy matters by the Council and the European Commission through the
practical implementation of the new EU health strategy and the consideration of future
developments in health care and care for the elderly. Hopefully this will result in the reestablishment of a leading and pro-active role for politics rather than the current muddling
through approach
As a physician I hope that these new initiatives will quickly translate into concrete benefits
for patients. It has been confirmed again in this years Forum that health services in Europe
need to become more patient oriented. Experts indicated that health systems can only be
further developed if the communication chain between politicians, providers, and patients or
all citizens is improved. Therefore, in terms of practical benefits I also welcome the
introduction of a European health card which Commission President Romano Prodi
announced recently. However having been involved with the legislative process of
introducing a health card in Austria I believe that the European card needs to become more
than just a replacement for the E111 and other forms. Should the European card become of
real value to citizens and patients it will need to integrate the various national health card
initiatives. Only by integrating medical data and in particular emergency information the card
Preface
17
will be of real (life saving) use for patients. This Forum and previous events have assessed
eHealth issues in detail. The technical solutions are there. What currently lacks is political
will. For the benefit of patients we should have the courage to implement these solutions.
Günther Leiner
Presiden
18
Gastein Health Declaration
European Health Forum
Gastein 2001
Creating a better Future
for Health in Europe
Bad Hofgastein, 29 September 2001
Gastein Health Declaration 2001
19
A MESSAGE FROM THE PRESIDENT ON INTEGRATING HEALTH ACROSS POLICIES AND
SECTORS.
The European Health Forum Gastein.
The European Health Forum at Gastein is a unique annual event, which brings together
experts, interest groups and politicians from across wider Europe to debate topical health
issues. The main stakeholders that form the pillars of Gastein are politicians, the health
sector, civil society represented by NGO’s, academics and the private sector. A significant
outcome of these events is a statement of observations, conclusions and recommendations
emanating from the discussion from the EHFG president to those with Governance
responsibilities in Health Policy Development and Implementation. This statement is
disseminated to key institutions such as those of the EU and member states and regions to
maximise impact. Subsequently, these recommendations are supported by the publication of
a full report of the scientific presentations.
The organising theme this year was “Integrating Health across Policies”. Six parallel Fora
were organised around the theme. Practical experiences at the national and regional levels,
the Common Agricultural Policy, international trade and globalisation, and the Single
European Market and information developments were all included. The Fora provided the
participants with an opportunity to learn about the policy issues, practical developments,
and to become more familiar with innovations. It enabled politicians and other stakeholders
to review the evidence and seek perspectives across a broad range of sectors on
recommendations of their interest.
The main observations of the six parallel Forum for this year are grouped below. Our hope is
that you find them timely and useful in application to your responsibilities for health
development.
Each Forum considered the implications for health and health systems and services at the
individual level as well as at the local, regional, national and supranational levels. The
EHFG includes the 51 countries within the WHO European area i.e. the EU and accession
countries, Central and Eastern Europe and the EEA countries. Every effort is made to ensure
that all of the different interests and perspectives are covered.
Günther Leiner,
President,
European Health Forum Gastein
The EHFG declaration does not necessarily reflect the views of all participants.
A publication of all scientific papers can be ordered from the International Forum Gastein.
Abstracts and Presentations are available at www.ehfg.org
20
1.) General EHFG observations and recommendations
Integrating health across policies is an issue that has now moved centre stage. Citizens and
the public at large will judge politicians and organisations by their ability to place health at
the Centre of other policies.
a.) Principles for promoting health across policies and sectors
The EHFG elaborated the following principles for promoting health across other policies and
sectors:
•
Health should be the driving force shaping economic and social development and be
considered as a public good and societal investment.
•
Health is an ideal vehicle for building good governance, effective organisations and
social cohesion.
•
Health policy should be transformed from a reactive into a proactive force for shaping
society.
•
The promotion and protection of health should be routinely considered in all policy
areas and sectors.
•
Health policy should always consider the wider determinants of health and public health
should routinely be considered when reforming and developing health systems and
services. Health policy should consider the right mix of “upstream” and “downstream”
solutions
•
Health should be regarded as a core component at the heart of sustainable development
and economic policy.
•
“Joined up working” across sectors, settings, disciplines policies and programmes for
health should become standard practice.
•
Actions to promote the public health should be genuinely consultative and transparent.
•
Governance and accountability for health and its determinants should be clearly and
publicly defined.
•
Health policies should consider the global dimension and be characterised by a sense of
social responsibility.
•
Organisations should ensure that policies and programmes narrow and do not widen
health inequalities.
b.) Other general EHFG observations and recommendations
•
A special international expert committee (similar to the WHO Commission on
Macroeconomics and Health) should be established to comprehensively review the links
between health, economics and sustainable development policy for Europe, European
countries and citizens.
•
Academic (Health) economists should be encouraged to undertake more studies on
macroeconomic issues.
•
The precautionary principle for protecting and promoting health should be applied
across all policy areas and sectors.
21
•
Health impact assessments should become standard practice for all relevant policy
developments and programmes.
•
The EU and national governments should ensure that sustainable development
incorporates health as a fundamental component in all such considerations.
•
Policies in the public and private sectors should
impact on health and development.
•
New forms of promoting health literacy for the public should be piloted and developed
that include the determinants of health as well as the beneficial use of health services.
be independently audited for their
2.) Specific Forum observations and recommendations
Forum I:
Health in other Policies and Sectors
•
Health policy should be developed according to the principles and mechanisms set out
in the WHO’s Ottawa charter for health promotion (1986), (i.e. it should include the 5
key dimensions of building healthy public policy, strengthening communities,
reorientating health services, promoting healthy lifestyles and creating supportive
environments.)
•
The WHO Ottawa health charter (1986) should be updated in relation to a. the health
impact of globalisation and b) the reduction of poverty and other determinants of health
inequalities.
Forum II:
Globalisation, World Trade and Health
•
There is a need for greater plurality and balance between nation states, corporations
and civil society in the development process for international trade agreements.
•
Health and human development goals should be central to the development of
international trade agreements.
•
The principles of transparency and accountability are essential components of
international trade.
•
Urgent funding is required for research into the interaction between trade and health
and on the health impact of international trade agreements.
•
Urgent measures are required to develop a critical mass of researchers on international
trade and health and globalisation at national and international levels.
•
There is an urgent need to develop and accelerate training for policy experts and
influencers, both within and outside health and across sectors in trade/health
interactions.
Forum III:
•
Health and the Single European Market
There is a need for the EU to monitor the impact of the SEM in respect of:
o
The labour market and movement of doctors and nurses.
o
Patient movement across national borders.
22
The impact of the SEM on candidate countries, especially in relation to financial
differences, loss of trained professionals and patient influx as a consequence of
areas of expertise and lower costs.
o
•
Making “Citizens Europe” a reality for health the major pillar of the new EU health
strategy.
•
Article 152 of the Amsterdam Treaty should be revised to allow SEM issues to be
considered in a health context.
•
The Directorate General for Health and Consumer Protection needs to take leadership of
SEM discussions and other crosscutting health issues such as trade and competition
policy and advising on universal minimum standards for health services.
•
There should be more SEM policy – relevant research within the 6th research framework
programme.
Forum IV:
Building a healthy Common Agricultural Policy
•
It should be universally affirmed that a “multifunctional” agriculture should incorporate
health objectives.
•
The European Commission should publish its Action plan on Nutrition Policy by the
spring of 2002.
•
An inter-service working group should be established on the Common Agricultural (and
food) Policies which should consider farming and food policy and health.
•
The Common Agricultural Policy should promote the consumption of fruit and
vegetables.
Forum V:
The Informed Patient/Citizen: a new partner in the political health arena
The development of new technologies and information systems in the past two decades has
led to an increase in patient power and participation in decision making and increased
informed choice and consent.
•
Health care systems should be reoriented away from the needs of institutions,
procedures and technology towards being centred around the relationship with the
patient and citizens they are there to serve.
•
The crisis in healthcare could be remedied to some extent by patient participation in
evidence based decision- making.
•
Regional, national and international institutions, governments, NGO’s and private
corporations working in healthcare should consider their involvement in:
o
Supporting research to increase the body of knowledge about civic
participation in health and healthcare.
o
Developing supportive mechanisms to increase the availability of balanced,
accurate and comprehensive health information to patients and citizens.
o
Introducing mechanisms to support a change in the traditional frame of
reference of perception about the roles of professionals and patients in the
healthcare system.
23
o
Analysing the consistency of the practice of institutions as compared to their
declared missions.
o
Making available information and case studies about good practice in
healthcare services and involve citizens in prioritisation and clinical decisionmaking.
o
Analysing, reporting and acting in case of overuse, misuse and under-use of
healthcare services and involving citizens in prioritisation and clinical decisionmaking.
o
Providing citizens with supportive information to help them choose the most
appropriate doctors, services and insurers.
•
There is a need to increase citizens/patients literacy about evidence-based decisionmaking and develop mechanisms and incentives to increase the public disclosure of
information.
•
The mechanisms of the EU – European Health Forum should be designed so that they
ensure the development of citizens/patients centred health policy.
Forum VI:
Development.
Health in the Information Age: Health Technology and Policy
•
eHealth should be defined as the usage of new information and communication
technologies and innovative ideas on the organisation of health services to benefit all
actors.
•
eHealth should develop a pan European strategy that includes a content quality
management process and an architecture/platform to integrate existing or new systems.
•
The use of eHealth in the healthcare system can improve efficiency; quality and patient
orientated services. But a number of side effects have to be considered.
•
Information and communication technologies do not change the healthcare system, but
can be used to facilitate changes in the system.
•
Successful eHealth needs regulatory, organisational and technological improvement.
•
eHealth applications enable (international) co-operation between actors. For reasons of
interoperability - standardisation is a very important task. Standardisation has to be
undertaken for terminology, data definitions, content, data format and structure.
International standards should be followed, and European and national diversity
recognised.
o
The process of standardisation should be given more attention and speeded up.
Furthermore rules and agreements on a legal or contractual basis are needed when
looking at cross-border solutions or looking at usage of healthcare services in
foreign countries. [as information and communication technologies (with the
Internet as a backbone) enable such solutions].
•
The EC should speed up eHealth standardisation and harmonisation work on an
international level in co-operation of the European nations and promote the results.
•
The EC should co-ordinate national eHealth initiatives to ensure interoperability
within Europe.
Inserat A1
Opening Ceremony
25
Opening Ceremony
Words of Welcome
Herbert Haupt
Dear Mr. Leiner,
Dear Minister,
Ladies and Gentlemen,
It is a great pleasure for me to welcome you to the 4th European Health Forum for which the
Federal Ministry for Social Security and Generations has been a co-organiser for the second
consecutive year.
I am very pleased to see that so many prominent guests are attending this year's event.
I believe the fact that, this time, we are looking at the beautiful Gastein Valley from a
somehow different perspective will not have any adverse effects on the high quality of the
Forum we have been accustomed to. I would even go so far as to assume that this year's
venue will be of benefit to the further development of the European Health Forum.
A glance at the conference programme will convince you that, once again, the organisers
have done an excellent job.
The European Commission, the WHO Regional Office for Europe, the Government of the Land
of Salzburg, Austria's business community, leading international and national health
institutions, non-governmental organisations, and last but not least my Ministry have
contributed to the solid preparation of this year's themes, laying the foundation for
interesting debates.
It is very rewarding for me, and I reckon for you as well, to see how the European Health
Forum has developed in recent years. The theme chosen for this year's conference is
"Integrating Health across Policies".
This topic indeed deserves a more in-depth discussion. It is not surprising that the issue of
integrating health in all areas of policy is a major concern of all European health politicians.
We are well aware of the unpleasant fact that health policy decisions are often not taken by
health politicians but by those from the economic, agricultural, social, traffic, environmental,
and other sectors.
At this point I intentionally include the EU institutions, and in particular the European
Commission's Directorates-General and the Council. We are still lacking an institutional
participation and co-decision right for health politicians for issues relating to health policy
that are, however, discussed and decided by other ministerial councils.
A positive development of these institutions has been the integration of the areas of food
health and consumer protection under Commissioner Byrne, who, by the way, will participate
at this year's European Health Forum Gastein.
26
Another issue that is very important to me and I wish to share with you is the health
compatibility check. This term is probably familiar to you, but why has the health
compatibility check not been put into practice yet?
The health sector does not have a lobby similar to that of the environment, and "health" is
obviously still regarded by politicians in other sectors as being an "appendage" of their
special fields and is not perceived as an independent, equal subject.
It is true and noteworthy, that, especially in the European Union, a lot has been done in
recent years to enhance awareness for the needs of health protection in other policy areas.
Nevertheless, I personally believe there is still a lot left to be done!
I very much welcome the expansion of the topics at this year's Forum to include the area of
commerce, also touching issues in connection with globalisation.
I believe this topic is extremely relevant to health policy and I hope that a sector-specific
debate on the issue of globalisation can help bring the emotionally laden climate of the
current political debate back on a rational level.
Another important item I assume will be on the agenda of all forums – and, looking at the
list of participants, I am sure the discussions will be of high-quality, authentic, and
competent - is the EU enlargement.
This year's Health Forum has once again succeeded in bringing together a series of
representatives from the membership candidates in Gastein.
Although health is not a central topic of the accession negotiations due to the lack of a
comprehensive Community acquis, I believe that issues relating to health care and health
services are of major importance on a personal, emotional level. This is true not only in the
EU member states, but also in particular in the membership candidates.
I think that in this area, too, we must take the existing concerns and hopes of the people
very seriously.
Therefore, we should take advantage of events such as the Health Forum to discuss these
issues. At this point, allow me to draw your attention to the workshop on the EU
enlargement that will take place on Friday afternoon and which was largely prepared by
members of my Ministry. I cordially invite you to participate at this workshop.
Finally, I wish to all participants, the speakers, and the organisers of this year's European
Health Forum in Gastein all success and an interesting event.
Thank you very much for your attention.
Gyula Pulay
Distinguished participants, Ladies and Gentlemen,
It is a great honour for me to have the opportunity to address the Opening Ceremony of the
Fourth European Health Forum in Gastein.
Opening Ceremony
27
Looking at the list of the invited speakers to this Session, I thought I would touch upon the
topics of the Forum not only from the point of view of the Republic of Hungary, but also
from that of other Central and Eastern European countries being in the process of accession
to the European Union.
It might be needless to emphasise that health is one of the most important values for
citizens of candidate countries as well. We all expect that as a result of our accession to the
European Union, inter alia, the quality of living conditions, consequently the health status of
the population will improve. The more we learn of common values of the European Union,
the more we understand the evidence that improving the health status of the population
cannot be regarded simply as a gain of accession, but at the same time, it is a precondition
to becoming a successful member of the European Union. The Internal Market of the
European Union is an economy, where competitive advantages may primarily be gained by
the development of human resources. Consequently, a high level of competitiveness cannot
be reached or maintained without making efforts to improve the health status of the
population and of the workforce. States, companies, entrepreneurs failing to invest in health
can only be losers of economic competition.
This recognition has essentially contributed to the recent decision by the Hungarian
Government to pass a 10-year public health action programme, identifying the major health
threats and health determinants in Hungary, and launching 17 well-defined projects. The aim
of the programme is to attain major improvements in the health status of the Hungarian
population, and to promote the convergence of the Hungarian health indicators to the EU
average.
Objectives of the 10-year public health action programme can closely be linked to the main
theme of the Forum, namely how to consider the health aspects, as well as health impacts,
when forming other sectoral policies. The leading strategy behind the Programme is a
multisectoral approach, collaboration and co-operation among various ministries, inter alia
the ministries of agriculture, transport, environment, education and health, governmental and
non-governmental organisations.
May I draw your attention to the fact that, after accession, development policies in candidate
countries will significantly be determined by the characteristics of the development support
to be provided by the European Structural Funds. It can realistically be expected that the
grants to be received from the Structural Funds may, as a whole, reach 30% of the state
budget of certain new member states. One of the eligibility conditions for these grants is the
provision of co-financing by member states. Presuming the average rate of co-financing will
be some 50%, we might come to the conclusion, that it will be reasonable to allocate some
30% of the central state budget of new member states to support such programmes which,
at the same time, fulfil EU eligibility criteria. Consequently, development priorities of the
European Union and the new member states will essentially converge. In case, health is to
be regarded as a priority area, when allocating European Structural Funds, and presuming
that health requirements in horizontal policies become more explicitly expressed at the level
of Community legislation, it is then very likely that the same situation will take shape in new
member states as well. Hence, it is our joint responsibility to act accordingly.
When examining the process of accession so far, we are faced with a dual picture. On the
one hand, in programmes supported by the European Union (Phare, pre-accession funds,
ISPA, SAPARD), the development of the health care system has not been paid too much
attention. The only exception to that is the development of the public health institutions
which has received major financial resources from the European Union. It is our concern, that
we might face a similar situation when benefiting from the support to be provided by the
Structural Funds. On the other hand, the process of learning more and more about
28
Community legislation and norms, has essentially contributed to widening the horizon of
Hungarian health policies.
In the European Union, a comprehensive and extensive body of Community legislation aims
at protecting life and health of humans. These Community norms can be found in areas like
health at work, environmental health, product safety, food safety, etc. Adapting to this
comprehensive and deeply rooted interpretation of health protection requires a multisectoral
approach. Our attention is called to the fact that the health status of the population is, to a
great extent, influenced by factors like the quality of drinking water or food, of the
conditions in the natural settlement, or of the working environment, of our ability to reduce,
or if possible to eliminate, health hazards.
During recent years, priorities in health legislation have significantly been influenced and
determined by this approach in Hungary. In the last 2-3 years, approximately half of the acts,
government or ministerial decrees, prepared by the Ministry of Health, served the
transposition of the relevant Community acquis, and have been accompanied by major
institutional capacity building and investment programmes, supporting the implementation of
Community health protection requirements. This process brings about a major shift in
priorities not only within the health sector, but also in other sectors of economy, through a
more conscious acknowledgement of public health aspects.
Within health policies of candidate countries another topic, also touched upon by this
Conference, is gaining more and more importance, namely the issue of the Internal Market.
It is evident for all of us that health should also be viewed as an integral part of the internal
market. Community legislation concerning, for example, consumer protection, competition,
transparency of state aid, or a number of other areas of Community competence within the
internal market, should be respected and implemented in the health sector, as well. Several
health-related measures taken in Hungary during the last few years are aiming at contributing
to the smooth and safe operation of the internal market.
Let me mention just a few of them: providing the legislative basis for the right of
establishment in the health professions; transposing and implementing Community
legislation concerning medical devices, together with the establishment of the necessary
institutions; transposing legislation on the registration, marketing and social insurance
reimbursement of pharmaceutical products; introducing an up-to-date national legislation for
chemicals etc.
I do hope, the examples mentioned above reflect accordingly the fact that health policy
challenges for Hungary and other candidate countries mainly coincide with those in member
states of the European Union. This Fourth European Health Forum in Gastein is aiming at
discussing the most important ones from among these challenges. Consequently, lectures,
debates on this occasion might teach candidate countries a number of important lessons.
James Walsh
Speech not available
Opening Ceremony
29
Günther Leiner
Ladies and Gentlemen,
I am very happy to welcome you once again this year to the opening ceremony of the
European Health Forum Gastein.
Following the breathtaking growth of recent years, it is a particular pleasure for me to see
that, in the meantime, our event has established itself as a fixed item on Europe's health
policy agenda. This, however, would never have been possible without the strong support
of our partners and sponsors who contributed contents, funding, and staff.
It is a particular pleasure to see so many high-ranking participants from the Federal Ministry
for Social Security and Generations this year, and to be able to welcome both Minister
Helmut Haupt and State Secretary Reinhart Waneck.
I wish to extend to you the greetings of the Governor of the Land of Salzburg Franz
Schausberger, and I must unfortunately excuse Vice-Governor Mrs. Gabi Burgstaller who
planned to attend the event as the representative of the Land of Salzburg. The President of
the Provincial Parliament of Salzburg died unexpectedly this morning, and therefore all
members of the Government had to stay in Salzburg.
I am personally very delighted about the participation of Mr. Padraig, Flynn the co-founder of
EHFG and former Commissioner for Health and Consumer Protection, and of Commissioner
David Byrne, who will join this year's EHFG once again tomorrow.
Allow me to extend a cordial welcome to James Walsh, the representative of our coorganiser, the EU Committee of Regions, and to all the other members of the CoR delegation.
As I shall further elaborate upon later, the creation of a citizen-friendly Europe constitutes
one of the major challenges for European Institutions. The European Parliament, represented
today by Cathrine Stihler and John Bowis, will play a significant role in this process.
Last year, already a large number of high-ranking representatives from EU member states,
the regions, and especially from the applicant countries for EU membership participated in
our event. I am very pleased to see that this circle has become even larger.
Allow me to welcome Simon Vrhunec, Jozica Maucec Zakotnik, Mojka Grunter Cinc, Gyula
Pulay, Pál Geher, and Maija Porsnova, the State Secretaries for Health from Slovenia,
Hungary, and Lithuania.
I also wish to extend a warm welcome to three high-ranking representatives of Europe's
regions, Minister Jane Hutt from Wales, Minister Eduard Rius i Pey from Catalonia, and Mr.
Rüdiger von Plüskow, State Secretary of Schleswig Holstein.
This year, the World Health Organisation once again provided its strong support by sending
several speakers, including regional director Marc Danzon, who will be joining us on Friday,
and Director David Evans.
Please excuse me for not personally addressing all high-ranking delegates of the various
European, national, and international interest groups, although, representatively, I wish to
welcome Professor Rolf Krebs, President of the International Federation of Pharmaceutical
30
Associations, Mr. Andrew Hayes, President of the European Public Health Alliance, and Mr.
Otto Pjeta, the President of the Austrian Chamber of Physicians.
Dear Ladies and Gentlemen, I wish to extend a very cordial welcome to all of you, the
speakers and participants from 33 nations.
You represent important stakeholders of the health sector:
•
•
•
•
•
•
•
Politicians and administrators on a European, national, regional, and communal
level,
The financers
The consumers and patients
The health care facilities and hospitals
The business world
The scientists, and
All health-related professions.
What is the use of all this new knowledge if it remains reserved to us here: the media play a
decisive role for communication. At this point allow me to welcome all representatives from
the world of media.
As you must have already established beyond doubt, this year's Health Forum takes place in
Bad Gastein. Some of you are already aware of the fact that the communities of the Gastein
valley, Bad Hofgastein and Bad Gastein, are important driving forces and supporters of our
forum.
After having organised the Health Forum in Bad Hofgastein for three consecutive years, we
hope that this change of venue will bring fresh impulses to the event.
Allow me to welcome Mr. Manfred Gruber, the Mayor of Bad Gastein, and sincerely thank him
for his support and cooperation.
“In Romania, infant mortality is three times higher than the EU average.”
“AIDS is the most common cause of death in South Africa.”
“1 million people die of malaria each year.”
These headlines have more to do with economic policy, world trade, or the Single European
Market than with international, European, or national health policy.
By choosing the general theme of "Integrating Health across Policies", this year we are
addressing one of the key issues of European health policy.
This concept of health and health policy as a multisectoral issue is proof of a new awareness
that successful health policy solutions require approaches reaching across disciplines and
sectors.
This was not least impressively demonstrated by the recent BSE crisis. The environment,
nutrition, and social surroundings, just to name a few, are important health topics which are
not, however, directly affected by traditional health policy.
Therefore, just as in other areas, networked thinking and acting is becoming increasingly
important. This does not apply only to the delimitation of policy areas but also to the fact
that many problems can no longer be regarded from a strictly national perspective.
Opening Ceremony
31
As a result, the vertical borders between Member States and the European Community are
becoming more and more permeable.
Two indicators clearly reveal the social, political, and economic character of health in the
population. First, there is a series of diseases and causes of death that are more common at
the bottom than at the top end of the social ladder. The health disadvantage of the lower
social stratum cannot be easily explained on the basis of one or two diseases attributable to
one or two risk factors. If one examines the some 80 most important causes of death (78
among men and 82 among women), in approximately 80% of all cases (83% among men and
76% among women) the death rates are higher among blue-collar workers than among
white-collar workers. The same pattern can be observed with the most important disease
groups: infections, cancer, coronary heart diseases, nutrition-related and metabolic diseases,
respiratory diseases, accidents, neurological diseases and mental illnesses.
Skin cancer (the result of excessive exposure to the sun) and breast cancer are almost the
only important diseases for which the social divide is reversed.
The extremely wide range of diseases linked to social and economic status proves that we
are dealing with a basically social, economic phenomenon and with society's attitude toward
the environment and nutrition.
This is not just a random coincidence of a few health factors that causes population groups
to fall under the one or the other category in terms of disease incidence.
Another very different but equally surprising indicator of the importance of social and
economical processes are health trends in Eastern Europe. When we compare the causes of
death in the countries of Eastern and Western Europe in 1970, by and large they match. (East
Germany would do better as compared to the old Federal Republic of Germany. The situation
in, say, Bulgaria and Romania was better than in many Western European countries.)
If we compare the death rates in 1990, however, all countries in Eastern Europe did worse
than the countries of Western Europe.
Ever since the early 70s, the rise in life expectancy throughout Eastern Europe had become
stagnant.
After having reached Western European life expectancy rates in the 50s and 60s, there was
no further improvement in the subsequent years. The health gap between Eastern and
Western Europe became increasingly large, despite continuous economic growth in most
Eastern European countries.
The socio-political nature of this problem is reflected in the fact that this stagnation cannot
be attributed to clear causes such as sinking standards in medical care, different economic
growth, or increasing air pollution.
In the early 70s, something went wrong in all these societies practically at the same time.
When one looks at these trends, one cannot help wondering whether we should have
noticed the social and economic causes and effects of the revolution of 1989; perhaps we
would have then realized what prevented further progress in health.
"Since health and society are so closely interlinked, we learn more about health if
we study society, and more about society if we study health
(Richard G. Wilkinson: Kranke Gesellschaft p.18)."
Let me express a few more thoughts on the acceptance of the European idea by the people
of Europe. I personally consider it very important to add these words at the end of my
contribution.
32
Lately, there is a lot of talk about citizens in Europe, and I want to raise the question
whether this really means that Europe's institutions are paying more attention to the citizens
– or whether it is just a panic reaction to the citizens' increasing scepticism toward this very
Europe, its officials, and its institutions.
What does such a European citizen look like?
Does he or she exist at all?
The European citizen is, indeed mentioned in the various EU treaties – themselves being too
complex to be citizen-friendly.
The European citizen enjoys a series of rights, e.g. non-discrimination toward other citizens
in other member states; free movement of labour, the right to vote and be elected to the
European Parliament – etc.
That's all very nice so far
– Question – who would call himself/herself (primarily oneself) a Euro-citizen?
The European citizen will only emerge when he or she spontaneously feel at home in all –
today still 15, soon more to come – member states and can build upon this a European
identity.
Only when Pan-European events take place in different European countries, when citizens
from all over Europe participate at the corresponding conventions in the various countries,
then citizens will feel closer and closer to Europe and will accept it as their own. Another
important requirement is that the authority to take decisions remains with the member states
and the regions. These can guarantee closeness to the citizens through their political
representatives!
In a similar manner, the European Health Forum Gastein must belong to each citizen in
Europe. We are here for them.
Seize Gastein and the Health Forum as if it were something you were entitled to as a
European. Something that belongs to you – and prove that you feel, think, and act as a
European.
Here in Gastein, we are a rather small, yet large European family.
33
Plenary Session I + II
The Work of WHO in Championing Health in Development
David B. Evans
Abstract
WHO’s constitution has one very simple objective - the attainment by all peoples of the
highest possible level of health. Health was defined as a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity. Of the 21 functions
designated for WHO, one was to assist in developing an informed public opinion among all
peoples on matters of health. In response to this mandate, the Organization has always
sought to provide information and evidence on how health is more than the absence of
disease, how it is an essential component of development, and how best to improve health
systems to attain the highest levels of health.
In the last few years the Organization has been particularly active in championing the role of
health in development.
This has included creating a Department on Health and
Development, with a focus on health and poverty and health and globalisation. It has
worked with the WTO, for example, to examine the impact of trade liberalisation policies on
health. It includes the activities of the Commission on Macroeconomics and Health, where
one of its primary roles was to provide the best available evidence on the links between
health and economic growth. Partly on the basis of these activities, the Organization has
strongly advocated increasing the resources devoted to health and has been an active
partner in the establishment of the Global Fund on Aids and Health.
Understanding the role of health in development, and advocacy for health action is only one
part of the process. The next step is to develop evidence on the best available ways of
using health resources, both in terms of the organisation and activities of the health system
and the types of interventions that it supports. WHO also has extensive activities designed
to provide evidence of what types of health system structures and activities work, and which
ones do not. It provides evidence on what type of interventions, or groups of interventions,
most improve population health for the resources available, and works closely with countries
that request it, to find ways of improving the levels of health for the available resources.
Speech not available
Presentation
slides
are
available
for
http://www.ehfg.org/website01/abstracts.htm
download
at
the
EHFG
web-site
34
Jane Hutt
Introduction
Integrating health across policies is a major challenge for us all. It is a challenge for
governments and organisations in all sectors and a challenge that exists at all levels – from
local through to national through to international. But, given what we know of the part
played by the social, economic and environmental factors in determining people’s health, it
also provides us with opportunities to achieve a far greater impact on improving people’s
health and well being.
For far too long, improving health has been seen as the responsibility of the health sector
alone. That view is changing fast and the proposed health programme for the European
Community reflects it. Effective and efficient health services to treat ill health and disease
remains a priority but the need for more action to prevent ill health and to improve health
has been recognised. The challenge is in making it happen and success will depend on a coordinated and sustained effort that harnesses contributions from all sectors.
Integrating health across policy areas is one of my specific goals as Minister for Health. For
this reason I am particularly glad to be here, not only to inform you of what we are doing in
Wales, but also to learn of others’ approaches.
The National Assembly for Wales was established as the Government of Wales in 1999, as
part of constitutional change within the UK. From the start, I and my Cabinet colleagues
realised that an overarching strategy was required to set the scene for connecting policies
across the Assembly’s responsibilities. Our strategy is grounded in recognition of the range
of social, economic and environmental factors that affect health and a desire to achieve a
more integrated approach where policies and programmes add value to each other.
All we do is framed by our strategic plan entitled Better Wales. Improving health and well
being is one of its priorities, along with a better, stronger, economy; better opportunities
for learning; better quality of life; and better, simpler, government. These, and the
Assembly’s crosscutting themes of sustainable development, equal opportunities and tackling
social disadvantage are all relevant to the theme of improving people’s health and well
being.
However, having such a strategy is only one part of the equation. We need to develop new
ways of working, new intersectoral approaches and new tools to assist the development of a
more integrated approach. Health impact assessment is one such tool with
considerable
potential.
We will hear more about health impact assessment this afternoon so I won’t go into detail
on this. However, I will say that health impact assessment is a key to our approach. Ours is
a pragmatic approach designed to develop its usefulness from within the policy development
process and, importantly, to learn from experience. It is helping us to understand better the
interactions between health and other policy areas, and to identify new opportunities to
protect and to improve people’s health.
Making the connections is important. Health is relevant across policy areas but there is still
some way to go to raise others’ awareness of this and, more specifically, to secure their
commitment to improving health as something to which they could contribute through the
35
policies and programmes in their sectors. Most important is recognition that it is usually a
two-way affair. Guidance is vital in winning the argument.
Take economic development for example. Broadly speaking, more employment is good for
people’s health but the converse is also true. Investing in improving people’s health can help
achieve economic development by helping them to break down health-related problems that
act as barriers to employment and training, and which deprive labour markets of skills and
families of incomes. We await the findings of the WHO Commission on "macro economics
and health" with interest.
To implement our vision we recognise that Wales must be served by modern, effective, and
accessible public services that compare with the best. We must also work actively in our
local communities where the voice of our local people can be heard and we want Wales to
be a fairer place where everyone is valued and given an opportunity to play a full part.
It is important that the National Assembly for Wales leads by example and with this in mind
our we are changing the way we organise and deliver our work. We are working to put
health and well-being on everyone’s agenda within the National Assembly, whether in
education, economic development, transport or agriculture, local government or social policy,
health impact and opportunities to improve health so that it is seen as everyone’s
responsibility.
To show how we are connecting policies and integrating action to improve health and wellbeing I will describe our plan to renew the National Health Service in Wales. The Plan has
been designed to be a sort of ‘Trojan Horse’ to get inside organisations. We are not only
looking to improve the balance between the protection and promotion of health and the
treatment of illness and disease, but we also intend to reinvigorate and strengthen the
partnership between statutory, social and business partners to engage the ‘whole system’. It
seeks to strengthen health advocacy and protection and establish a new focus on community
health development in which all policy makers, organisations and citizens can combine their
efforts for a better, healthier tomorrow. We intend to use the renewal of the NHS in Wales
as a catalyst for change across the policy sections at local and national levels.
These are challenging aims but Wales has often led the field in innovative and effective
public policy, particularly in the field of health and health services and we intend to lead the
field again.
The challenge for us is to improve the health of our population.
Our public health strategy `Better Health Better Wales’ published in 1998 was a land mark for
us. It recognised that the factors affecting people’s health are not always within the direct
control of individuals. It was built on evidence of the importance of joined up working and
joined up policies between the NHS, Local Government, NGO's and other bodies with an
interest in the well-being of communities.
Additionally, the implementation of the Objective One programme in Wales has given us the
opportunity to address strategically the broad range of social, economic and environmental
issues that impact on health and well-being.
In February of this year we published The Plan for the NHS Wales with its partners and it has
set the scene for the NHS over the next ten years. The Plan is underpinned by the
recognition that the NHS was always intended to be a service for all, provided free at the
point of use and must meet the collective aspirations of the Welsh people for better health
for all. The implementation of the Plan will involve a decade of change and development in
which we intend :
36
•
To improve our performance in the maintenance, protection and promotion of
health;
•
To ensure that all we do contributes significantly to population health improvement
and the quality of life of our citizens;
•
To tackle inequalities in health and inequalities in access to health care and
support.
Life-long investment for health is one of the vehicles that will carry us along the road to
health improvement and will help diminish health inequalities. This demands that we adopt
strategies for investment which cover the life course and are targeted at those transitions
where health risk to individuals is the greatest. Such strategies will provide a new balance
between the protection and promotion of health and well-being and the treatment of disease
and ill health.
We base this approach on our valuable learning from the groundbreaking Verona Initiative
and the clear need to have cohesive and holistic public policy in our communities. As you
will see this approach is straight out of the World Health Organisation’s text books. We
have seen that across Europe, the need for this action is not new and has been well
documented in the literature relating to Investment for Health . As it says: “We instinctively
recognise the need. But for this to be taken seriously and lead to action existing structures,
habits and thinking must change. New skills will be needed. Change is difficult and the
forces of inertia are strong. But the potential benefits are enormous.”
We have decided that the National Assembly for Wales and our NHS must be champions of
this cause and must work with our partners to engender a new determination to improve the
health and well being of the people of Wales. We have learned a great deal from our
involvement in the Verona Initiative and our approaches have been much influenced by the
multi national discourse that Verona made possible. Wales is keen to continue to be
involved in this and similar initiatives and we are sure that our experience in the massive
programme of change I have described will add to the shared pool of knowledge, so
valuable in helping us to learn and develop. We also see our membership of the WHO
Regions for Health Network as very important.
To enhance health and well-being, the NHS in Wales must be seen to be owned by the
people of Wales and the voice of patients, their families and the public at large. This will
involve greater attention to building user-centred services and citizen-centred policies. We
seek to engage the public as partners, finding new and more effective ways of doing this.
We are determined that Communities become key players in the definition of health needs
and the identification of solutions.
The health and well-being agenda is not just the business of the NHS. To make inroads into
the legacy of ill health and to promote health, requires that the NHS - in concert with local
government and the voluntary sector – establishes joint planning mechanisms, joint scrutiny
of the health agenda and joint working. We have many examples of good practice in joint
working in Wales which will act as exemplars.
We have 22 City and County Councils in Wales and over the last two years each has formed
a Health Alliance of a wide range of statutory, non-governmental, independent and business
organisations to identify health issues in their communities and to find ways, in partnership
to deal with them. These have developed well but we now intend to introduce a new
statutory responsibility that requires Local Government and the NHS to formally enter a
Strategic Partnership to produce and implement Health and well-being Plans for their local
populations. They will be required to engage with the whole community and will use Health
37
Alliances as a core resource for gathering grass roots health intelligence and assessment of
need. It is at this level that local cross cutting policy will be initiated.
The successful transformation of the NHS rests, in part, on our vision of what changes are
necessary to deliver a service focused on health inequalities and health improvement.
Developments will occur in the organisation and practice of primary, secondary, intermediate
and tertiary care. These improvements will repair the fragmentation of the service over the
last twenty years turning the NHS into a unified and whole system more capable of engaging
with its partners and influencing their policies. Continuous improvement will be a central
theme in all that we do. Public health professionals will have an important role and public
health teams will be developed in the primary and community settings as a resource to all
the community. Primary care will be strengthened and will take a more active role in
population health, but also their surgeries will increasingly become Community Centres
where advice on welfare, housing and other basic social needs can be provided under one
roof and opportunities for patient involvement encouraged.
The development of the health workforce is also necessary to deliver renewed health services
not only to meet the rapidly changing clinical demands but also to better equip them to deal
with the new partnerships with patients and the wider community.
Alongside all of this, we are refining and improving how we measure the performance of the
system and the outcome of our action. We are developing a set of measurement tools,
health gain targets and mechanisms that will ensure the continued improvement of the NHS
in Wales and its partners.
The structure of the service will be made simpler, it will become more accountable for its
action and services, and it will have a more democratic voice in the way it is governed. To
achieve this the local and national organisations will be strengthened, our existing five
Health Authorities will be abolished and at a local level we will set up 22 Local Health
Boards that will include representatives of local health professionals, elected members of
local government, NGO's and members of the public. This will provide a truly inclusive
platform to ensure that all interests are represented.
At the national level I am forming a Health and Well-Being Council to advise me on health
policy. This will be an inclusive arena in which representatives of all the stakeholders in the
community will bring their experience to bear on the development of policies and plans.
They will look at the development of public policy and help in considering the health impact
of policies at both a national and local level. The supporting infrastructure of the Assembly
is being reorganised so that its policy divisions related to health and well-being will be
better placed to provide strategic leadership and direction.
To achieve our aims four main interconnected areas for action have been chosen to ensure
that scientific, economic, social and political sustainability drive the implementation of health
improvement in Wales :
•
multi-sectoral strategies to tackle the determinants of health, taking into account
physical, economic, social, cultural and gender perspectives, and ensuring the use
of health impact assessment;
•
health-outcome-driven programmes and investments for health development and
clinical care;
•
integrated family and community-oriented primary health care, supported by a
flexible and responsive hospital system;
38
•
a participatory health development process that involves relevant partners for
health at home, school and work and at local community and national levels, and
that promotes joint decision-making, implementation and accountability.
Of course, while the Plan for the NHS provides us with a framework for concerted action it
builds on work already underway. The Assembly has developed – and is implementing – a
number of cross cutting strategies to counteract social exclusion and to create a socially
inclusive Wales. It recognises the importance of building and supporting strong communities
where the values of citizenship and collective action can grow. A new way of making and
implementing policy has taken root and is being nurtured. Instead of the old practice of
restricting the development of important policies to a relatively small group of experts in
government, the new Wales is characterised by an opening up of the policy making process.
This Plan builds on wide consultation over the elements that make it up and is part of the
process of replacing elite policy making by participative policy development. Our policy here
is to build on this commitment and to continue to enhance the citizen’s voice at the heart of
policy.
The Assembly has begun to put right years of under-funding in the NHS in Wales and over a
four year period ending in 2004 there will have been an increase in 37.5% in funding to a
total of £3.6 billion. The Assembly has already initiated a number of significant
developments aimed at improvement and the reduction of inequalities in health. For
example, we have set up a health inequalities fund to help support action and service
development in our most disadvantaged communities. In the first year we have a target
action to prevent coronary heart disease.
We are not happy that the existing health funding formula in Wales does not truly reflect the
needs of our communities and we have set up a review, the result of which we intend to
implement next year. This is aimed at addressing not only means to provide more equitable
access to high quality health services, but also the particular health needs associated with
areas of socio-economic disadvantage including rural and remote areas.
As I have said, we are clear that the NHS must not be an island or a service that is focused
on ill health. The renewed NHS will move centre stage into our new citizen and community
development focus. It will be an important player but not the only one. It will become part
of a whole system that looks at all aspects of the quality of life in the community and will
ask itself constantly: “what can we offer to make this a better place? What can we do to
influence the determinants of health not only as members of the community but also as a
large organisation with social responsibilities like any other? What unique contribution can
we make to the health and well-being of our citizens? How can we influence other policies
that impact on health ? What could we do better if we worked closer with others and could
they work better with help from us? Do we know enough about the health and well-being
needs of our people and are we responding well enough? Do we listen to our people and
communities and do we really know and understand their needs and expectations? Do we
know how well we are doing and are we flexible enough and geared to learn and change?”
Basic questions yes, but ones if answered well, and actioned, will transform the way the NHS
in Wales operates. Neither are they new or original questions but we are determined that
they will be answered.
In conclusion I believe that we must keep on asking ourselves not only what other policy
areas can do for health but what investment in improving people’s health can also do for
other policy areas. We have to get this message over to others as well. It calls for a coordinated and sustained effort across policy areas and I was pleased to see that joint action
is reflected in the Commission’s proposals for the Community’s new Public Health
Programme. With this discussion of how we are renewing the NHS in Wales I hope that you
39
can see that it will move from primarily being a sickness service to become a major advocate
in health and well-being and influential in changing the face of public and business policy at
both the national and local levels. We have a challenging agenda but we are determined to
see it through.
The Potential and Limitations of Health Impact Assessment
Roscam Abbing
Abstract and speech not available
Progress and prospects for promoting and protecting health across
EU policies and actions
Bernard Merkel
Abstract and speech not available
Establishing Health as a Key Component of Economic Policy
Sarah Burns
The Speech was largely based on below copied NEF briefing
Keeping the GP away
A NEF briefing about community time banks and health
”This alternative method of treatment has led to a lot of patients being taken off antidepressants. Too often in the past, doctors would give people drugs or nothing at all. Now
we have this new method, and the results I have seen have been remarkable. I’ve seen
smiling faces on people who were very depressed before they started the scheme and I can’t
wait to start the in depth evaluation which will give us more information about how people
use the community time bank and what they get from it.”
Dr Richard Byng, pioneering GP at Rushey Green Group Practice
“The regeneration of communities and individual people’s lives can also come in other
ways [than government programmes] and particularly from within. The idea of using and
40
trading in community time has been one particularly effective and now widespread
phenomena.”
Tessa Jowell MP, as Minister for Education and Employment, March 2001
This briefing provides an introduction to how community time banks – the social
infrastructure known as ‘time dollars’ in the USA – can be adapted successfully in the health
sector, to keep people healthy, to speed up recovery and to save scarce NHS resources. It is
intended to do two things:
•
•
Introduce the concept of community time banks as a health regeneration tool.
Provide a brief summary of the first evaluation of a time bank used in a GP’s
surgery at Rushey Green in Lewisham.
The evaluation is part of a much more comprehensive three-year project involving Guy’s,
King’s and St Thomas’ hospitals – carried out by the Socio-Medical Research Centre at St
Thomas’ Hospital – which will not report for some time. It was carried out by one of the
doctors at the practice, Dr Isobel Garcia, and will be published in full shortly.
Background
‘Time dollars’ or community time banks are the brainchild of Washington law professor Edgar
Cahn, who developed them as a way of providing non-medical services for older people –
helping them to stay in the own homes, keep hospital appointments and stay healthy.
Supported from 1986 by the Robert Wood Johnson Foundation, the first wave of time dollar
schemes in the USA a new kind of money, known in the UK as ‘time credits.’ These are now
used in over 200 cities in the USA to fuel volunteer schemes, health maintenance
programmes, support old people and a range of other local social projects. There are around
700 similar schemes in Japan, backed by the government, and more in China – both places
with high proportions of older people in the population.
Community time bank schemes work by measuring and rewarding the time people spend
helping each other in their local communities. Everyone’s time is worth the same and the
time credits earned can have their value underpinned by local authorities or concerned
businesses making goods available in return for them – reinforcing reciprocity and trust. But
even without that, time banks are one way of putting neighbours in touch with each other,
using people’s skills and imagination – particularly older people’s time, which is ignored by
the market economy – and building a network of neighbourhood support.
Evaluation conducted by the University of Maryland’s Centre on Ageing throughout the 1990s
established that time banks were able to attract people who don’t normally volunteer, keep
old people healthier and cut drop-out of volunteers.1 Most dramatically, the hospital group
Sentara, in Richmond, Virginia, found that using a time bank to provide peer support for
people with asthma, cut emergency admissions to hospital by 74 per cent and saved
$217,000 over two years.2
One of the most successful projects in the USA, is Elderplan, a social Health Maintenance
Organisation in New York City. In their first 12 years, mutual volunteers from their Member to
Member project have put in over 100,000 hours helping each other, teaching each other and
supporting each other to be independent. Member to Member enables volunteers to earn
1
Robert Wood Johnson Foundation (1990): Service Credit Banking Project Site Summaries, University of
Maryland Centre on Aging, Baltimore.
2
Time Dollar Institute (1999): Angels and Health: Time dollars and healthcare, Time Dollar Institute,
Washington DC.
41
and pay time credits for giving and receiving non-medical services like, shopping, friendly
visiting, bill-paying, hospital visiting, home repairs, walking clubs, support groups, self-help
courses and others – all funded by time credits earned through the scheme.3
"Often you can't buy what you really need," says Mashi Blech, Elderplan's director of
community services. "You can't hire a new best friend. You can't buy somebody you can
talk to over the phone when you're worried about surgery. But by getting people helping
through the time bank we want to involve people as co-producers of their own health care.”4
The New Economics Foundation (NEF), supported by a grant from the King’s Fund, organised
a series of UK seminars by Edgar Cahn in 1997. The visit generated a great deal of interest,
particular from the health sector and the King’s Fund agreed to support NEF to pilot a UK
approach to time banking over a two-year period – and in particular to set up an
experimental community time bank in London around a hospital or health centre, primarily
with and for older people. Since then, a range of other partners have become involved in
the development of time banks – including the South London & Maudsley NHS Trust – and
there are two major networks of time banks up and running, the London Time Bank (www
.londontimebank.org.uk) and Time Banks UK (www .timebanks.co.uk).
Rushey Green
The pilot community time bank was developed in partnership with the Rushey Green Group
Practice, based at two locations in Catford, in south east London. It has a team of 14
clinicians: six GPs, two nurses, together with a nurse practitioner, a psychologist, a
counsellor, a child mental health specialist and a health visitor.
Interest in developing a time bank at the practice was sparked by GP Richard Byng, who was
keen to explore and develop alternatives for tackling isolation and depression. Initial
research found that both staff and patients supported the idea and felt that the scheme had
the capacity to generate much-needed social support for the most isolated older people – as
well as families and provide low level practical help to enable older people to stay in their
own homes.
Cllr Mee Ling Ng, the deputy mayor of Lewisham officially launched the time bank in March
2000. Now, 18 months later, the Rushey Green Time Bank has 68 members: 59 individual
members and nine organisations, including the health centre itself, the local garden centre, a
local nursing home, Voluntary Action Lewisham, Lewisham Community Health Council and St
Laurence Church. The time bank is co-ordinated by Liz Hoare, who recruits new members and
links up their offers and requests for help.
The time bank has generated over 2,950 hours of service. The range and type of services
include: befriending, running errands, giving lifts, arranging social events, woodwork, poetry
writing, teaching sewing, babysitting, gardening, lifting that requires muscle, swimming,
fishing, teaching the piano, catering, form-filling, design work, drawing and giving local
knowledge.
New members join the time bank, on average at the rate of one to two per week and
turnover is low, with most of the members who joined at the beginning still involved. By far
the most common reason for leaving the time bank is returning to, or finding paid
employment. Other members have moved and three older members have died. There are
3
See for example: Boyle, David (2001): The Sum of Our Discontent, Texere, New York.
Washington DC.
4
42
also 23 people who initially contacted the time bank and decided subsequently not to get
involved.
The time bank is made up of 29 per cent men, 71 per cent women. Of these, 44 per cent are
from minority ethnic groups and 52 per cent have some kind of disability. Exactly a third of
members are over 65 and 18 per cent are over 80 years old. The oldest member is 91 years
old; the youngest 16.
What difference has the time bank made?
A two-year evaluation, supported by the King’s Fund has now been launched by the SocioMedical Research Centre at St Thomas’ Hospital, led by Dr Tirril Harris. Combining both
qualitative and quantitative approaches, the research will document how the time bank
works and measure how it impacts on participants and their:
•
•
•
•
•
Confidence and self-esteem
Social networks
Access to preventative as opposed to merely reactive care
Self-perception of health as well as clinical health
Possible cost savings to the NHS.
Initial research was conducted by Dr Isobel Garcia, a GP at the practice. She interviewed 24
time bank participants, and surveyed practice staff about their experiences of the scheme.
Her main finding has been that – as well as the volunteer support to local people who need
it generated by the time bank – it has also helped to build people’s confidence and selfesteem by shifting the emphasis from areas where they are challenged or failing, to activities
and skills that they enjoy and can share with others.
In this way, the scheme has given a sense of self-worth to people who had previously been
passive recipients of care. Many of the members are elderly or disabled and cared for, at
least to some extent. The time bank has also given them the opportunity to give and
become ‘carers’ themselves in different ways in the community.
By blurring the distinction between givers and receivers and encouraging more vulnerable
people, such as the elderly and those with mental heath needs, to get involved and share
their time, the time bank is helping to build more community based self-help and mutual
support:
•
•
“I was asked to go and sit with an elderly lady. She was blind and very isolated
but she lived just across the road from me and by getting to know her and starting
to look after her, I came out of my depression.”
“ I am supporting them, but if there’s a time I need to be supported, I am sure
they will be there for me.”
Other impacts include the following:
Support for traditional carers
Because participants are very much involved in the management and development of the
scheme, they have come to take more responsibility for each other. This has helped to
reduce the burden on traditional carers in the form of both family and social services to
some extent by providing support from other local people:
•
“We discuss who can help and who’s had a stroke or who’s just returned from
hospital and may need someone just to come in and sit for a while.”
Respondent to the research questionnaire
43
Peer support
Participants have also drawn support from sharing health challenges with peers:
•
“Talking to other people who have had the same problem that I have calmed me
down.”
Widening support networks
The time bank has also been successful in increasing the number of people, participants felt
they could trust and call on for help when they needed it. Some participants even felt that
the time bank offered an alternative to visiting the GP:
•
•
“It makes me feel good that I can actually trust people again... It’s just nice to
know you have someone you can call on.”
“Rather than just keep going to your GP, you can always go to the Community
time bank people.”
Respondents to the research questionnaire
Getting people active and engaged
Being involved in the time bank has enabled people to play a more active part in their local
community:
•
“And at the same time, because I felt better, I was able to get involved in other
things…and I think it’s all because I went out doing my Community time bank that
gave me the push.”
•
“It has made me feel brighter about Catford.”
Respondents to the research questionnaire
Broadening the professional view of health
The time bank was also found to have had an impact on GPs and nurses at the practice, who
are now able to offer a friendly chat or a helping hand when it is needed – rather than
prescribing medicine or a lengthy referral to another agency.
•
“The time bank has broadened the view of how we as clinicians see patients; so
patients get some benefit even if we don’t refer them to the time bank. We
consider patients in more societal terms. The time bank has helped form an
identity for the practice, and a focus for patients. Patients’ groups often fail
because they focus too much on illness. But [through the time bank] we’ve formed
a community.”
•
“Community time bank members have made a great difference to people arriving at
the Central Lewisham surgery. The flowerbeds at the front of the building were
dismal – full of weeds and rubbish – and they had been like that for years. Then
the members started taking care of it. Mothers coming to our clinics often comment
on the change – especially the wonderful display of daffodils in the spring. It
cheered them up and made them feel better even before they got to see a health
visitor or GP!”
Local health visitor Mercynth Johnson
Challenges
With any social innovation like community time banks, there is bound to be a considerable
amount of on-the-job learning. For example, while many members have a great deal to offer,
44
they need time and encouragement before they feel ready to give. At least half the
membership requires ongoing support to keep them involved and contributing. This is one of
the main tasks of the time bank co-ordinator, requiring special listening and people-skills.
Other challenges include:
•
•
•
Safety of participants: To make sure community time bank members feel safe,
references are taken up for all new members. This can pose a problem for some
people, like refugees and people who are very isolated and have nobody who can
give information about them. By offering group activities, such as gardening or
shared meals, the time bank has been able to provide a safe space for people who
are without references to participate and gives the co-ordinator, as well as other
participants time to get to know them better.
Diversity of participants: Referrals to the time bank from people with mental health
needs have been very high. But the success of the scheme has rested on its ability
to mix people up and engage them on the basis of what they can do, rather than
segregate them and confine them to activities organised around their particular
health condition. The health centre is part of a rich network of help and support in
local people’s lives and the research implies that the time bank is most effective as
part of this and therefore an integral part of the local scene. Links have been made
with voluntary groups, churches and local businesses and the bank will continue to
foster these ties.
Getting people to ask for help: Whilst most time bank participants enjoyed giving
and receiving help, one third found it more difficult to ask for help. Bad weather,
illness and depression were the main barriers which periodically deterred some
members from being actively involved. Links were most successful when
participants had already met – normally through the time bank – and when there
were additional social opportunities, like parties.
Conclusions
It is becoming clear that participation – and especially participation through time banks – can
make an important difference to people’s experience of the NHS, to their health and to the
cost of curing people and keeping them healthy, although what those cost savings might be
remain to be seen.
Community time banks do seem to provide a way to make it clear to professionals and
patients alike that they need each other if either are going to succeed. Doctors need
patients, as much as patients need doctors, in other words. And although this is a truism, it
has been hard to make that mean something in a health context. The key findings of the
initial research at Rushey Green are as follows:
1. The community time bank approach does help to engage patients as partners in the
business of delivering health.
It does this by helping to shift the focus from people’s problems to their abilities.
Professionals traditionally concentrate on what patients can’t do: often this becomes the
accepted way of triggering help. And traditional volunteering makes a distinction between
those who can give and those who need help. Community time banks focus instead on
people’s assets, what they can do and how these activities can complement and support
existing services. In this way, time banks can provide a valuable force for social exclusion.
45
2. Time banks can lever hidden resources in the community.
The Rushey Green model seems to be able to access people’s time and goodwill in such a
way that they can provide a useful arm to the surgery. Seen like that, the local community
can relieve some of the support burden from health professionals.
3. Time banks allow health centres to supply a broader view of health.
Time banks are not a stand-alone model, but a flexible approach that can be grafted onto
existing activities. By linking up and using these hidden resources in the community –
including organisational resources (like other community groups), health centres are able to
provide access to a much wider range of services than traditional surgeries – anything from
basic DIY to self-help bereavement counselling.
4. Mutual support can make a difference to the way people experience the NHS.
Mutual volunteering among patients through a time bank can benefit both the giver and the
receiver, can have an effect on people’s health, and can be far cheaper than conventional
drug therapies by themselves.
Recommendations
We propose that the time banks model should be developed further in a health context.
This will require:
1.
Other layers of NHS provision need to experiment with time banks: Sandwell Health
Authority and South London & Maudsley NHS Trust have both launched their own
programmes, but there need to be experiments building time banks and mutual
volunteering into other forms of care-management and hospital discharge planning.
2.
Boundaries between the different providers of health service need to break down
further: Local authorities and education authorities using time banks need to be
able to link up with other providers – from surgeries to social services – to make
the health component more effective.
3.
Community participation and involvement should be recognised and rewarded as
work: This can’t be done with money, but it can be done with time credits.
4.
The remaining bureaucratic hurdles for people on benefits taking part in time banks
need to be removed: Given the high proportion of members who are disabled, or
have mental health problems, it is essential that time bank participation is seen as
a therapeutic self-help activity, without implications for receipt of incapacity benefit.
5.
The ambiguity about the charitable status of time banks needs to be cleared up: As
mutual institutions, the Charity Commission doesn’t necessarily recognise time
banks as charities – though they are clearly a regeneration tool for the benefit of
disadvantaged people.
6.
We need to develop more sophisticated accounting methods, so that the savings on
future NHS spending from time banks can be clearly recognised.
7.
There needs to be a legal obligation on any public institution to involve clients as
equal participants in the business of health: Time banks are a useful mechanism to
help them do this.
Appendix A
46
Further information
There are a number of websites that can provide more information about the time banks
idea, notably the Time Banks UK website (www .timebanks.co.uk), the London Time Bank
website (www .londontimebank.org.uk) and the Fair Shares website in Gloucestershire
(www.fairshares.org.uk). The American Time Dollar Institute also has a useful website
(www.timedollar.org).
If you would like more information about how to develop time banks in a health setting, you
can contact:
Sarah Burns (New Economics Foundation):
tel: 020 7089 2859, email: sarah.burns @neweconomics.org
Liz Hoare (Rushey Green Time Bank):
tel: 07946 411177, email: liz.hoare @neweconomics.org
Tirril Harris (Socio-Medical Research Centre at St Thomas’ Hospital):
email: tirril.harris @kcl.ac.uk
Gill Seyfang (University of East Anglia);
email: g.seyfang @uea.ac.uk
Jason Evans (Sandwell Health Authority):
email: jason.evans @sandwell-he.wmeds.nhs.uk
Karina Krogh (South London and Maudsley NHS Trust):
email: [email protected]
Appendix B
Other UK research
The national evaluation of community time banks in the UK, currently being conducted by Dr
Gill Seyfang at the University of East Anglia, shows that they are a successful tool for
engaging socially excluded groups in building their local community.5 Whilst most schemes
surveyed were still relatively young, participant involvement increased over time rather than
burning out and moving on after a short period of activity. Significantly, most participants
were active both as givers and receivers of time.
The social groups which constitute time banks are precisely those who participate least in
traditional volunteering – the poor, unemployed, those with disabilities, the elderly.6
Compared to the demographic profile of traditional volunteers, time banks are attracting a
different constituency of participants - notably a higher proportion of women, retired,
disabled or sick people, jobless and low-income participants.
For example, while only 16 per cent of traditional volunteers have an annual household
income of under £10,000, the proportion of time banks participants in this category is 58 per
cent - nearly four times as many. Also, while 40 per cent of traditional volunteers are not in
5
Seyfang, Gill (2001): Spending time building communities, Time Banks UK, London/Gloucester.
Davis-Smith, Justin (1998): The 1997 National Survey of Volunteering, National Centre for Volunteering,
London.
6
47
formal employment, the figure for community time banks members is 72 per cent, or nearly
double.7
This reveals that community time banks are successful in their objective of attracting
members who are socially excluded, and would not normally get involved in volunteering.
Indeed, the majority of survey respondents (82%) were confident that they were attracting
people who had not volunteered before, and overall co-ordinators estimated that 51 per cent
of their members would not otherwise have got involved in volunteering.
Other findings included:
Over half time dollar participants (51%) are people who would not otherwise have been
interested in volunteering.
Time dollars are succeeding in their aim of being reciprocal – participants in the 15 time
banks studied had earned 15,776 hours in time credits and spent 13,838 (the total figure in
September 2001 was over 32,500 hours earned).
Over 90 per cent of respondents said time dollars were meeting some of the needs of
participants – as well as building new friendships and trust among them.
Dr Seyfang discovered a range of innovative arrangements – retired people teaching
conversational English to Iranian women, others teaching the piano to teenagers in return for
help in the garden. In Newcastle time credits can be spent getting into local sports centres;
in Cheltenham getting into home matches played by Cheltenham Town.
Appendix C
Other US research
A report by the Time Dollar Institute in Washington outlined some of the other ways that
time banks were being used in a health context in the USA, some of which could be applied
in the UK too.8 The development of time banks in the USA is happening partly as a result of
a general push to keep down the burgeoning costs of providing medical services, and partly
in the face of a wider long term-care crisis in healthcare as the population ages. People over
65 are expected to make up over 21 per cent of the US population by the year 2030. By
2020, the number of Americans who will need some kind of help because of a chronic
condition is expected to be around 23 million. Specific innovations include:
Member Organised Resource Exchange in St Louis, which pays time credits to participants
across the city for visiting older people, training in health promotion (asthma and childcare)
and passing on the training to others. They can spend the credits on help for themselves or
in a network of time bank ‘stores’ around the city.
Volunteer Caregiving in Richmond, Virginia, where asthmatics are enrolled in a telephone
time bank and befriend other asthmatics: the experiment cut the cost of treating those
involved by 73 per cent - a total of $80,000 saved in the first year of the asthma program,
rising to $137,500 in the second year.
Time Bank in Denver, which pays time credits to participants for visiting older patients to
make sure they are taking important medication.
7
Davis-Smith, Justin (1998): The 1997 National Survey of Volunteering, National Centre
for Volunteering, London.
8
Washington DC.
48
Care Xchange, part of the Blue Shield health provider in California, which runs a time bank
devoted to mutual support and telephone reassurance – with a special concentration on
support for diabetics to catch glaucoma early.
Abriendo Puertas in Miami, which runs a time bank as part of its mental health programme –
encouraging patients to find they have skills and are useful members of the community.
PALS in Pittsburgh, where the time bank concentrates on providing support for and by
housebound elderly and disabled people. Credits earned can be exchanged for grocery
vouchers.
The WHO Investment for Health Project and the Verona Initiative (*)
Erio Ziglio
(*) An amended version of this paper was presented at the 5th International Conference on
Health Promotion, Mexico City, 5-9 June 2000.
(**) The views represented in this report are those of the author and not necessarily those
of the organization for which he works)
Abstract
Can we produce health in today’s societies? Can we promote the health of the population in
a sustainable and equitable manner? Can we identify an approach effective in integrating
health across development policies that in addition to bringing about population health
gains, provides added value to economic and social results in an equitable and sustainable
manner?
These are questions that national, regional and local governments will increasingly be
confronted with in European countries. The author maintains that a thorough understanding
of the social and economic determinants of health will increasingly play a major role in
addressing the questions above. Likewise, those working in policy-making, and in healthrelated research, ought to refocus their efforts and methods of work. For example, still too
much of contemporary epidemiological work focuses merely on the description of ill-health
patterns. Far too little work is carried out with a clear focus on how to invest for the
promotion of population health. The Investment for Health (IFH) approach, developed by the
European Office of the World Health Organization – or even the concept and principles of
health promotion as embodied in the 1986 Ottawa Charter – are not at the centre of current
health work in many European countries.
Dr Ziglio will start by outlining the background of IFH as an approach to promoting
population health. It will be pointed out that the implementation of an IFH approach
requires a thorough understanding of the social and economic determinants of health.
Secondly, the issue of evidence related to the social and economic determinants of health
will be discussed. Thirdly, the main principles characterizing the IFH approach will be
outlined. Finally, examples on how a better understanding of the social and economic
determinants of health will be crucial for future development in policy-making will be
outlined.
49
In order for participants to have further information and scientific documents on the issues
related to the above, special material has been developed, mainly through the Verona
Initiative: Investing for health: the economic, social and human environment.
http://www.who.dk/Verona/main.htm . The Verona Initiative is a yearly forum, meeting over
a three-year period, designed to create opportunities to learn how to invest for health by
creating synergy among three types of development: economic, social and health. It brings
together leading exponents of intergovernmental organizations (IGOs), nongovernmental
organizations (NGOs), business, local and national politicians, academics and the media
across Europe, East and West.
1. Introduction to the Investment for Health (IFH) approach
Population health is, by and large, determined by social, demographic, and economic factors
and public policies well beyond the traditional remit of medicine or even public health
(3,4,6,8,9,13,15,34,37,39,41,48). Throughout history, the greatest improvements in people’s
health have mainly arisen from social and economic improvements which also promote
health (18). Conversely, a healthier population can make a more productive contribution to
overall development, requires less social support in the form of health care and welfare
benefits. Therefore, investment aimed at securing positive health and wellbeing also brings
social and economic benefits for the whole community.
IFH is a practical approach based on these interlocking facts. It is based on the rationale that
resources are best applied in a way which both attacks the main causes of ill-health in a
credible, effective and ethical manner, and which also furthers the achievement of goals for
social and economic development.
Priority social and economic policy areas - such as education, income maintenance,
workplace regulation, housing, transport, agriculture and communications – as well as private
initiatives, have a profound influence on health. Governments, and supra national institutions
such as the EU, have great potential to improve or worsen people’s health through their
policy decisions in these areas. This increasingly applies to the private sector too. Great harm
can be done to health by misguided public policies or private initiatives alike. The IFH
approach offers practical measures to prevent this – by building social and economic
strength together with health improvement for the population in an equitable, empowering
and sustainable way.
The IFH approach therefore calls for a new form of partnership. In today’s complex world,
action for the promotion of health cannot come from the health care sector alone. It needs to
be built on strong cross-sector alliances between health and health care, social development
and equitable and sustainable economic development.
Kickbusch (20) argues that at least three key questions need to be addressed in developing
a strong and credible health promotion strategy:
•
•
•
Where is health promoted and maintained in a given population?
Which investment and strategies produce the largest population health gains?
Which investment and strategies help reduce health inequities and are in line with
human rights?
These questions are at the heart of IFH (77). This approach also poses and seeks to answer
a fourth question: Which investments contribute to economic and social development in an
equitable and sustainable manner and result in high health returns for the overall population
(76)?
50
Hardly any of the ‘health sector’ reforms underway in many European countries address
these four questions in a systematic manner. (77,45). IFH is a practical attempt to answer the
above-mentioned questions by: identifying relevant policy attributes; considering factors that
may enhance or inhibit policy change; assessing options that benefit both health and the
specific policy sector; and planning the political process of achieving the necessary
legislative, regulatory, financial, organizational or educational changes (76). In some
circumstances IFH will require substantial policy change, which may involve major financial,
institutional, human, regulatory, or educational efforts. Ensuring and managing these changes
is a key part of IFH practice.
In summary, IFH is a deliberate attempt to address the main “causes” of health in a credible,
effective and ethical manner that engages other sectors of society as well as the health care
sector (40,76). The approach develops policies and programmes that are based on, and
address, key determinants of health. Such determinants are mainly linked to economic and
social factors (61,66,68,73). Stimulating and securing the self-interest of other relevant
sectors of society is critical. Positive changes for health should be facilitated at both
individual and community level. Therefore, unhealthy life conditions (e.g. poverty,
inequalities and social exclusion) should be modified not only bio-medical risk factors!
Finally, it should be emphasized that IFH does not take a narrow view of solely utilitarian
aspects of investment and economic trade-offs. It places the protection and promotion of
the health of the population firmly within a human right perspective, as well as an indictor of
human and social development. Thus, IFH is not confined to mere issues of costs-benefits
analysis of selected prevention and health promotion programmes. Indeed, Investment for
Health focuses on maximization of assets for health. This issue will be explored in more
detail below.
Likewise, IFH is sensitive to the removal of social, economic and
environmental barriers to the promotion of health. These adverse conditions can be
associated with a wide range of factors, including lack of democracy and infringement of
human rights, the burden of the external debt of many developing countries, or the unequal
distribution of resources and opportunities for social and personal development.
2. Social and economic determinants of health: The evidence for IFH
Until quite recently, public health practice, including the range and selection of interventions,
has been guided almost exclusively by evidence drawn from medical epidemiology (60; 68).
Far less attention has been given to the effect of economic and social development on a
population’s health. The notion that public health decisions must be profoundly linked to
wider social and economic goals to ensure sustainable benefits is still not widely
appreciated. Nevertheless, an expanding literature has been making a powerful case for the
relationship between health and economic development (11,12,21,30,31,33,34,41,43,44,56).
2.1 Evidence from the Past
In the last 150 years, in the European Region, there has been a dramatic change in the
epidemiological patterns of ill-health. Much has been published already on the fact that in
the more advanced industrialized nations of Europe (as well as world-wide) there has been a
reduction in the massive toll of infectious diseases such as cholera, poliomyelitis,
tuberculosis, etc. These were the epidemics which typically affected populations in earlier
stages of urbanization (33). Using data from England and Wales (similar results have been
obtained in studies carried out in several other European countries), McKeown (34) confirms
that the halving of mortality rates (from 23/1000 in 1851 to 11/1000 in 1980) and the doubling
of life expectancy (females: from 40 years in 1840 to 76 years in 1980; males: from 43 years
to 70 years) are explained by the reduction of infectious causes of death associated with
51
improvements in the environment (e.g. the introduction of sanitation measures), living
conditions (e.g. better housing and nutrition), and other factors related to social and
economic development (e.g. increased family income). Medical breakthroughs, such as the
availability of vaccination and immunization, came after the Second World War, by which
time the major drop in mortality rates had already occurred (35).
In developed countries, the receding pandemics of infection during the 18th and 19th centuries
were attributable more as a response to social, economic and environmental changes than to
medical breakthroughs (34). The latter were few and came too gradually and too late to be
responsible for the changes in health and disease patterns. The policy implications of all this
are still largely overlooked. There is no doubt that the explanation for this reduction in
mortality is strongly linked to improvements in living and working conditions brought about
by social and economic development (14,33,34,35,41,43,79).
To argue that falls in death rates and the decline of pandemics in the last two centuries have
been primarily related to changes in the environment, in the nutritional status of the
population, in the supply of clean water, in the effective disposal of excreta, rather than to a
specific medical intervention is not to downplay the role of the medical profession in
achieving these successes. In many cases it was physicians who saw the relationships
between nutrition, water supply, sanitation, poverty and illness and forced the authorities to
take action (46,47). Health professions have played, and continue to have, an important role
to play in changing disease patterns. What is important to recognize is that the actions to
control or eradicate diseases are often social, economic or environmental interventions.
2.2 Evidence from the Present
Turning to the present, a number of recent studies focus specifically on the issue of social
and
economic
development
as
key
categories
of
health
determinants
(8,9,13,31,35,48,53,54,56). Several studies point out that the early signs of deterioration in
the health status of populations are, in general, determined by changes in their social,
economic and environmental conditions (see for example: 23,48,50,56,57,58).
At national level, there is a demonstrable relationship between economic performance,
income distribution, and health status, which has significant implications for social and
economic policy-making. The higher a country’s average income per capita and the more
equal its income distribution, the greater the likelihood of longer and healthier lives for its
population (61,64). Maternal and child health patterns often reflect general economic trends.
For example, child and infant mortality rates have been found to be sensitive to economic
hardship. Studies in developing countries have shown that a 10% increase in income per
capita corresponds to a 3.5% fall in child mortality rates (57). According to the World Bank,
this estimate reflects the total impact of income on health. It includes efforts working directly
through income (e.g. food consumption), as well as indirectly through factors that are
themselves mainly determined by income (e.g. access to safe water and sanitation,
availability of health care, etc.).
There is now overwhelming evidence that much of contemporary illnesses and death (and
thus the potential for the promotion of the health of the population) are rooted in the
prevailing type of economic development and linked to social factors (8,9,11,12,13,30,48,53).
In general, if economic development goes hand in hand with decreasing social inequalities, is
environmentally friendly and strengthens social capital, it will have positive impact on a wide
range of social and health indicators. In both developed and developing countries the
number of people in poverty is an especially important reason for differences (inequalities) in
health. In every society the income and status of women exact a powerful influence on
population health. Especially in the poorest countries, policies that accelerate family income
52
growth, reduce poverty and expand opportunities, particularly for girls, help people achieve
better health (57).
In his book “Unhealthy Societies”, Wilkinson confirms the necessity to bring social and
economic issues up front in order to better understand their effects on health (56). This very
interesting study analyses data from several European countries as well as the United States
and Japan. From Wilkinson’s work the main lessons can be summarized as follows:
1.
2.
3.
above a certain level of wealth, it is not necessarily the richer societies which have
better health, but those that have the smallest income difference between rich and
poor;
increased inequality imposes economic, social and psychological burdens which
reduce the wellbeing of the whole society;
there is no basis for choosing between greater equity and economic growth; on the
contrary, by lubricating the economy and society, investment in “social capital”
increases economic efficiency.
Income distribution is important not only for health but also for social cohesion. Societies in
which there are high levels of income inequality also tend to have higher levels of violent
crime. Deprivation leads to stress and economic hardship, reduces people’s ability to fulfil
roles, and contributes to psychological ill health. Income inequality must, however, also be
looked at in the wider perspective of the extent to which social goods (e.g. free education)
are available to lower income groups.
Socially cohesive societies are those with well functioning institutions and well developed
civic communities. With reduced income inequality and improved standard of living for the
whole population, people can form and participate in social networks across society and
through a variety of social organizations, purposes and activities. A sense of moral
collectivity and social purpose remains important. When inequalities increase, social divisions
become deeper. Societies which pursue more egalitarian polices often have faster rates of
economic growth and higher standards of health. The cost of inequality is a cost incurred for
no economic benefit, but one that imposes a substantial economic burden and reduces the
competitiveness of the whole society (70).
In many parts of today’s world, a rising proportion of people is living in poverty, and Europe
is not untouched by this phenomenon. High economic growth in conjunction with rising
unemployment, job insecurity and low-paid jobs lead to widening income gaps and to rising
social inequality (54,56). Changes in living conditions and a widening range of family
structures (single parent families, divorce, commuter families, etc.) are an increasing reality in
most European countries. A narrowing labour market and fragile social and family supportnetworks result in a higher proportion of children at risk of living in poverty (9). We know
that this will have serious short and long term ill-health consequences. Unless decisive,
coordinated, intersectoral policies are explicitly designed to address these phenomena, and
effectively implemented, the maintenance of health, let alone its improvement, will be much
more difficult to achieve (77). There is much at stake if such strategies are not applied.
A study by Cornia (8;9) explores the reasons behind the mortality crisis during the transition
period (1989–1995) in the countries of central and eastern Europe (CCEE). During the first
reform years, life expectancy at birth fell in 12 out of 16 of the CCEE for men and 10 out of 16
for women. In all these countries, life expectancy in 1995 was still lower than in 1989. In the
1990s, most CCEE have been affected by an unprecedented fall in output and incomes, a
rapid impoverishment of large sections of society, an increasing level of uncertainty and a
mortality crisis (50). According to Cornea between 1989 and 1994 “the number of the poor in
the region rose by 75 million, the crime rate tripled and the number of additional deaths
reached 2 million. Changes in the labour market were no less dramatic … . The mortality
53
impact of these and other changes has been very large.” (8, p.1). Neither popular
explanations nor theoretical models are able to fully explain the mortality crisis that occurred
in this part of Europe. There is growing evidence that it was largely due to the psycho-social
stress generated by an unguided, unassisted and unmanaged process of restructuring, the
pace and pattern of which was (and in many cases still is) left to highly imperfect markets
and still weak institutions (8,9,70)
It is because of this powerful evidence that economic and social determinants play such a
central role in the IFH approach.
3. Principles for Strategy Development
Through WHO’s practical work to date with governments (national, regional and local), the
private sector, business, researchers and other interest groups, a number of common
features of successful IFH approach have emerged. The core principles on which IFH is
founded are:
1.
2.
3.
4.
5.
6.
a focus on health
full public engagement
genuine intersectoral work
equity
sustainability
a broad knowledge base
The objective is effective action to tackle the root causes of ill health and create
opportunities for better health and development. Health improvement will not always be the
primary policy goal. But it is important to assess the population health impact (both positive
and negative) of public policy decisions, development strategies and investment decisions,
particularly those with social and economic implications. Economic development can be used
as a means of improving both the social infrastructure and people’s health. But the way in
which investments are made ought to contribute to health improvement.
Genuinely involving the public, whose health is affected by such policy decisions, requires
going beyond traditional electoral and consultative approaches. There must be new, formal
opportunities for full democratic involvement at all political levels. Such opportunities must
respect gender, age and racial differences consistent with the principles of social justice.
In view of the importance for health of decisions and actions by sectors such as agriculture,
education, finance, housing, social services and employment, a sensible, effective strategy to
improve health requires the active inclusion of all sectors to achieve the synergy required to
improve population health.
The WHO global strategy of achieving health for all is fundamentally directed toward
achieving greater equity in health between and within populations and between countries.
Equity implies that all people will have equal opportunities to develop and maintain their
health through a fair distribution of the resources that support health.
Sustainability, as used here, has a dual significance: signalling firstly the aim to create an IFH
process that is durable and resilient; and secondly, that investments are made and resources
are managed in ways which do not compromise the health and wellbeing of future
generations.
The development and implementation of policies and plans which will contribute to the
achievement of IFH goals cannot rely solely on technical information, but must be sensitive
to community aspirations and goals, so that ‘knowledge’ here will include community
54
judgment and insight as well as research data and other ‘scientific’ sources and practical,
hands-on experience.
The ideas behind these principles are not new. We intuitively know them to be right. But
very few (if any) countries or regions in Europe systematically apply these principles to
decisions about improving the health of their people.
In order to implement these principles, a strategy is required involving the concerted efforts
of a variety of players at all levels of government and society. As mentioned earlier, the
successful strategy must influence sectors such as health care, social services, education,
environment, and economic and social development. Public and private initiatives, the
media, non-governmental organizations, and all other institutional arrangements crucial to
social cohesion, social justice, and human rights must be involved. (59; 60; 64, 66; 69). With
so many interests visibly involved, the strategy for promoting health has to be intersectoral,
it must involve multiple levels of policy-making in economic and social development (local,
regional, national, and in several instances supranational), and it needs to use a wide range
of levers for change (educational, legislative, fiscal, etc.). To achieve such broad and
encompassing influence over so many sectors of society, those with an interest in the
promotion of health must offer something in return to other interest groups or policy sectors.
The IFH approach attempts to do precisely this. An analysis (IFH appraisal) conducted in
several European countries at the request of their Parliament (including Romania, Slovenia,
Hungary and Malta) indicates clearly that economic regeneration will not be sustainable
unless there are parallel improvements in the health of the population. The initial findings of
the WHO Commission on Health and Macro-Economics (chaired by professor Jeremy Sachs)
substantiate the need to position the promotion of population health at the heart of the
development agenda of countries.
4. Methodologies and practical experiences
We noted earlier that one of the key challenges in applying the concept of IFH in practice
was moving from theory and belief to making decisions and implementing them. This section
summarizes a selection of the tools that have been developed, applied and refined in various
IFH demonstration projects and national IFH appraisals carried out by the WHO Regional
Office for Europe.9 Through these on the ground experiences it has become clear that to
make IFH a reality requires methodologies, tools and policy-making processes capable of:
•
•
•
assessing the structures, systems and processes with a country/region or local
area’s current and future opportunities, within and outside the health sector, that
promote or hinder the health of its population and identifying ways in which this
infrastructure can be improved;
identifying the key elements for a strategy that enhances the population’s health
through selective investment (both within and outside the health sector) while
supporting key economic and social priorities;
negotiating for investment for better health with policy makers and key decision
takers in other leading social and economic sectors.
It is clear that there is much to be learned regarding the efficacy of health investment
processes. Evaluation of these is made harder by the fact that economic and social
circumstances vary, making transfer and replication difficult (24,25). It is only by testing
things in practice that we can begin to identify and order those variables that contribute to
9
In this process WHO was assisted by a wide range of cooperation with countries and institutions.
Among these it is important to acknowledge the support of the Office for Public Management.
55
effective health investment processes and outcomes. We need ‘living laboratories’ where
decision making investment processes can be observed and appropriate adjustments in
policy targets, administrative and logistical supports, and action strategies can be made. In
these practical experiences the focus should be on maximizing community health assets, not
only on minimizing or alleviating the negative impact of social and economic changes.
4.1
Maximizing health assets
Since 1995, the WHO Regional Office for Europe has undertaken a series of advisory studies
at the request of Member States in a spirit of mutual learning about how health investments
can be decided, implemented and evaluated (63,67,71). These experiences have shown that
it is important to take account of the whole spectrum of health promoting assets to pinpoint
where new developments are needed. These assets include policy investments, regulatory
changes, nurturing of non-governmental resources and programme initiatives, strengthening
of health promoting infrastructures and decision-making, refocusing education, investing in
research, training in requisite health promotion skills, and environmental improvement.
The identification and strengthening of assets is of key importance in the IFH approach. What
happens next – the areas that need changing – is to a large extent dependent on local
circumstances and assets: the willingness of a community to change and improve its living
conditions; the quality of the physical environment, the level of social capital, or any other
collective resource that could be used to promote health and gain more control over the
determinants of population health.
Thinking in terms of assets for health does not come naturally. Most interventions to
promote the health of the population ought to focus on the needs or problems of a
population. Although appraisals take into account health needs, need reduction is not the
primary objective of implementing IFH. The status and potential of health assets (resources)
is, of course, the main focus of IFH (Fig. 1).
Let us assume that a community’s level of need is A on the need axis. At this level, the type
and degree of IFH depends on the community’s level of assets. This could be low (B) or high
C.
If the chosen strategy has no effect on need (e.g. from B to B1), traditional epidemiological
or other need-based indicators would suggest that health promotion has no effect at all,
whereas, as a matter of fact, the strategy increases the community’s assets for health.
Similarly, if the initial condition of a community is C and, as a result of a given strategy that
community moves to C1, according to conventional need-based evaluation there is no effect,
but in practice C-1 is worse than the initial C overall. Furthermore, if a community moves
from C to D, D is not necessarily in a better condition, because the reduction in need comes
with a drop in assets for health.
IFH involves accounting and searching for asset maximization, not just need reduction.
Furthermore, IFH helps identify different health promotion strategies when a country, region,
or local community belongs to different quadrants in the need/assets diagram (see Fig. 1).
56
57
4.2 The health gain map: the Trentino Alto Adige demonstration project
This tool was developed as a result of an IFH demonstration project in the Northern Italian
autonomous region of Trentino Alto Adige. In this region the major issues affecting people’s
health and sense of wellbeing, were identified as employment, education, security, and
housing, with transportation, urban cleanliness, and access to health care following closely.
However, moving from general agreement on issues to operational strategies is, in most
cases, not a simple endeavour. But this practical step is of key importance in the IFH
approach.
In this demonstration project various methods to assess the impact of public policy on
health both qualitatively and quantitatively were utilized. A “health gain map” (Fig. 2) and
other inventory of the impact of public policies, private initiatives, regulations, and
programmes were used to form a baseline as well as an ongoing accounting system (62,75).
Fig. 2.
Health Gain Map
Health
Service
Population
Group 1
XXX
Population
Group 2
XX
Education
X
XXXXX
Transport
Social care Environment
XXX
X
O
X
Criteria for Action• Health Gain?
• Implementation costs?
• Investment trade-offs?
• Values?
XX
XXX
etc.
O
O
Population Health Gain Plan
Various methodologies can be used to create a health gain map of a particular community or
geographical area. These include typical health impact assessment methods (1,28,40;), policy
analysis (5,29,42,49,51,52,56), and simulations (32). Important information can be gathered
by involving the community in the appraisal. Nominal group techniques, focus groups and
other methods have proven valuable in this respect (2,10,26,27,74).
These techniques are particularly useful in identifying the potential contribution to health of
various policy sectors in a “health gain matrix”. Very often, when different IFH options have
to be weighed according to a number of criteria. Fig. 3 shows a health gain matrix with four
58
criteria (C1–C4) that have been agreed upon for appraising the options. In the demonstration
project these criteria included:
•
•
•
•
equity;
sustainability;
empowerment;
overall resources needed.
The above-mentioned techniques were used in weighing the relative importance attributed to
these criteria by various segments of the community, policy-makers and other stakeholders.
Fig. 3.
Mapping Investment Opportunities
C3
C2
C1
Population
group 1
Population
group 2
Promoting
Healthy
Youth
Healthy
Ageing
Health
services
Social
services
+
+
+ +
Physical
Education Transport Housing environment
+ +
+
+ +
+
Tools such as the health gain map are very practical in the early stage of mapping
investment opportunities to promote health across public policy .
59
4.3 The bargaining framework: the Valencia demonstration project
Policy sectors are not sitting around waiting to be reformed or even advised by health
experts (21). Motivation for strengthening the health impact of a policy area must exist, be
fostered, be sufficient to encourage sharing of data and exploration of options that fit a
sector’s “culture”, and carry no negative consequence (such as additional costs, loss of jobs,
jurisdictional conflicts).
These lessons were reinforced in a demonstration project carried out by the WHO Regional
Office for Europe in southern Spain in cooperation with the Valencian Institute for Public
Health and the Valencian Regional Government (65). The main goal of the demonstration was
to explore the possibility of developing IFH alliances with sectors crucial to the economic,
social and health development of the Valencian region. The identified sectors were health,
tourism (which represents a major proportion of the region’s GDP) and agriculture
(historically a very important sector for both culture and productivity and still one of the
largest economic domains).
Fig. 4.
60
The demonstration identified shared goals and policy decisions (“D”) among the three
sectors that would result in gains for all three (Figure 4). The common agenda for IFH could
be achieved not only through search for “win-win-win” solutions (i.e. “D” decisions), but also
through other important decisions taken with the IFH approach and placed within a
“bargaining” policy environment. Thus, the health sector would be prepared to support “B”
decisions for example financial incentives for developing “agri-tourism”, (win-win for
agriculture and tourism, no effect on health) as long as the agriculture sector was prepared
to support “A” decisions, for example, the reduction of urban congestion and pollution
during the high tourist season (“win-win” for health and tourism) and the tourism sector was
willing to support “C” decisions, for example, reduction of accidents and mortality in rural
and agricultural countries (“win-win” for agriculture and health).
Many tools and techniques can be used by policy sectors as they revisit their development
priorities and establish new and shared ones, thereby setting a common agenda for
Investment for Health. These tools include opportunity appraisals, conflict assessment
analysis, multi-attribute modelling, stake-holders analysis, and behavioural and
organizational simulations (16,17,19).
5
Conclusions: what direction for the future?
The arrival of a new millennium provides a unique opportunity to enhance the health and
wellbeing of European people. New technologies, better communication and the desire for
social and economic reform provide the scope for improving health in a radical and
imaginative way.
Decisive efforts should be made by the international community,
development agencies and government to ensure that these opportunities are available to
the disadvantaged nations and population groups throughout the world. Inequities, be they
of health, social or economic nature, should be drastically reduced within and among
countries. This is a key condition for sustainable investment for health and development.
For IFH principles to be effectively applied, traditional policy making approaches must
change. New commitment and skills to work both within and, most importantly outside the
health sector, and new skills of policy analysis and assessment will all be needed. Each of
the demonstration projects, as well as the national IFH appraisals outlined in this paper, has
shown that the challenges of moving from an understanding of IFH to implementing it should
not be underestimated. It is a huge step from believing that the connections between health,
economic and social development are real to getting others, including ourselves, to change
the way we work. Change is difficult, and the forces of inertia are strong, but the potential
benefits of IFH are enormous. So how can the ground be prepared for cultivating IFH in
practice? There are some essential developments that need to be fostered:
1.
There needs to be political priority given to health. Health can no longer be seen
just as a matter for doctors, nurses, their patients and the Ministry of Health. This
needs to be more than a commitment in principle and words. - politicians need to
develop a better understanding of the factors that determine health and illness and
what can be done to address them. For Ministries of Health this presents an
unrivalled opportunity to take a leadership and advocacy role within government,
encouraging colleagues with other portfolios to see the relevance of the health
agenda to their own sphere of activity and interest and supporting them to develop
the right and political skills to make decisions that improve health.
2.
Beyond political priority there also needs to be clear accountability for health
improvement across policy sectors and departments. “Health for all is the business
of all” has become a cliché. As in business, so in politics: there must be
61
accountability for results. If ministers, policy makers and managers are to be held
to account for their successes and failures in health improvement, there will need to
be more effective ways of measuring health. Unless we can measure improvements
there can be no accountability. Most countries collect data on mortality and
morbidity, few focus on positive health indicators. So with accountability comes the
development of systems, processes and analytical tools to assess health and health
impacts of policy options.
3.
There needs to be a public understanding of health and how the health of the
population can be promoted and sustained. Public opinion is too easily captured by
hospitals and illness. Public understanding and commitment to investments that
promote health will be essential if politicians are to be able to make the difficult
decisions that they will need to make.
4.
There are always competing options when decisions are made on an investment.
This is equally true for IFH. Some options may be obvious; others less so. The more
IFH is explored, the greater the range of options that will be uncovered. There
needs to be recognition of the trade-offs between health, economic and social
development outcomes. Not all stakeholders who have an influence on health have
health improvement as their main priority. Associated with this is an urgent need
for decision-making processes that allow those in different sectors to understand
and make those trade-offs in their decisions.
5.
At all levels of society skills need to be developed in working across sectors. Each
sector of society has its own interests, goals, resources and ways of working.
Common action to improve health requires common ground - shared ideas,
resources, a place to meet. These do not just happen - there must be stimulation
and processes to bring people, and other resources, together.
6.
New incentives need to be developed. Sectors will not cooperate because someone
says that it is a good idea. They must see benefits for their own remit and see
incentives sufficient to justify policy adjustments that may promote health. Political
drive, tax breaks or special reward schemes might be needed - imagination and
negotiation certainly will.
7.
A clear picture of what an IFH strategy can deliver needs to address not only what
is possible at state or civil level but also what individuals and communities can do.
Bottom up approaches that mobilize community resources can be sustainable but
they need to have a context within which to work.
8.
New infrastructures may be required to support Investment for Health. But these
cannot run in parallel to outmoded systems. Far more important is the adaptation
of the current infrastructure to sustain IFH. (see also the Technical Report on
Infrastructure for Health Promotion).
9.
A new data set of Investment for Health indicators should be developed. There is
still a paucity of health/salutogenic indicators (as distinct from disease/pathogenic
indicators) used at the global, national and local level. Such indicators ought to
include measures relating to the determinants of, and assets for, health. National,
regional and local governments should publish regular reviews of progress on
health improvement and social and economic development against clear indicators
of success.
10. Crucial to all the above is a willingness to learn about how to make IFH work.
WHO’s Verona Initiative and this Forum in Gastein have unique and fascinating
62
roles in facilitating cross-fertilization of ideas, practical experiences and research
findings across countries and governments.
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Introduction to Parallel Forum Sessions
Paul Lincoln
Speech not available.
Forum I: Health in other Policies and Sectors
67
Forum I: Health in other Policies and
Sectors
John Bowis
My theme is partnership and how to work together to take account of the impact of other
policies on health – not just the damage that such policies can do to health but the positive
contribution they can make. And by policy I mean the plans and actions of governments,
councils, employers, communities and, indeed, individuals.
When I was a national MP we had a disastrous rail crash in my constituency. What was
impressive that morning was the cooperation of all the agencies to deal with the crisis.
Medical teams alongside fire, police and local council personnel and all the back up from
canteens to blood transfusion services. They were all working for health – after considerable
forward planning – yet the headlines were all about transport. I doubt if many transport
officials that day realised they were involved in health activity.
In Paris at the IUHPE conference this summer I recalled visiting in my London Constituency
an elderly lady sitting watching television with the sound off.
I asked her why and she said she was rather deaf and could not hear the sound. Could I ask
someone to see if she could get a better hearing aid, I asked her.
Oh no, that was not the problem, she said. A very nice lady had called and arranged for her
to have a hearing aid but the problem was she could not manipulate the volume control on
it with her arthritic fingers.
One person with two disability problems.
Neither resolved because the two agencies concerned had not had the nous to talk to each
other.
Another day another constituent.
He was suffering from depression, living in a modern sheltered flat. He had previously lived
in very poor housing on a run-down estate but, he said, he had been happy there.
He knew people; he knew the neighbourhood and every Saturday night he played the piano
in his local pub.
Now he had been moved by well-meaning housing officers to a lovely flat but where the
rules did not allow him to practice his piano.
So he sat there, his fingers growing stiff and his life made miserable.
Two examples from my own experience of services not talking to each other and the system
not being flexible enough to provide the seamless care a person with health or disability
problems needs.
Nor is it just services that need to work better together.
68
Government Departments rarely talk to each other and are fiercely possessive of their
individual budgets.
Trying to persuade Health, Education and Social Services to come together to share
responsibility for children and adolescents with mental health needs, was a nightmare I
fought every day, yet the child concerned needed an input from all three services.
Now I am in the European Parliament and the same failures to form partnerships are
apparent.
As I said at Gastein last year – and will go on saying until we achieve results if the European Union decided next week to spend billions of Euros processing heroin or
marketing lead toys, I think I can guarantee an army of men in white coats would descend
on Brussels and take us all away for treatment in a secure institution.
Yet the biggest obstacle to progress on health in Europe and the success of the European
Union’s new proposed Health Action Programme is lack of money to spend on implementing
it effectively.
And the biggest reason for this is that, while we propose to spend a tiny, tiny sum on health
of Euro 50million a year for six years, we are content to increase our spending on growing
tobacco to over Euro 1,000 million a year.
Euro 6,000million to sponsor a known killer, a waster of lives, the biggest single cause of
cancer and heart disease and just Euro 300million to cover all the ills of our European world
that flew out of Pandora’s Box.
It is immoral and ludicrous economics.
And why does it happen and why is it so difficult to correct?
It is because tobacco subsidies come under the Common Agricultural Policy and Ministers,
MEPs and Commissioners from the countries that grow the stuff are more interested in the
votes of farmers than they are of the health of their citizens.
But now we have a new European Health competence under the Treaty of Amsterdam, which
both places Health Promotion firmly on our agenda and requires that a Health Impact
Assessment be carried out on any major new policy.
I believe that Europe needs a Health Wake Up Call. I wrote the Report for the Parliament on
the Health Impact of Enlargement and set out the problems that most of the countries of
eastern and central Europe had in maintaining health standards at a time of economic
difficulties.
The health systems are not just breaking down there, they are crumbling within our current
EU, under the pressures of demographic change (with people living longer); and of the pace
of scientific advances in medicine (with a new drug or treatment, often very expensive,
immediately causing a new queue to form); and of an increasingly well informed public, who
demand instant access to what is available and look for compensation if drugs or treatment
fail them.
To meet that challenge we need imaginative and cooperative partnerships
•
health professionals; and social workers; and housing officers; and benefit
managers; and trainers; and employers; and advocates; and service users; and
families; and NGOs; and planners; and architects; and teachers; and all
•
69
a one stop shop of care and support.
I am a politician – one of those who are often portrayed as ‘Them That Will Not Hear’
•
•
•
•
the Politicians, Governments, Commissioners, National and International authorities
and agencies,
that have the power to do something and the purse to make things happen
But if we do not listen, we cannot hear and understand.
And we were only blessed with two ears each.
Those ears are dominated by media and constituents’ concerns on floods, wars, rail crashes,
traffic gridlocks, crime, drugs, food safety, animal welfare and all the “big” stories of health –
shortage of cancer specialists, AIDS, intensive care beds, CJD and we don’t see the
connection..
And as to Health promotion, there is little understanding by governments, politicians or even
health service planners.
The main reason is they have no idea what it is about or why they should be interested.
So, when trying to convince my colleagues, I start from the other end.
Start from the end, which hurts in government.
Start from the cost of not doing anything.
Start from the fact that people are living longer and, on the whole healthier, lives, but in
their later years a growing number of them become frail of body and mind. Start from the
fact that, although the number of carers is steady, it is a fact that, whereas they used to be
next generation, now they are same generation - spouses, partners and friends - who will
have problems of their own, and may be unable to cope without support.
And if they can’t cope, the taxpayer will have to.
And then go on to promote the reasons for investment in health:
•
•
•
•
•
•
If fewer people smoke, you cut the cost of cancer services.
If more people eat and drink and exercise sensibly, you cut cardiovascular service
costs.
If motorists drive at an appropriate speed to their environment, A & E costs less.
If housing policy cuts overcrowding, it also cuts the cost of TB.
If families in difficulty are supported earlier, you cut the cost of child and
adolescent mental health services, by reducing the number of children with
behavioural or, perhaps, eating disorder problems.
If employers have in place effective mental health-at-work policies, with, for
example, non-threatening and confidential counselling services and flexible work
schedules for carers, they will have employees who, individually are more able to
cope with their own or their family’s mental health problems and who are therefore
more able to contribute to a collectively more productive workforce.
And perhaps light begins to dawn in the hardest of Finance hearts.
Investment in health promotion can save us money later and enable us to pay for those
illness costs, which we began to fear might never be affordable.
Then we may all understand a little better that the problems of the day are a seamless
health message.
70
•
•
•
crime, drunkenness, accidents, absenteeism, street hooliganism, disruptive pupils,
rough sleepers, beggars, neighbourhood noise.
Get that message across and practitioners and policymakers are astounded to find
themselves on the same wavelength.
All health in origin or in effect.
In my home city of London, a recent survey showed nearly a third of rough sleepers to have
been discharged from the armed forces and found themselves unable to cope with civilian
life.
Whether the figures are wholly accurate or not, it shows even Defence Ministries have a role
in Promotion and Prevention.
The downside of failing to address the causes for someone in such a situation is lost income,
lost family, lost home, lost self-respect and so on.
The upside of preventing it, by promoting wellness, is that you have someone leaving the
army and being helped to cope with his new life.
Any employer knows a fit and happy and informed workforce repays the investment through
productivity,
just as any sporting team manager knows his investment in the mental as well as physical
fitness of his team will be returned in goals.
My argument is that we have to look beyond the health and social care professionals;
beyond the drugs and therapies;
beyond the hospitals and community health teams.
We need to engage with new partners to prevent illness and to avoid relapse. Housing
people, for example, not in the isolation of high-rise flats on run down estates, but in
communities where the living environment will be part of the support and stability a person
needs.
And rehabilitation and training, so that he or she can regain self-confidence and self-respect
and, in so doing, make readmission less likely or at least less frequent.
Policies for ageing work – not just policies for pensions and care but looking for ways in
which retired people can find a role and be useful, in social and educational contexts, for
example – and preparing people for the moment they leave the place of work they may have
been going to for 40 years
Collaboration between agencies can work, not just in support of an individual, but to screen
out health risks, to identify cross-discipline problems and to ensure appropriate dual
diagnosis and treatment.
The Treaty of Amsterdam of course gave us a new tool – the Health Impact Assessment. If it
works, it will make other policy areas stop and think how their sparkling new policy might
impact on health.
If it works, they will start by being more conscious of the negative impacts it might have.
If it really works they will go on to understand the positive contribution their policy could
make to the health of the nation and of Europe. They will realise that as decision makers in
governments or commission ‘we are all health ministers or health commissioners now ‘.
But we are at the drawing board stage – that critical point when we have to get the design
and measurements right for the system to be effective.
71
Does the media have a role in promoting health policy and bridging
the gap between policy and implementation? PR or “ER”?
Shirin Wheeler
Abstract
My position - as a member of the news media and in particular television- stems from the
premise that it is not up to the media to bridge policy / implementation gaps. It cannot be a
propaganda tool for government, politicians or the medical profession.
You cannot rely on the media to disseminate information on health policy. The message the
media seizes upon may not be the one you believe is most important as a policy maker.
But as a policy maker bridging these gaps successfully will somewhere along the way involve
the media. When the issue and its relevance to policy is translated into pictures, radio and
popular press its impact can be enormous . Television for example has the potential to
articulate visually and verbally making links between health issues and other policy sectors
for example respiratory illness and transport policy in ways
Carlos Ribeiro
Abstract and speech not available.
Bosse Pettersson
Abstract
In Sweden a green paper – “Health on equal terms” – for a national public health policy was
published by a Parliamentary Committee in December 2000. It presents 18 broad national
objectives, further broken down into 50 sub-objectives to which proposals for indicators are
linked. 14 of the broad objectives are expressed in terms of health determinants and the
remaining 4 deals with basic infrastructures for public health. The Governments white paper
is planned to be presented to the Parliament in December 2001.
72
Tackling the determinants of health implies a multi-sectoral approach. This has already been
settled in the field of environment, where national state authorities are given the
responsibility to accomplish the environmental requirements that falls within their remit
respectively. The National Public Health Committee is using this approach as a model.
Simplified the rationale is built on a 3-step sequence:
1.
2.
3.
Identifying scientifically based determinants of health and in particular their impact
for increased equity in health,
Undertake appropriate actions in different sectors on different societal levels,
Follow up health outcomes by monitoring indicators and using comprehensive
measures for (ill)health.
Important tools and mechanisms for placing health in other polices are considered to be:
Establishing a structure in the Government’s Office in which public health
issues are managed horizontally,
Directing and guiding national state authorities according to the national
public health strategy by putting the responsibility for relevant health
determinants as part of their remit,
Developing a solid and politically strong monitoring mechanism. In
addition to a public health report a report on the development of healthy
public policy is proposed, as a resource for the Government to report on
Public Health to the Parliament once every 4th year,
Implementing health impact assessments (HIA) in major issues as part of
the decision making process, and local welfare management systems for
integrating health in municipal comprehensive planning schemes,
Establishing structures for facilitation, collaboration and co-ordination
between different authorities, agencies and other actors on different
societal levels. A living and open debate and dialogue is fundamental to
build credibility around a concept where health should be part of many
considerations.
Mike Ponton
73
Mojca Grunter Cinc
Abstract
Although Slovenia is a small country it is extremely diverse in terms of geography, culture,
health, economic and social development. Today, the country is in the process of
consolidating and completing its transformation to a competitive market economy, with the
ultimate aim of improving the living standards and quality of life of its citizens and joining
the European Union.
After independence, Slovenia’s political, economic and social systems have undergone
profound changes. These changes have also effected the health care sector. These
developments offer the opportunity to consider the potential contribution of health as a
resource for social and economic development of a young country like Slovenia; to move
health policy beyond health care. If the health of a population will be regarded as an
economic asset then health promotion will be seen as economic investment.
Health is determined by the interplay of wide-ranging factors. To achieve population health
gains broadly based strategy must be employed which requires concerted action by many
different players, including government, many sectors of society, the media, nongovernmental organisations and other public and private bodies which contribute to
economic activity, social cohesion and human rights.
In 1995, the Parliament of the Republic of Slovenia invited the Intersectional Health
Development Unit (Health Promotion and Investment Unit) of the WHO Regional Office for
Europe to assess Slovenia’s health promoting resources, supporting infrastructures, the
efficacy of existing collaborations, and the options for decision making. The main conclusion
of this group was that Slovenia has great potential for implementing a robust investment for
health approach which is in synergy with its economic and social priorities.
Slovenia joined the Verona Initiative with an aim to further develop and disseminate basic
health promotion concepts and investment in health approach at the local level which was in
line with proposed WHO recommendations. Furthermore, the process of development and
testing the practical tools like benchmarking system to support politicians, policy-makers and
practitioners in implementing the investment in health approach was appealing.
The main lessons learned from the exercise of testing the benchmark model at the local level
in Slovenia will be presented. Also the broader impact of the process at the national level
will be highlighted.
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Luigi Bertinato
Abstract
All too often, discussions on health policy and healthcare focus on cutting costs and not on
improving health. The Verona Initiative: Investment for Health, in contrast, took a lesson
from the economic and financial sectors and proposed a new approach to health policy, one
based on the principle that the right investments can benefit all sectors and all citizens.
With solid evidence from the past years that most of the determinants of health lie outside
the health sector, it follows that to change health status, governments must invest (time,
effort and money) wisely and carefully to have the desired impact on health status. This was
the case of the Regional Government of the Veneto, one of the twenty Italian regions
situated in the north-east of Italy, with a population of 4.5 million inhabitants.
The First Milestone: Appraisal and Benchmarking
The Verona Initiative revolved around three Arena meetings that served as a forum for
debate and consensus. Meetings were held in Verona, one of the seven major cities of the
Veneto Region, in 1998, 1999 and in July 2000, bringing together an unusually broad
spectrum of participants in person and via satellite TV and the Internet for a non-traditional
conference.
The first meeting established the Verona Benchmark, which identified characteristics of
systems that support Investments for Health.
A document called the “Verona Benchmark” was developed for health and health system
appraisal in a number of pilot projects. The objective was to determine what systems would
need to exist at national, regional or local level for a government to implement the IFH
approach.
The appraisal examined the overall situation in the country or region, undertaking a sectorby- sector analysis of policy options for intersectoral considerations, and explores structural,
organizational and institutional issues.
Policy-Making and the Verona Challenge
The second Arena meeting established the characteristics of the decision and policy-making
process needed to promote IFH. Essentially, the process can be viewed as an investment
triangle where social and economic development anchor two points of the triangle and
health promotion holds the third spot, illustrating the main principle of IFH: that investments
intended to improve health must also add economic and/or social value.
The third and final meeting focused on how to persuade policy makers to take action. It
issued a series of “challenges” that define the next steps and in effect suggest priorities for
health:
Highlights of the challenges include:
•
•
•
For national governments: establish a clear mechanism for coordinating policy
development across government departments; establish a communication strategy;
publish regular reviews of health improvement progress against indicators.
For local and regional authorities: establish targets for health improvement linked
to sustainable economic and social development; engage the population in
decisions about health; ensure integrated local and regional investment plans.
For industry and commerce: work with government to support initiatives
•
•
•
•
75
For international agencies: develop mechanisms for transferring learning between
countries; provide advice on developing indicators for success, including tracking
health impact assessment.
For nongovernmental organizations: mobilize community organizations and
advocate for including health in all public policy
For the media: create a climate for action; hold decision-makers to account
For the healthcare system: reorient health services to place greater emphasis on
sustainable economic development, health promotion and community health action;
recognize that health is determined by policies and actions outside the healthcare
sector
The experience of the Veneto Region to impact some of the principles of the Verona Initiative
into its health care system will be presented during the session.
Summary Report of Forum I
Cecily Kelleher
Summary
The objectives of this forum were threefold; to reflect on conditions necessary to move a
given policy from objective to implementation, to provide practical exemplars or accounts of
the development of multi-sectoral policy development in Sweden and Wales and to describe
in Italy and Slovenia (a member and applicant European country respectively) the application
of a benchmarking system for the implementation of a multi-sectoral policy. Each example
highlighted the particularity of the context in moving policy forward, the need for pragmatic
inter-sectoral alliances and the surprising progress that had been made, at International,
National and Regional level, because of the commitment of players across sectors to the
promotion of the public health. The fine balance between epidemiological evidence and
effective implementation strategies was emphasised.
The lesson for others in studying these examples is not so much why the various
stakeholders have ignored the healthy public policy agenda, but rather, why so much
progress has been made. The often silent partners, that is, the civil servants, have been
much involved in operationalising this inter-relationship between elected representatives, lay
groups, experts, statutory and non governmental organisations, often entailing a change in
their own role to a more facilitatory one. The question of ethical practice was raised in a
number of contributions, particularly the balance between the rights of the individual and the
need to act at community level for the good of society as a whole. A re-examination of public
health ethics is both appropriate and necessary. Finally the whole question of the meaning of
health promotion was highlighted. Rather than compartmentalising it as a lifestyle education
function, in this forum and in the meeting more generally, it means what the Ottawa Charter
(1986) conception envisaged, a process contributed to by many players within the health
sector and beyond, with re-oriented public policy a key component.
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Background
The determinants of population health are outside the control of any form of individual-level
health care system, although self evidently it has an important contributory role (1). Crosssectoral collaboration is therefore not simply rhetoric but a pre-condition to the desired
outcome, that of good health. We live in a paradoxical age, which we need to recognise and
live with, rather than necessarily change. Particularly over the last 50 years the world has
become a smaller place in social terms. We are more closely inter-linked and interdependent than ever and we have never had such unprecedented access to knowledge.
However, we have become all the time more compartmentalised in how we deliver on any
goal, in a climate of expertism and defined roles (2). Especially in the working world we
define our identity as individuals through those roles. The process of policy implementation
becomes one of complex negotiation between vested and responsible interests, often at a
remove from the strategic objectives. Cross-sectoral strategies accordingly must strike a fine
balance between the overall strategic objective and the practicalities of the situation at
operational level. Each contribution at this meeting reflected this fact.
Session 1: Bridging the gap from policy to practice and awareness
This comprised contributions from three professionals in different roles, the politician, the
media representative and the expert policy committee member.
John Bowis, a current member of the European parliament and a former health minister in
the United Kingdom, opened with practical, anecdotal examples in his constituency
experience of how a failure by different service providers to the same individual to interrelate can have an all too human cost. He highlighted the paradoxes at public policy level
that can occur through this same failure to communicate. For instance the 1800 million Euro
budget for health research is both relatively modest and considerably less than the subsidy
in the equivalent period of 6000m euros to the tobacco farmers in the EU region. This
paradoxical situation is explained by the reality that the politician delivers to his
constituents, in this case the farmers. The challenge therefore is to ensure an informed public
who will require from their politicians what they actually need. Health Impact assessment is a
useful potential tool because it can be used to make an understandable case for a given
policy to the general public. A useful practical way to persuade the finance minister, who is
not concerned primarily with the health agenda, to free up resources is to point out the cost
of not doing anything, in a wider social rather than purely monetary, sense. Shared
knowledge is a form of empowerment in expanded networks like the European Union, so
that people now compare service provision across countries rather than within their own.
Shirin Wheeler, an experienced journalist, indicated that the media have a role in equipping
the public to deal with health issues, by informing them of what is current. Media personnel
have no obligation to promote health in itself, nor are they propagandists. However there is
potential for mutual collaboration between the health sector and the media, with the shared
goal of empowering the public. The television medium necessarily distils complex messages
into succinct short presentations, averaging reports of two to 3 and half minutes. She used
a short report from North Karelia as an example, which combined eye-catching scenery, with
human-interest stories and credible expert comment. The media can add impetus to an
existing public health campaign. This works best where there is a climate of trust and
mutual understanding of each other’s roles. The media have an obligation to entertain and
inform in a novel way, and without strong top line facts, such as in this case apparent
evidence of a major effect (3), such a story is not news and couldn’t be made.
77
Carlos Ribeiro presented the position of the EU Economic and Social Committee in relation to
health policy, particularly with the signing most recently of the Amsterdam treaty. He
highlighted article 3, which stresses that health protection is guaranteed across policies and
activities. He noted the community action programme for health for the years 2001-6. This
includes the need to ensure increased information and knowledge of citizens across the EU
region, to increase capacity both for a rapid action response to threats to health and to
eliminate potential risks to human health, (whether spontaneously generated or, in part, as a
consequence of the open market and borders across the region). The committee regretted
the fact that while health impact assessment will go ahead as a measurement tool, the
fourth provision of the Health Action plan, the need to take account of the health impact of
policies generated in other sectors, had not been implemented. Integration of health
considerations in the way envisaged by the health plan must necessarily take account of
ethical considerations, such as the right to privacy of the individual. This in turn opens up
the wider question of an appropriate ethical framework at every level to address these
increasingly complex public health considerations. There is a need for partnership with
existing organisations and quangos with a public health function, not least to avoid
duplication of effort.
Session 2: Experiences from Sweden and Wales
Session 2 contrasted the experiences of public health policy development in both Sweden
and Wales, both countries with a strong record of attempts to implement healthy public
policy. Bosse Petterson works at the National Institute of Public Health in Sweden and is
advisor to the secretariat of the parliamentary committee in Sweden whose work is now at
the final stage of an almost 4 year process. The proposals will be presented to Parliament in
December and will be launched formally next March. He opened his presentation with some
useful general remarks. First, he likened policy to an obstinate stationary elephant. This
means that we in the health sector may wish for policy to take a certain direction, but it is a
matter of negotiation with a different type of animal to ourselves, rather than an imposition
of will. There may also be good examples from different sectors. In Sweden the road traffic
strategy is an effective example from a different sector of a move away from individual level
behavioural education to more supportive environmental changes, with the ultimate zero
goal that no-one should be killed or injured on the roads. He also described the
terminological evolution of the last 25 years. Inter sectoral as understood in Health For All
(World Health Organisation 1984) meant that the health sector took the lead and explained
the need for actions to other sectors. In Health 21, the term multi-sectoral meant now
showing the self interest for other sectors in taking account of the health impact of policy, as
in the case of the response of the food industry to consumer demand. Finally, integration,
as used in this meeting, means that the health sector aspiration must be matched to what is
the existing strategy goal in the partner sector. He used the Swedish political and public
health organisational structure to demonstrate both the vertical and horizontal aspects of
policy. Vertical approaches for instance must take account of the autonomy of other bodies.
Mainstreaming had already successfully occurred in Sweden with other issues such as gender
equality, sustainable development and the rights of children
The committee was based on a parliamentary process, had a selected chair and included
scientists and stakeholders. Sweden is probably unique in publishing a series of consultation
reports as part of this process. This transparency in itself was seen as an aid to the policy’s
ultimate acceptability to all stakeholders, including the public and to its ultimate successful
implementation. A strong emphasis was placed on the evidence base and an epidemiologypolicy model was developed. 16 expert groups, generating a very thoroughly documented
database for decisions made, examined the determinants of health. This in turn facilitated
78
the planning of interventions and the setting of goals or outcomes. The final policy shape
was represented in pyramidal terms. At base was the fundamental goal of health on equal
terms for all. In turn this constituted 6 overarching guidelines. These were translated into 8
working goals, a further 50 sub goals and 115 candidate indicators for use in monitoring the
success or otherwise of the policy. This offers the possibility of wide-ranging action at
primary care and health promotion level, facilitates inter-sectoral action by clarifying the roles
and responsibilities of all in achieving outcomes, provides a feasible working framework for
health impact assessment and facilitates intermediate evaluation. The policy will set out a
plan of action up to 2010. This process also revealed underlying ideologies and challenged
politicians in particular to examine their social values in relation to the solution proposed.
Political patience with the pace of the process was helped in large part by the preparation of
the need for this approach by the responsible civil servants and others.
Mike Ponton is a member of the new Welsh assembly and responsible for the new Welsh
strategy. By contrast with the Swedish experience, the period of policy development was
short, less than six months, because the need was already established, the challenge lay in
consulting on the process of implementation. This meant clarity about milestones and a
means of learning from experience and modifying the agenda accordingly. Better.Wales.Com
is an all-embracing strategy in many ways, that aims at improving the overall quality of life,
so that what would emerge was a prosperous, healthy, well-educated country. In this sense
health impact assessment would be, or indeed had already become, a way of life that
conditioned thinking not just of politicians, but also of officials. It meant a change in the
nature of the public servant. Now all heads of function have to work not just to their own
brief but also as a concerted team. In the case of the public health strategy people had to
be persuaded of its personal importance to them as individuals, so that agenda setting was
driven by this. Issues like workplace or housing standards rose to the top in this process.
There was also a pragmatic realisation that if we do not proactively manage change it will
happen in some forms anyway. It was not just about reforming the National Health Service
but re-positioning it. In following this investment for health concept, well-being becomes
hugely important and community development a key. It was about putting individuals in
context.
A major distinguishing feature of this system was the separation out and doing away with,
layers of bureaucracy. In effect the five regional boards were abolished, with a National
structure and 22 local authority/local alliances. In this structure it is all-important to improve
democratic participation in decision making by stakeholder representation. A process of
listening to what local people were saying was brought about, as well as ensuring local
accountability for decision making. A means of achieving this has not been finalised but
statutory partnerships governed by legislation are envisaged. In this sense it is very much a
bottom up structure, feeding these various local plans into an aggregated national plan. It
therefore has three hallmarks, a bottom up approach, a framework of health impact
assessment and means of delivery in place with a system of accountability. This aspiration
of a “people’s NHS” is an example of progressive management to make a difference.
Both these National approaches take account of the relevant contribution of expertise and
the need for meaningful consultation and both contain both top down and bottom up
elements. However the Swedish model appears to hinge crucially on evidence underpinning
credibility, whereas the focus in the Welsh model is on the need to involve and deliver. This
difference in emphasis may be explained by the historical differences between the two
countries. Both have a strong epidemiological tradition but Sweden has a history of
participatory action in other sectors whereas this type of process is perhaps more novel in
Wales.
79
Session 3: Measuring progress and impact
This concerned a description of the WHO supported Verona initiative (4), both in the
eponymous region of Italy and adapted in the context of Slovenia, that attempts to take
account of the economic, social and human environment. Verona is a province of 250,000
people in the North east of Italy. Luigi Bertinato indicated that here had not previously been
a tradition of inter-action between the health sector and others. An objective of the project
was to create an arena of debate between various sectors and to compare and discuss
experience of various health issues. It was intended to create a true European multidisciplinary learning and working environment. For instance three themed meetings between
1998-2000 on macro trends and their relative impact and the positioning of health promotion
for the 21st century were debates, rather than conferences, with an ongoing chat line system.
The concept of investment for health was not new to the Verona initiative but had been
developed over 5-6 years at WHO Copenhagen. It was concerned with planning the political
process for achieving the necessary changes in population health. This included identifying
relevant policy attributes, considering factors that might enhance or inhibit policy change and
identifying what sectors to involve. By contrast with the epidemiological model of study, the
initiative was concerned with the means of implementing their findings. This meant dialogue
on how to choose local partners, how to explain it to these and how to win their
involvement and support. After 3 years of debate the Verona benchmark guidelines were
produced. These included identification of means of monitoring success, adopting a
sustained approach, accountability, and putting an emphasis on high priority for health,
social capital for health and a process of public engagement. This entailed seven system
characteristics that were hallmarks of good practice. Finally he highlighted and discussed
concrete initiatives. The process of discussion meant a completely new health promotion
structure and a new observatory system for the elderly population. The use of an existing
surveillance system, in this case the international HBSC survey (5), highlighted social
variations in health behaviours, directly responsible for persuading politicians to fund a
drugs prevention programme. Challenges include shifting theory to practice, and the need to
introduce a new vision of public health among health professionals themselves.
Moyca Grunter Cinc is under secretary for health in Slovenia. This small country of 1.9
million people has undergone major social, cultural and economic change since its
independence 10 years ago. Not alone do these changes affect health care sector provision,
but also the population health. There have been major changes in health status in Middle
and Eastern Europe in the last decade (6). In 1996 a WHO Euro appraisal was undertaken
and between 1998-2000 they were participants in an adaptation of the Verona initiative.
Slovenia joined pilot in Benchmark 2 at local level. Main aims were to assess the readiness
of administrative areas to implement an investment for health approach and testing an
appropriate needs identification tool. Main lessons learned included the fact that health is
perceived as the responsibility of the traditional health sector, with limited existing
collaboration, a lack of appropriately qualified public health specialists and a lack of formal
organisational structures. This was balanced by willingness for involvement. Since then
developments have included a broadening of the minister for health’s title to include health
care, the establishment of a number of inter-sectoral agencies and the active involvements of
ministry of health in inter-sect oral action. These two examples therefore illustrated that the
shared principles of cross-sectoral collaboration and re-oriented health professional practice
could be applied in two markedly contrasting social and political contexts.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
80
References:
1. World Health Organisation. The Ottawa Charter on Health Promotion. Copenhagen 1986
2. Kelleher CC. Theories, Values and Paradigms: Reflections on the Fourth World Conference
on Health Promotion in Jakarta. In: Edmondson R and Kelleher C. Health Promotion.
New Discipline or Multi-Discipline? Irish Academic Press. Dublin and Portland, Oregon.
2000.
3. Puska P, Vartiainen E, Tuomilehto J, Salomaa V, Nissinen A. changes in premature deaths
in Finland: successful long-term prevention of cardiovascular diseases. Bull World Health
Organ 1998; 76(4): 419-425
World Health Organisation Euro Home Page.
www.who.dk/Verona/main.htm
The Verona Initiative Website.
http://
Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J (eds). Health and Health
Behaviour among Young People. WHO Policy Series: Health Policy for children and
adolescents Issue 1. International Report. Copenhagen 2000.
Kelleher CC. Editorial: Evolution of cardiovascular risk factors-light at the end of the tunnel?
Wiener Klinische Wochenschrift. The Middle European Journal of Medicine. 2001; 113 (1516): 552-557.
Forum II: Globalisation, World Trade and Health
81
Forum II: Globalisation, World Trade
and Health
The Forum was structured as an enquiry process. Expert witnesses were called to make a
statement of the facts from their particular point of view to a representative panel of
stakeholders. Delegates had the opportunity to feed questions into the enquiry process and
were called upon to actively participate in the open floor debate
Introduction - Health and Free Trade Conflict or Synergy
Julius Weinberg
The possibility that there might be conflict between commerce and health has been
recognised for many centuries. For several hundred years the only effective measure to
combat infectious disease was quarantine, a restraint on trade. As the plague swept across
Europe in the epidemics of past centuries quarantine, the closing of town gates and the
isolation of communities was a common response. Attempts to regularise the international
response to infectious disease were the major drive to the development of international
collaborations in health. However the first International Sanitary Conference in 1856
foundered for two main reasons, first there was no understanding of the microbial basis of
infectious disease and secondly because some of the participants, particularly Britain saw
attempts to control infections disease as infringing free trade.
Since this time balancing the interests of trade with the interest of disease control has
proved problematical. The International Health Regulations explicitly state that any measure
taken should be the minimal appropriate for the control of disease and that there should be
least possible disruption of trade.
As International trade and travel has increased and as the problems associated with
infectious disease have reduced the problems have become more complex. Now the concerns
include the internationalisation of non infectious threats to health, and the responses to
those threats.
The Internationalisation of potential threats to health is associated with trade in food and
other commodities such as tobacco, pesticides, GM crops; the internationalisation of the
response is associated with the trade in pharmaceuticals and health related services.
The essence of the conflict is based upon:
•
•
That local authorities should be able to undertake appropriate measure to control
threats to health.
That there should be minimal impediments to trade and that there should be a
“level playing field” in health with regulation of standards.
These two principals will inevitably be in conflict on occasion.
There is little in International Law which is primarily concerned with health – the International
Health Regulations are only concerned with Yellow Fever, Cholera and Plague. Whilst there
are a large number of International Laws and Regulation in the area of trade – some of these
might include a health element.
82
World Trade Organisation
The World Trade Organisation was established under the Uruguay Round of the General
Agreement on Tariffs and Trade (GATT), passed in 1994. The WTO is a permanent
institutional structure with provisions beyond the usual area of trade agreements (tariffs and
quotas) and includes provisions which concern domestic public health, food safety,
consumer, worker and environmental protection policies. The agreement constrains members
to “ensure the conformity of its laws, regulations and administrative procedures with its
obligations as provided in the annexed Agreements.”
The WTO provisions assert that “domestic health, safety, and environmental policies must be
designed in the "least trade restrictive" manner and national laws and standards should be
standardized internationally so as to maximize economic efficiency in cross-border trade.”
Standards providing more protection to consumers or public health or local communities or
the environment can be challenged as unfair barriers to trade. The WTO has provision for
global standard setting, which takes place in international standard-setting institutions, and
equivalency agreements,
global standard setting: Specific international standards are set by organisations such as
the International Organization for Standardization (ISO) in Geneva and the Codex
Alimentarius Commission (Codex). ISO, which sets product and manufacturing process
standards, is a private sector organization, funded by industry and largely comprised of
industry representatives. Codex, consists of governmental representatives, but with an
important formal role for industry. Participation by health or consumer groups in both is
limited.
equivalency agreements, Regulatory systems and standards in other countries can be
declared "equivalent" to domestic regulatory systems. Once a foreign system is declared
"equivalent," it must then be treated as if it were a domestic system. Mutual Recognition
Agreement (MRA) is a reciprocal agreement between nations which allows one nation to rely
on the other's verification that a product meets a required standard.
"Codex Alimentarius" . The Codex Alimentarius Commission (Codex) is recognized by the
WTO for setting global food standards. It was established as a voluntary standard-setting
body in 1962 by the World Health Organization and the U.N. Food and Agriculture
Organization, to facilitate international trade of food and agriculture products. Codex is
officially comprised of government representatives, with active and formal assistance from
official industry advisors, who serve as actual members on country delegations. A 1993 study
showed that over four-fifths of the nongovernmental participants on all delegations to Codex
committees represented industry, while only one percent represented public interest
organizations.
International Organization for Standardization. The International Organization for
Standardization (ISO) in Geneva is a private, industry standard-setting body. The ISO has
been recognized by the WTO as the presumptively-legal international standard setter for all
non-food products. ISO started in the 1950s to standardise sizes for consumer products to
help industry expand markets (i.e. batteries). ISO's areas of interest have expanded and
now include standards for environmental products, eco-labels, and humane fur trapping
standards, ISO is now developing additional standards that focus on management practices.
Disputes
Disputes under the WTO are decided by tribunals comprised of three trade experts, chosen
on the basis that has been criticised as ensuring that panelists will have a favorable view of
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current trade rules. For example, to qualify for a WTO tribunal a person must have worked at
the GATT or WTO or represented a country there, with limited exceptions.
General Agreement on Trade and Services
Since the meeting on international trade rules in Seattle in 1999 talks have begun to
strengthen one of the 28 agreements overseen by the WTO – the General Agreement on
Trade in Services, GATS. GATS covers sectors of the economy like banking, construction,
education, insurance, retail, telecommunications, tourism, health or waste disposal.
Via GATS, private companies can insist on being allowed to enter the market for publicly
funded services. In the countries of the OECD public expenditure on health services and
education accounts for 13% of GDP. Much of this goes to public or voluntary bodies but
could end going to for-profit groups. As of 1998, 59 countries had put one or more aspects
of their professional (medical, dental, veterinary, nursing, midwifery, physiotherapy) services
or health-related and social services (including hospitals) under GATS. 39 countries had
agreed to open up hospital services to foreign suppliers. 76 countries have made financial
services sector, including health insurance commitments.
“We believe we can make much progress in the [GATS] negotiations to allow the opportunity
for US businesses to expand into foreign health care markets . . . Historically, health care
services in many foreign countries have largely been the responsibility of the public sector.
This public ownership of health care has made it difficult for US private-sector health care
providers to market in foreign countries.” The US Coalition of Service Industries.
TRIPS
The WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) covers
a wide range of subjects, copyright and trademarks as well as patents. A patent on a
pharmaceutical product can cover the product or the manufacturing process if these can be
shown to be novel. The aim of the patent is to reward the inventor and enable research
costs to be recovered. Once the patent has expired, other companies can make the drug –
these “generics” are often cheaper as they do not have to cover the research element,
furthermore competition lowers the price.
TRIPS standardises the use of patents, so that all WTO members have to grant patents for
twenty years, previously some countries had shorter periods and could therefore permit the
production of generics. All countries including those which had not had patent processes will
be expected to implement the provisions of TRIPS
There is concern that the attempt to balance the interests of public health with the interest
of innovators is tilted towards the pharmaceutical industry and that without access to
generics new drugs will remain too expensive for poor countries. Furthermore the generics
manufacturers in developing countries will be adversely affected. TRIPS also allows for action
to be taken against countries with patent laws which are perceived to be inadequate.
The are some safeguards for protecting Public Health interests within TRIPS.
Governments can set justifications for compulsory licensing which could include a “national
emergency”, however this is not clearly defined. The TRIPS Agreement says products made
under compulsory licences should be “predominantly for the domestic market” however
some countries may not have the capacity and wish to use compulsory licenses for import.
Parallel imports are also allowed and this may keep process down however there is concern
that this might lead to re-export of cheaper products.
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Key Issues
There are a number of key issues that are of concern
•
•
•
•
•
•
The relationship between objectives which further trade and those that serve public
health objectives – to what extent are they in conflict.
Does trade liberalisation improve health and reduce inequalities in health
What are the respective rights, responsibilities and capacities of the private and
public sector
Should international standards serve as a ceiling or as a floor that all countries
must meet.
What assessments have we got for the efficacy of service liberalization.
A major challenge is to strike a balance between the need to provide incentives for
innovation and the need to enable all people to benefit from innovation.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
The stakeholders - Statements on organisational and professional
interests
Nina Hvid
Statement not available
Mehtab Currey
Statement not available
Mihaly Kökeny
As a former Minister of Welfare of Hungary, - a country which has experienced what a
government can and cannot do for placing health higher on its agenda, under economic
pressure while in transition, -I feel that the socio-ecological perspective of health is not well
recognised in the countries of Central and Eastern Europe.
85
Health is not the most prestigious one of ministries compared with finance or defence and
tend to be dominated by the medical model. As this model is based on the challenge of
disease rather than the challenge of health, the task is seen as medical care of the sick,
rather than reducing the disease burden. The impact of globalisation on health and the
increasing globalisation of certain diseases as well as health damaging practices have only
recently been gaining the attention they deserve.
Environmental degradation, BSE and the dioxin crisis have all contributed to the
reinforcement of the focus on health within the EU and to clarifying the need for Europe to
have an unambiguous and evidence based common public health platform.
However, much has to be done until the public health mandate of the European Community
is fully implemented and the enlarging EU takes health responsibilities seriously. If the
accession countries observe the dichotomy that Brussels spends “pocket-money” on anticancer programmes on one hand and more than a billion euros subsidising tobacco farmers
on the other, they will not be prepared to meet public health policy obligations. Such an
experience suggest that in spite of rhetorics EU marginalize health problems during the
enlargement.
I would like to see and work for a vigilant and demanding health policy position from the
European Union, serving the creation of a global health arena in which old and new actors,
governments and NGOs, businesses and policy networks are jointly coping with transnational
influences on health. A number of invaluable lessons have been learned on public health.
The most important one is still to be fully understood, that various forces interested in
health gains, can withstand and fight disease effectively and efficiently only if they are
united.
Ron Labonte
The EPHA and IUHPE do not oppose liberalized global trade and investment per se, nor
changes in tariff structures and other national regulations that impede such trade and
investment, provided the effects of trade/investment liberalization are ecologically sound,
lead to a fairer distribution of goods (including income) within and between nations and
generally improve the goals of human development as articulated in numerous UN and
multilateral declarations and accords. Liberalization proponents claim that open markets are
both necessary and sufficient to accomplish these ends. Twenty years of experience with
Structural Adjustment Programs and other forms of market liberalization do not empirically
support this claim. Strong, internally developed and saturated economies benefit by
liberalization; poorer domestic economies rarely do. Given the growth of income inequalities
between rich and poor nations, and the ecological impossibility of fossil-fuel based
development of poor nations to the existing level of rich ones (which would require, by one
estimate, an additional four planets to exploit), human development on a planetary scale
demands a global re-distribution of wealth from rich to poor. This is an inescapable fact, and
one that cannot be resolved by trade or investment liberalization and, indeed, is exacerbated
by it under present liberalization rules. If the WTO is to uphold its promise of creating a
"rules-based trading system" that will help weaker participants offset the economic power of
stronger participants, its basic premises of the relationship between trade liberalization and
human development must be reversed. Its Agreements need to be subordinated to human
development and environmental sustainability goals, and not allowed to overbear them.
86
Decision-making on trade and human development needs to be opened to a wider range of
multilateral and civil society actors. Assistance and resources for more equitable participation
in the emerging network of global governance must be made available to poorer
populations, generally and poorer nations in particular.
Regarding the GATS, the existing Agreement should not be extended or deepened at this
time. GATS could increase the already substantial migration of skilled professionals, including
health professionals, from poorer to wealthier nations. GATS may also increase privatization
of and decrease access to many public services (health, education and so on) essential to
health and well-being. Individual countries remain free to exclude such services from the
Agreement, but the GATS built-in principle of "progressive liberalization," and the difficulty in
foreseeing all possible future implications of services liberalization when specifying
exemptions or modes of service delivery, renders such assurances questionable. Moreover,
EU countries have already committed most of their health services to the GATS. It is
important to recognize that the major force behind the GATS are private sector interests,
such as the US Coalition of Service Industries and the European Services Forum. They are
primarily interested in increasing private access to the public service market, i.e., the global
health care market (worth US $3.5 trillion annually), education market (worth US $2 trillion
annually) and water market (worth US $1 trillion annually).
Regarding TRIPS, intellectual property rights similarly entered the world trading system at the
behest of corporate interests. Unlike other WTO Agreements which require nations to remove
trade protections, TRIPS requires that they extend protections, specifically corporate
monopolies over drugs, foods (seeds) and other "intellectual property." TRIPS provisions
(which are enforceable) currently contradict other multilateral Agreements, such as
commitments to technology transfer, the right to food and health, and the Convention on
Biodiversity (which remains unenforceable). TRIPS provisions also allow increasing
"biopiracy," the patenting of traditional medicines and other indigenous knowledge by
corporations based in wealthier nations. TRIPS, alongside TRIMS, is cited by the UNCTAD
Director-General as the two WTO Agreements most potentially harmful to the abilities of least
developed countries to develop their own internal economies. The TRIPS Agreement needs to
be re-negotiated to reduce its extended patent protections, and to exclude property rights on
life forms per se. This ban should extend to "micro-organisms" and "microbiological
processes," which are currently allowed patent protection. Substances found in nature are a
discovery and not an invention; they should not be patentable. There is also a presumption
that decreasing the patent reach of TRIPS will lead to a retreat from scientific research and
progress. Yet there were not generous patent protections in place when many of the great
discoveries of the past century occurred. There is little evidence that generous patent
protections lead to increased scientific research and progress (and certainly not for diseases
affecting most of the world's poorer peoples), while there is substantial evidence
that it is increasing drug costs. In public systems, this reduces the funding available for
primary and public health care services of great importance in early disease intervention and
disease prevention. Moreover, much of the research on new drugs, particularly antiretrovirals, is supported by public grants or tax deductions, rendering the distinction between
private and public investment, and hence private and public "ownership," moot. Finally,
Fortune magazine has just named the drug industry as "more profitable than any other." The
industry was also rated the most profitable industry last year and has been consistently
ranked number one or two by Fortune over the past few decades, including periods when
patent protection was not so generous.
In the case of both Agreements, how much profit is enough? At what cost to public health,
both within and between nations?
87
Maurice Mittelmark
The International Union for Health Promotion and Education (IUHPE) is an independent
professional association of individuals and organisations that for nearly 50 years has been
committed to improving the health of the people of the world through education, community
action and the development of public policies. With more than 2,000 members in over 90
countries, the IUHPE is the only global non-governmental organisation that provides an
opportunity to build an international network to encourage the free exchange of ideas,
knowledge, technical skills, and experience.
The mission of the International Union for Health Promotion and Education (the IUHPE) is to
promote global health and to contribute to the achievement of equity in health between and
within countries of the world.
The IUHPE fulfils its mission by building and operating an independent, global, professional
network of people and institutions to encourage the free exchange of ideas, knowledge,
know-how, experiences, and the development of relevant collaboration projects, both at
global and regional levels.
In line with its mission, the IUHPE has three major goals:
a) Advocate for health - to advocate for actions that promote the health of
populations throughout the world.
b) Improve effectiveness - to improve and advance the quality and effectiveness of
health promotion and health education practice and knowledge.
c) Build capacity - to contribute to the development of capacity in countries to
undertake health promotion and health education activities.
The IUHPE pursues these major goals by:
•
•
•
•
•
•
•
advocating for investment in health promotion and health education by
governments, inter-governmental organisations, non-governmental organisations
and the private sector;
undertaking activities that contribute to the development of knowledge and practice
that further the field of health promotion and health education;
disseminating evidence-based knowledge and practical experience in health
promotion and health education;
providing mechanisms for the exchange of ideas, experience and knowledge that
promote health;
providing a global forum for mutual support and professional advancement of its
members;
building alliances and partnerships amongst all sectors, based on agreed ethical
principles, mutual understanding and respect;
strengthening the capacity of the Organisation to fulfil its mission.
88
The expert witnesses: European Trade policies and their impact upon
health
Paul Strickland
Introduction
•
Seattle – concerted attack on patented pharmaceuticals. Main message being that
patents make drugs excessively expensive. An eye–opener for the industry and
international organisations, including the European Commission.
•
Since the beginning of 2000, DG TRADE of the European Commission has held
regular meetings open to all non-governmental organisations and the
pharmaceutical industry with a view to defining and analysing perceived problems
in connection with intellectual property rights, medicines and health. Parallel
bilateral meetings with major stakeholders have also contributed to trying to
solve these problems. Commissioner Lamy has also regularly met with the NGOs
and the industry. All this has contributed to an open, and to a certain extent,
creative discussion.
•
The outcome of this ongoing procedure is that a lot of issues have been listed as
problems in connection with access to medicines and health care. Patents may
add to the total cost of medicines but this is only one issue among many.
•
Poverty - the major obstacle to the lack of health, health services and medicines.
Poverty means that people are more prone to communicable diseases due to lack
of proper nutrition and poor hygiene. In addition, a lack of education creates
difficulties in terms of setting up prevention schemes. Most poor countries have
no social security nor any other reimbursement system in force, i.e. the patients
have to pay the full price of medicines out of their own pockets and not many
can.
•
It is clear that the pharmaceutical industry in Europe and US charge very high
prices in our markets. Why? Our social security systems (whether based on public
or private insurance) can afford them even though the debate on cutting public
expenditure is growing. I guess this discussion will continue.
•
One of our aims is to get the pharmaceutical industry interested in supplying
medicines at heavily discounted prices in developing countries. This may involve
trying to prevent cheap products from being diverted from the markets they are
intended for. The industry has been requesting the European Community to
reinforce the regulation system in the EC to ensure the continuance of market and
price segmentation. At the same time, importing countries should also make all
possible efforts to ensure the medicines are consumed by their sick population,
and not diverted. There is a common interest that this is done, otherwise
investment in R & D in non-profitable diseases could further decrease.
•
The debate on access to medicines also touches upon Human Rights and
intellectual property as well. This year the Sub-Commission on Human Rights of
the UN Economic and Social Council commissioned a report on a Resolution that
protection of IPRs as embodied in the TRIPs agreement conflicts, in one way or
another, with a number of Human Rights. The EC and its Member States consider
that Human Rights and IPRs are, in many ways, complementary and that their
89
objectives, if considered to be in conflict, can be reconciled – private rights are
human rights too, if it comes to that. Again, the lack of access to medicines in
general in the developing countries is primarily a result of poverty, lack of
research into non-profitable diseases, poor infrastructure of health care systems,
prevention and distribution systems.
EC positions
•
On 20 September 2000, the Commission adopted the Communication on
Accelerated Action targeted at major communicable diseases within the context of
poverty reduction. It focused on the need for immediate action targeted against
three major diseases namely Malaria, Tuberculosis and HIV/AIDS.
•
The Communication constituted the basis for consultations with the widest
possible number of interested parties at the Round Table which took place in
Brussels on 28 September, 2000. The Round Table expressed a clear and
unambiguous message, namely the urgent need for a joint action to achieve
results in the fight to help the sick in developing countries hit by infectious
diseases.
•
On 21 February 2001 the Commission adopted a follow up to the September
Communication in the form of a Programme for Action: Accelerated action on
HIV/AIDS, Malaria and Tuberculosis in the context of Poverty Reduction" (COM
(2001) 96) setting out the activities that should be pursued by the EU during the
next five years. The Programme outlines the actions to be taken within the next
five years concentrating mainly on:
-
optimising the impact of health, AIDS and population interventions
strengthening of pharmaceutical policies and capacity building
developing capacity for local production of pharmaceuticals
establishing a global tiered pricing system for pharmaceuticals
reducing tariffs and other costs on pharmaceuticals
supporting WTO developing country members in implementing the TRIPs
Agreement and promoting an international discussion on the link between
the Agreement and public health protection issues
strengthening and increasing support for research and development
including capacity building and incentives for development of specific
global goods.
Work in Progress
•
The EC considers that the supply of key medicines at differential or tiered prices
seems to be the most realistic and feasible means to deliver results on a short
term basis. For that we need firm and long-term commitments from both the R&D
based and the generic industries to sell at lowest possible prices covering at least
medicines against the three diseases targeted in our Communication.
•
Tiered pricing is not a new concept. It has been applied for decades in respect of
vaccines and contraceptives. Applying the principle also to the most sophisticated
drugs on the market (i.e. antiretrovirals against AIDS/HIV) does complicate the
issue. The need for long-term medical care and supervision in connection with
medication of this kind does put heavy pressure on already weak health systems.
Reinforcement of health care and prevention are therefore of utmost importance.
90
•
The R&D based industry claims it is efficiently applying differential or tiered
pricing by participating in the Accelerated Access Initiative, consisting of offers to
supply antiretrovirals against HIV/AIDS from several large pharmaceutical
companies in co-operation with UNAIDS, WHO and other UN offices. Until now
arrangements have been concluded with approximately 10 African countries plus
Romania. Around 35 countries have expressed interest in participating. Clearly this
initiative is insufficient as it only reaches a maximum of a few thousand patients.
•
This year we have seen a number of individual offers from the industry including
some generic producers. CIPLA, the main generic manufacturer in India, which is
producing antiretrovirals legally due to lack of IP legislation, has announced that
it is offering AIDS antiretrovirals at heavily discounted prices to all African
countries. To avoid patent conflicts, CIPLA has asked the R&D industry to issue
licences in the countries where the products are patented. These requests have
not been replied to but the R&D based industry has followed suit with some very
low-priced offers which points in the right direction. However, in spite of these
offers we see no increased supplies of essential medicines to poor countries!
•
The European Commission is addressing tiered pricing in a global setting trying to
set out the principles for a system based on voluntary and long term
commitments from producers – a paper is in preparation. In this connection the
need to address possible increased measures to prevent re-importation into the
European Union has to be addressed. This will most probably become an
important issue if exports of cheap medicines increase significantly. (The European
Commission might at such a stage propose a separate regulation addressing this
issue.)
•
The European Commission is also concerned about some importing developing
countries application of relatively high tariffs and other taxes and fees. We are
looking into this matter with a view to, if necessary bringing the discussion on
tariffs to the WTO.
•
Local production of medicines may well be a valuable instrument in the long term.
It is important that both the R&D based and generic industries are forthcoming in
making long term commitments in terms of technical transfer, possibly supported
by aid programmes. (TT more likely if a patent regime is in place.) The first step
should be, however, to ensure standards and capacity of existing manufacturing
facilities in developing countries.
•
Need for increased research into diseases that are unprofitable is another key
issue. It is important to boost public funds and create co-operation opportunities
between private and public facilities to provide incentives for research into
diseases common in developing countries. The Commission has published calls for
proposals focusing on these diseases and will shortly be reviewing the new multipartner project proposals received. In order to increase the amount and the level
of co-ordination of testing of new drugs and vaccines in developing countries, the
Commission is currently supporting initiatives in order to set up a specific trial
platform with Member States.
•
The EC has called for an accelerated response, and for new approaches to deliver
more effective aid. The establishment of the Global AIDS and Health Fund (GAHF)
is one such welcome development. A Transitional Working Group has been
established and a Technical Support Secretariat (set up in August in Brussels) is
tasked with defining the modus operandi of the Fund by the end of the year. The
transitional working group is chaired by Minister Crispus Kiyonga of Uganda and
91
the support secretariat is headed by Paul Ehmer from USAID. Work will include
governance and management structure, fiduciary arrangements, eligibility criteria,
country processes, implementation options, monitoring and evaluation,
procurement, resource mobilisation and communication strategies.
•
Pledges to the Fund have now reached US$1.8 billion from about 40 donors. The
Fund has received broad support from governments and to a lesser extent, from
the private sector. The EC has contributed 120 million Euro for year 2001. The
Transitional Working Group is expected to define clear guidelines and working
methods by end of the year and for the first funds to flow in first half of 2002. In
terms of drugs purchasing, expectations are high always subject to preferences of
recipient countries.
Role of IPRs in an international setting
•
The importance of a strong IPR system in order to secure future research and
investments in medicines must be stressed. On the other hand, the protection
should not provide excessive benefits to right holders. The TRIPs Agreement
provides an adequate minimum level of protection, the balance of which should
not be altered. TRIPs is not so much part of the problem, as part of the solution.
•
The EC view is that TRIPs offers a significant degree of flexibility including the
right to apply compulsory licensing in accordance with the conditions set out in
article 31 of TRIPs. Discussions as to whether or not national health concerns and
in particular access to medicines are adequately addressed in the TRIPs
agreement, are being pursued in the TRIPs Council. In particular, Articles 6
(exhaustion and parallel import), 7-8 (objectives and principles) and 31
(compulsory licensing) are targeted in this debate.
•
The discussion in the TRIPs Council on access to medicines has now taken place
on three occasions. Positions are relatively well established. Presently (end
September 2001), work goes on to negotiate a text for a declaration in
preparation for the Doha Ministerial meeting of WTO members.
Such a declaration should address the political fundamental requisite that TRIPs should
not prevent members from implementing their national health policies and also address
certain key provisions that need clarification. Discussions continue, and the EC hopes for
a positive (not minimalist) declaration at Doha in November.
The role of international agencies in health protection and in
developing health positive trade policies
Robert Beaglehole
The World Health Organization is the main intergovernmental agency responsible for the
prevention of disease, disability and injury and the promotion of health at the global level.
The context for this relatively new programme of work by in the Department of Health and
92
Development is the new global environment for public health practice: health is now firmly
on the global policy agenda; achievements in health are critical to the fulfilment of
international development goals; and domestic action alone can no longer ensure people’s
health locally. The dangers, for population health from this new environment are numerous,
for example, exclusion/disconnection from global markets; increasing private ownership of
knowledge with potential impact on technology transfer and access to drugs; the continuing
migration of health professionals; cross border transmission of disease (infectious and
noncommunicable such as tobacco caused); environmental degradation; and increased
conflict. The opportunities for public health are increasingly recognised and arise from: the
new levels of interconnectedness; the new market incentives for research and development
for diseases of the poor; the new and major resources promised to scale up existing effective
interventions; the wider dissemination of knowledge of effective interventions; and the new
global health rules to control cross border and global risks.
The strategies being used by WHO to assist member states take advantage of these
opportunities include: expanding and sharing knowledge on the effects of globalization on
health; continuing to act as an independent provider of knowledge and evidence; developing
appropriate policy responses; strengthening national negotiating capacity to place public
health interests higher on the trade, investment and development agendas; supporting the
control of public health bads and the production and access to public health goods. Specific
areas of work include: analysing the impact of globalisation on health (risks, opportunities
and responses); documenting the public health implications multilateral trade agreements;
promoting new avenues for international financing for health development; assisting the
processes of managing interdependence for health and negotiating across boundaries;
analysing the implications of global public goods for health; exploring opportunities for
strengthening global health governance.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
93
The role of health issues in multilateral trade agreements
Rolf Adlung
Presentation was based largely on an article previously published in Issues in European
Health Policy, 5th Issues, July 2001.
THE GENERAL AGREEMENT ON TRADE IN SERVICES:
APPLICATION TO THE HEALTH SECTOR
The General Agreement on Trade in Services (GATS) is the multilateral trade agreement in the
area of services. Its entry into force in 1995 was one of the major achievements of the
Uruguay Round of trade negotiations (1986-1993) and a landmark event in the history of the
trading system, comparable to the inception of the General Agreement on Tariffs and Trade
(GATT) in 1948. While the GATT was initially conceived as a framework for merchandise trade
between the post-war economic powers, it has since achieved almost global coverage. The
World Trade Organization – its successor since 1995 – has 141 Members at present, including
some 80 developing countries and close to 30 least-developed countries. The WTO
comprises the GATT, as amended in eight successive rounds of trade negotiations, the GATS,
and the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). All WTO
Members participate in, and have assumed obligations under, all three Agreements.
Despite many significant reforms since the late 1940s, core elements of the system have
remained unchanged. These include the consensus principle – i.e. no decision is taken as
long as even one Member objects – and Most-Favoured-Nation (MFN) treatment, i.e. a
requirement on all Members not to discriminate in their trade regimes between products and
producers of different foreign origin. The commitment to MFN treatment reflects not only
economic efficiency considerations but, more importantly, the system's exclusive reliance on
rules- as against power-based policies. All goods and services imported from abroad must
be accorded the same treatment, regardless of the economic clout of the originating country
and any specific policy considerations.
For decades, the non-existence of a services agreement had not been viewed as a
particularly pressing problem. Apart from international transport and communication,
services have predominantly been considered as domestic activities, requiring the
simultaneous presence of supplier (e.g. banks, hotels, hospitals and their staff) and
consumer (depositors, tourists or patients). However, this view has changed significantly in
recent years as a result of technical developments, including new communication
technologies enabling e-banking or tele-health services, as well as economic reforms that
have increased the "openness" of many services sectors. Although cross-border trade in
services is still dwarfed by merchandise trade, accounting for no more than 20 per cent of
total exchanges, it has grown faster over the past two decades.
While the emphasis of the Uruguay Round was on creating a comprehensive set of trade
rules, the liberalizing effects of GATS have remained limited to date. Most WTO Members
have confined their access commitments to binding status quo conditions in a limited
number of sectors. The ongoing services negotiations, launched in January 2000, offer them
a new opportunity to consider the advantages of internationally guaranteed, more open
access regimes. Increased foreign presence in a sector may help, for example, to fill
domestic supply gaps; to broaden a country's resource base (including capital and
expertise); to promote efficiency through competition; and, in infrastructural sectors such as
94
communication, transport or finance, to strengthen economic links with external suppliers
and customers.
The implications of the GATS for any individual service sector depend mainly on three
parameters:10
The institutional structure of the sector
The GATS excludes all public services, i.e. services provided in the exercise of governmental
authority. This carve-out applies whenever a service is provided neither on commercial basis
nor in competition with other suppliers; free medical treatment in public facilities is a case
in point. Such services are not covered by the Agreement, and will not be made subject to
future negotiations. Although it has been alleged that WTO Members "decided" that the
relevant provision needed to be interpreted narrowly and did not cover the whole sector, no
such decision exists.11
General obligations under the GATS
Trade in virtually all other services is governed by some general, cross-sectoral rules.
Foremost among them is MFN treatment. WTO Members are thus not allowed to discriminate
between like services offered by different trading partners. Whatever the trade regime in a
sector – whether free access, closed markets or something in between – it must be the same
vis-à-vis all foreign suppliers.
The scope of market access and national treatment commitments
Each Member must submit a schedule of specific commitments under the GATS. This lists
the sectors, and any relevant limitations, in which the Member grants market access and
national treatment. Full market access would imply, inter alia, the absence of quantitative
restrictions, while full national treatment would guarantee foreigners the same competitive
opportunities as those enjoyed by domestic suppliers. All commitments are specified for
four modes of supply, reflecting in many services the need for physical proximity between
provider and consumer. The modes relate not only to the traditional concept of cross-border
trade (mode 1), but to the consumption of services abroad by nationals of the scheduling
Member (2), to the supply of services via foreign commercial presence (3) and to supplies via
presence of foreign natural persons (4).
In any sector included in a schedule, Members are free not to commit on a particular mode,
i.e. to leave it "unbound", or to further condition their commitments. Typical conditions
("limitations") scheduled for health services specify maximum numbers of doctors or
hospitals, the non-eligibility of foreign hospitals for subsidies or their exclusion from public
insurance schemes. However, non-discriminatory public policy requirements, e.g. obligations
on private hospitals to reserve some capacity for the poor or to train more staff than needed
for own purposes, are compatible with relevant GATS provisions and do not have to be listed
as limitations.
Country schedules vary widely in their sector and modal coverage. While some Members
have scheduled less than a handful out of a total of some 160 services sectors, others have
included 100 and more. Health services have not proved very popular in this context. For
instance, more than 90 of the WTO's current 141 Members have not undertaken any
10
For more details see R. Adlung and A. Carzaniga, Health Services under the General Agreement on
Trade in Services, Bulletin of the World Health Organization, 2001, Vol. 79, No. 4.
11
See A. M. Pollock and D. Price, Rewriting the regulations: how the World Trade Organization could
accelerate privatisation in health-care systems, Lancet, 2000, Vol. 356. A reply is given on the WTO
Website.
95
commitment on hospital services, i.e. these countries are free to operate in this sector,
subject to the MFN principle, whatever restrictions they deem appropriate. The European
Communities' schedule does contain, however, some significant commitments. For instance,
for hospital services not provided by public utilities, it guarantees foreign investors full
market access and national treatment in Denmark, Germany, Greece, Ireland and the United
Kingdom.
Health Services: Country Pattern of Commitments (July 2000)
Sub-sector
Members with commitments1
Total
Developing
economies
Medical and dental services
54
36
Services provided by nurses, midwives,
physiotherapists
29
12
Hospital services
44
29
Other human health services (ambulances
etc.)
17
15
1
The scope of individual commitments varies as a result of mode-specific exemptions
or limitations.
Source: Adlung and Carzaniga, op. cit.
The reticence of many Members to undertake commitments in the Uruguay Round might have
been due, inter alia, to lack of information or negotiating interest, absence of coordination
links between competent ministries or fears that commitments might jeopardize basic quality
and equity objectives. However, such fears are not justified. The GATS creates a framework
for the conduct of services trade, but does not undermine a government's ability to regulate.
The Preamble to the Agreement explicitly recognizes "the right of Members to regulate, and
to introduce new regulations, on the supply of services within their territories in order to
meet national policy objectives". National regulations may specify, for example, certification
requirements for doctors and hospitals, or minimum availability standards ("universal service
obligations") for the services rendered.
There are claims, nevertheless, that legal test are under consideration that would outlaw the
use of non-market mechanisms such as cross-subsidization, universal risk pooling, solidarity
etc.12 Such claims are patently absurd. The relevant negotiations, pursuant to Article VI:4
of the GATS, are confined to developing disciplines that would prevent qualification
requirements and procedures, technical standards and licensing requirements from
constituting unnecessary barriers to trade. The relevant mandate is closely circumscribed
and does not call into question governments' ability to determine regulatory objectives and
content. Any modification would presuppose an amendment to the Agreement itself which,
in turn, would require Parliamentary approval in many countries (for example, the European
Parliament and the Parliaments of all EC States would need to be involved).
12
Pollock and Price, op. cit.
96
Schedules are not cast in stone. A government may modify or withdraw any specific
commitment it feels unable to live up to. Such modification or withdrawal does not depend
on any other government's approval. However, in order to discourage excessive use and
protect the overall level of commitments, the relevant Article provides for negotiations on
compensation with affected trading partners. Moreover, under a general exception clause
contained in Article XIV of GATS, Member governments are entitled to take any measure,
regardless of their obligations under the Agreement, that is necessary to protect human,
animal or plant life or health. A recent dispute settlement case has confirmed the relevance
of this clause.13
To date, in the context of the new services round, some 40 WTO Members have specified
their negotiating interests in the form of written proposals. Like other relevant documents,
these are available on the WTO Website (www.wto.org). However, among the 90-odd
proposals received, none refers specifically to medical or hospital services.
All views are those of the author and should not be attributed to the WTO.
The role of commercial enterprises in health
Petra Laux
At GlaxoSmithKline - one of the world's leading research based pharmaceutical companies we want to improve the quality of human life by enabling people to do more, feel better and
live longer. But developing new medicines is not enough if the patients who need them are
denied access. We are acutely aware that millions of people in developing countries do not
have access to even the most basic healthcare services, including safe and effective
medicines, that are taken for granted in the developed world.
This has led to a global healthcare crisis, in which life threatening diseases such as
tuberculosis, malaria and HIV/AIDS are spreading unchecked in countries that have neither
the resources nor the facilities to deal with the epidemics.
Poverty is at the root of the issue. Large parts of the populations of developing countries
often do not have access to food and clean water, let alone healthcare services. If the health
of the developing world is to improve, then all sectors of our global society - governments
and international agencies, as well as the private sector - must work together in partnership.
GlaxoSmithKline is committed to playing a full part by taking an innovative, responsible and
above all, sustainable approach to meeting the healthcare challenges of the developing
world. There are three key areas in which we believe we can contribute:
1.
Continuing our investment in the research and development of diseases that affect
the developing world in particular.
We are the only pharmaceutical company that is conducting R&D into both prevention
and treatment of all three of the WHO's top priority diseases - HIV/AIDS, malaria and TB.
However, the fundamental framework on which medical advances depends, and which
13
See reply to Pollock and Price on WTO Website.
97
has led to sustained investment in research and development, requires intellectual
property protection.
2.
Offering sustainable preferential pricing arrangements in Least Developed Countries
and sub-Saharan Africa for currently available medicines that are needed most.
We have done this with our vaccines for nearly 20 years and our HIV/AIDS medicines for
the past four years - we will extend this programme.
3. Taking a leading role in community activities that promote effective healthcare.
At a corporate level, GSK is currently involved in community partnership activities in 96
countries, with additional donations at a local level. And we run the world's biggest
donation programme to eliminate lymphatic filariasis.
We strongly believe we are making a real difference to healthcare in the developing world.
We believe this is both an ethical imperative and key to business success. It is our intention
to make access to medicines a continued priority of our company. If we provide the
medicines society needs, and help solve the problems of access to those medicines, then we
will demonstrate what it truly means to be an industry leader
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
Summary Report of Forum II
Julius Weinberg
1. Workshop Description
The workshop was organised along innovative lines and addressed the question of whether
the impact of the flows of capital, goods, ideas and peoples across borders, and the
institutions and rules established to regulate them was good or bad for health.
First an introductory talk set out the history of the relationship between globalisation and
health. This talk also described the roles of relationships between the various international
agencies and the “language of globalisation”.
Following the introductory talk a number of experts drawn from International Organisations,
the Pharmaceutical Industry and Non-Governmental Organisations made presentations. The
presenters were then questioned by a panel of experts, following which discussion was
opened to the audience.
The panel of experts then summed up the contribution of the presenters and the responses
to the questioning, drawing together the issues that had been raised.
Presentations were made from the point of view of:
•
•
•
•
•
The
The
The
The
The
World Trade Organization
World Health Organization
European Commission
Pharmaceutical Industry
panel of experts were drawn from a variety of stakeholders.
98
It was agreed that globalisation had an impact on national policy and there was potential
loss of national autonomy. There was a probable impact on health risks and an impact on
household incomes and their distribution.
2. Workshop Progress
Some key areas of disagreement and concern were identified. It was commented that the
voice of developing countries was inadequately represented in the debate.
2.1 Issues
There was no consensus over whether the arrangements for international trade were
beneficial for health or not. Nor was there agreement over the relationship between trade,
health and economic growth. There was some debate about where the major problems lay –
patents and trade were considered by some contributors to be a side issue, the real problem
being poverty.
There was agreement that the evidence on the relationships between the impact of trade,
changes in inequalities and health outcomes was inadequately understood.
There were concerns that there had been little input from health experts, and those with an
interest in public health in shaping the various international trade agreements. It was agreed
that the possible impact of the General Agreement on Trade and Services was unclear, and
there was no common understanding of whether Public Health services would be protected
by exemptions under the GATS agreements
There were increasing concerns that patents make drugs unacceptably expensive, and there
was increased sensitivity to the problem of the affordability of pharmaceuticals in the
developing world. The major R&D areas are not relevant to developing world and the
argument that patent protection was essential for innovation did not seem clear. Much
innovation seemed to be curiosity driven in Universities.
2.2 Data and Research
There was no good data upon which to base sound arguments, elements were taken out of
context and inappropriate conclusions drawn. There was urgent need for good research into
the relationship between trade and health.
2.3 Advocacy
Health experts had not been present in many of the policy decisions and needed to make
their voice(s) heard. This meant understanding the language and issues. There were
problems over how this was to be funded. Ministries of Health were weak in this area –
work needed to be done in developing “Health Impact Assessments” of economic policies
and in understanding the policy making process.
Decision making was not transparent within the International Agencies and Public Health
advocacy for open policy making was important
Attention needed to be given to the widening inequalities gap.
2.4 Governance and Accountability:
There was need for better systems of global governance, where the various stakeholders are
better represented, and where the less well resourced are supported so as to be able to
contribute to the debate.
The developing role of Health Impact assessment of economic policies was considered
important
99
Accountability of decision making was not always clear. Many of the International agencies
do not have a health mandate. There seems to be unbalanced accountability towards the
needs of trade.
Health is central to global development goals and on the WHO Policy agenda.
2.5 Intellectual Property Rights
Lack of access to medicines is primarily due to
•
•
Poverty
Lack of research into the disease of the poor
There was no agreement over the impact of TRIPS, the international agreement on
Intellectual Property Rights. The debate polarised between a view that patent protection was
essential to reward and promote innovation and a view that it meant that essential
medication was too expensive for poor countries. There was extensive debate over the
effectiveness or otherwise of the safeguards present in the TRIPS agreements.
It was suggested that amendments to the TRIPS systems with tiered pricing systems and
stronger links to public health could make TRIPS work more effectively, with better
management of knowledge dissemination.
Pharmaceutical industry is to make a profit, but needs to have a sense of social obligation
and is part of civil society, there needs to be reasonable and proper balance between the
interests of the poor and the need for profitable private industry
2.6 Summary Comments from Expert Panel
Around globalisation, facts disappear and prejudice dominates the discussion. The language
of the international regulatory agencies is opaque and difficult. Many people feel excluded
from the discussion and become alienated. There was concern that although there were
protective mechanisms available for countries it was unclear how they could be used in
practice – there was not a “level playing field” for countries in their ability to influence and
use the international agreements.
3. Consensus
Areas where consensus was reached:
•
•
•
•
•
•
International trade rules should contribute to increased health for all.
There is a need for increased R&D in innovative medicines relevant to the
problems of the poor in under-developed countries – patent law does not seem to
have achieved this.
Lack of treatment is not just due to price.
All stakeholder in the healthcare business recognised that the implementation of
just international trade rules is pivotal for the promotion of health care in the
poorest countries.
Co-ordinated sustainable solutions to the major threats to health in the least
developed countries were strongly supported.
Multilaterality and rules based systems are the only way to avoid the “bully on the
block”.
4. Not consensus
Areas where consensus could not be reached:
•
Does globalisation and international trade promote health, or not?
100
•
•
•
•
Should public health concerns prevail over trade rules – ends and means?
Does the debate discourage the pharmaceutical industry from entering research
market?
Is the TRIPS agreement flexible enough?
The role of IPR in promoting new drug development.
5. Recommendations
5.1 Research Agenda
•
•
•
Health effects of globalisation/international trade and trade agreements on the poor
EU research framework to support the development of methodologies for research
on trade policies in health
Need to bring researchers together - nationally and internationally – meetings and
fora
5.2 Training Priorities
•
•
•
•
•
Influence the policy debate/Advocacy – Intense training on trade policy law / core
ethics training for IOs NGOs national Level
Develop Workshops on specific issues
Train the Public Health Workforce on the linkages between health and trade
Simultaneously look at burden of disease in global context
Training for purpose: targeted training on policy influencers
Public Health Legal Base
5.3 Advocacy/Communication Priority
•
•
•
•
•
Need to know what we are advocating for
Advocacy for accountability at national level, at wider numbers of stakeholders, for
resources.
Greater balance between the stakeholders to ensure plurality of balance of
representation in trade rounds
The EU is asked to provide technical assistance to least developed countries and
ensure transparency
Promote public understanding of health issues ensuring shared language and
practical ability to participate
5.4 Governance
•
•
•
•
Need for a coherent system of global governance which is health promoting
Fill the gaps in power and the gaps in knowledge
Health impacts of international trade and trade agreements should be taken more
seriously.
Health and human development goals should be integrated into discussions on
Trade negotiations, ensuring plurality of interest and transparency of all those
involved.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
Forum III: Health and the Single European Market
101
Forum III: Health and the Single
European Market
Introduction: The European Union and health care
Philip Berman
The labour market for doctors and nurses
Bie Nio Ong
Background.
As one of the largest employers in Europe, health services, clearly, have the potential to be
affected by the impact of labour mobility on the demand for and supply of doctors nurses,
and other health professionals.
Health service workforce planners in Europe have
traditionally overlooked this potential impact. Integrated workforce planning that adopts a
European dimension is an undervalued but increasingly important process.
Taking the UK as the main example we present a description and analysis of the labour
market for doctors and nurses in the EEA. The European dimension to workforce planning is
important not least in terms of the Government’s Comprehensive Spending Review
(Department of Health, 1998) and the announcement of an increase of 7,000 more doctors,
15,000 nurses and 6,000 more nurse training places for the NHS. This announcement must
be considered in parallel with identified pressures that the British health service has recently
faced (Buchan, 1998; Jinks et al. 1998; Lambert and Goldacre, 1998; Snell, 1998; Friend,
1998; Lyall, 1997). These pressures include, for example:
•
•
•
•
major domestic nurse and doctor recruitment and retention problems
a change in gender balance to the UK Physician workforce. This has led to a rise in
the number of UK physicians seeking part time employment
a trend towards early retirement
specific concerns about recruitment difficulties for general practice
In the past, the above pressures have been moderated by the supply of doctors from both
overseas and the EEA. For example, EEA qualified doctors contribute significantly to the
Senior House Officer cadre (SHO). Recent figures show that ten percent of SHOs in England
and Wales are from the EEA (Jinks et al, 1998). The potential impact of labour mobility thus
becomes apparent when new registration figures from the General Medical Council are
examined. These figures indicate that the number of new full registrations of doctors from
other EEA member states are in decline. See Figure 1 below.
102
Figure 1. New full GMC registrations of EEA, UK and Overseas doctors (1988-1999)
Figure 1 suggests that European junior doctors are now less likely to come to the UK to train.
This decision could be affected by employment opportunities in their host country. Indeed, a
recent study undertaken by the Permanent Working Group (PWG) of European junior hospital
doctors (PWG, 1996) has indicated that medical unemployment on the continent will continue
to fall well into the early part of this century. This trend has clear implications for policy
makers both in the UK and on the continent and, thus, presents important research
questions: to what extent are people moving; what are the factors that facilitate or prohibit
mobility; and, what are the implications of mobility for health services?
103
Policy Framework for Free Movement of Individuals
The Treaty of Rome lays the foundations for the free movement of labour within Europe. Key
articles that facilitate freedom of movement are illustrated below in table 1.
ARTICLE NUMBER
DESCRIPTION
48
Freedom of Movement for Workers
52
Freedom of Establishment in another Country
59
Freedom to Provide Services
07
Prohibition
Nationality
57
Mutual Recognition of diplomas, certificates and
other evidence of formal qualifications
of
discrimination
based
on
Table 1: Articles from the Treaty of Rome (Mobility of Labour)
The above policy framework facilitates the free movement of doctors and nurses across the
EU as there is mutual recognition of qualifications. Furthermore, language ability does not
have to be proven. Doctors who wish to work in the UK need to register with the General
medical Council, while nurses UK need to be registered with the United Kingdom Central
Council.
One example of how EU policy on the freedom of movement has had a direct impact in the
UK can be seen from recent changes to postgraduate and specialist medical training. In the
early 1990s, the European Commission queried the way in which the UK issues certificates to
its own specialists and the way it recognised specialist medical qualifications issued in other
countries.
In 1992, the British Government responded to pressure from the EU by establishing a
working party to advise on how Britain could be brought into line with the EU directives.
The working party made a number of important recommendations, (the Calman proposals),
including, for example: the introduction of a Certificate of Completion of Specialist training
(CCST). This is awarded to a doctor when the relevant medical Royal Colleges considers that
training has been satisfactorily completed to a level of competence compatible with
independent practice and eligibility for consideration for appointment to a consultant post.
Another important recommendation was the unification of registrar and senior registrar
grades to a new grade of Specialist Registrar.
104
Identifying EEA Doctors and Nurses in the UK NHS.
The policy framework that underpins the movement of health care professionals has been
defined. The next question, therefore, is to what extent are people moving ? Previous
studies on labour mobility (Buchan, Seccombe and Ball, 1992, Hurwitz, 1990) are rare. The
lack of previous research into labour mobility among healthcare professionals in Europe is
not surprising when considering the inherent challenges in doing so.
Investigations for this study support earlier observations, (McKee, 1993), that there is little
systematic collection of the numbers of people moving throughout the EU. Comprehensive
and consistent national data on the number of EEA qualified doctors in the UK and,
importantly for workforce planners, their whereabouts, is missing.
Figure 2: New full GMC registrations of EEA doctors per year by country of qualification
(1996-1999).
105
Figure 2 supports data from the GMC that the numbers of EEA doctors coming to the UK are
in decline (a total decline in England by 227 between 1996 and 1997). A shift in the profile
of doctors between grades is also evident.
For example, there has been a rise in the
number of EEA doctors at Consultant or Specialist/Senior Registrar grade; and, a decline in
the number at Registrar grade. Importantly, there is also a decline in the number of EEA
doctors at SHO and HO grades. Traditionally, EEA doctors embark on training programmes in
the NHS at SHO grade. This is where the greatest decline in the number of EEA doctors
practising is seen - a decline in number of 207. The number of UK SHOs has, however,
increased between 1996-7 by 330.
The mobility of nurses can, at present, only be traced at a national level. No systematic data
collection takes place at regional or local level and even if Trusts record country of origin,
there is no consistency across different organisations. Thus, we only present national level
data here.
Table 2: Initial registration of nurses and midwives.
Year
Other countries
Overseas total
94/95
EU countries
798
1,654
2,452
95/96
763
1,999
2,762
96/97
1,141
2,633
3,744
97/98
1,439
2,861
4,300
98/99
1,412
3,568
4,980
99/00
1,416
5,945
7,361
Source: UKCC press release, 14/6/00
Table 2 demonstrates the rise in EU nurses in 1996, with a more modest increase in 1997
and then the levelling off of this trend. In contrast, the rise of nurses from other countries,
notably South Africa, Australia, Philippines and the West Indies has been considerable.
Buchan (2000) argues that this differential rise is due to the importance of communication
with patients, advantaging staff from English-speaking countries.
A more detailed breakdown of nurses registered with the UKCC as to the EU country of origin
is provided through an analysis of trends in the number of European nurses and midwives
coming to the UK. For example, in 1998/99, 5.42 per cent of the total number of admissions
to the UKCC’s professional register were from practitioners qualified in other EU countries.
Figure 3 illustrates how admissions of practitioners from EU countries compare with
admissions from elsewhere.
106
Figure 3: Nurses registered with the UKCC (1996-1999)
Figure 4: New admissions to the UKCC
(1996-2000).
via EC arrangements by country of qualification
107
The number of admissions of EU practitioners to the UKCC professional register rose for the
first time between 1997 and 1998. The greatest number of new admissions in this time were
from practitioners who had qualified in Sweden and Finland. The number of admissions of
EU practitioners to the register has, however, recently fallen from 1,239 between 1997/98 to
1,165 between 1998/99. Admissions of practitioners from Sweden and Finland have fallen,
whilst the admissions of practitioners from Germany and Spain have risen.
It is important to bear in mind when looking at the figures that registration with the UKCC
does not necessarily mean that the nurse in question is working within the health system.
Conversely, nurses might work in the UK as auxiliaries during a period of adaptation before
being accepted onto the UKCC register (Buchan, 2000).
Case study.
In order to investigate in more detail the movement of doctors, the reasons behind mobility
and the perceptions of key personnel involved in their training and overall guidance the UK
team undertook a survey of EEA doctors in the North West of England. The Region’s
Postgraduate Dean’s medical staff database was used to identify a sample frame of EEA
doctors. A total of 167 EEA doctors were identified (110 SHOs, 48 SpRs and 9 GP Registrars).
Each EEA doctor was sent a short postal questionnaire. Pre-paid return envelopes were
provided. A reminder (including a second pre-paid envelope) was administered after four
weeks. There were 17 exclusions due to “addressee unknown”. An adjusted response rate
of 53 % was therefore achieved.
The survey aimed to:
1.
2.
3.
4.
5.
6.
Identify EEA doctors in the area covered by the Manchester Deanery
Investigate the reasons for labour mobility and, therefore, coming to the UK
Investigate the process of registering to practice in the UK and actually practising in
the UK.
Investigate the experiences of training in the UK and satisfaction with training
progress.
Identify EEA doctors career intentions.
Identify a sample of doctors for interview.
The role of Clinical Tutors is important in the selection and monitoring of junior doctors, and
thus, EEA doctors fall within their remit. Seven Clinical Tutors from the NW region were
selected, representing the full range of hospital settings (general and teaching hospitals) and
geographical locations. The purpose of the semi-structured interviews was to explore the
specific issues pertaining to EEA doctors in comparison to both UK and overseas doctors.
The interviews took a chronological format and also considered experience with EEA doctors
against both EU regulations and the doctors’ impact on the UK health care system.
Interviews were either conducted face-to-face (tape recorded and then fully transcribed), or
via telephone format on prepared schedules. The interviews lasted between 30-60 minutes.
From the EEA doctor survey a stratified sample was drawn consisting of twelve 12 doctors
reflecting the composition of the overall sample in terms of grade and nationality. The
purpose of the follow-up telephone interviews was to explore the issues covered in the
sample in more depth in order to get a better understanding of the perspectives and
experiences of EEA doctors. All doctors were asked to provide times, which suited them to
be interviewed. Notes were taken during the interviews on prepared schedules and after the
interviews they were transcribed. The interviews lasted between 30 - 45 minutes.
108
Selected findings.
The survey.
The main reason for labour mobility reported by doctors who responded to the survey is
related to labour market conditions in EEA doctors’ home country. Medical unemployment or
lack of specialist training posts were most frequently sited as the reason for leaving the host
country and coming to the UK. A higher standard of training in the UK was also a commonly
sited reason.
When asked how easy or difficult it was to obtain permission from UK authorities to train or
practice in the UK, an overwhelming majority of respondents, (89% in total), found it was
very easy or easy. A smaller number, jut over half, found it easy or very easy to obtain an
actual training position once here (total 51%). A very small number of EEA doctors who
responded to the survey found obtaining permission to train in the UK to be a difficult
process. However, the number of those respondents who found it difficult or very difficult to
obtain an actual training position was much larger. Of those doctors who expressed difficulty
in obtaining a training position, 37% were Greek, 18% German, 18% from the Netherlands
and 9% each from Ireland, Poland and Spain.
When asked whether satisfied with their current training programme the majority of answers
were favourable. However, 9 % stated that they were dissatisfied and 20 % were neither
satisfied or dissatisfied.
In relation to the issue of whether patients accepted them as they would accept a UK doctor,
the overwhelming majority (90%) of respondents felt that they were accepted on an equal
basis. Only 8% felt that they were not accepted by patients as UK doctors would be. Asking
a similar question with regard to whether they felt UK doctors accepted them as they would
accept other UK doctors, the number who responded “no” was much higher than above
(18/79 or 23 per cent). The number of respondents who did feel accepted as a UK doctor
would be accepted was 59/79 (75 per cent).
EEA doctors were asked about their career intentions and; whether, or not, they intended to
remain in the UK. These findings are of particular interest. Only a quarter of those who
responded intend to remain long term in the UK with over a half intending to leave in the
short and medium term. The data highlight the considerable amount of uncertainty among
EEA doctors who responded to the survey. 16 per cent of SHOs and 17 percent of SpRs are
currently undecided as to whether or not to remain in the UK. Furthermore, the majority of
SHOs stated that they intend to remain only in the medium and short term (32 per cent and
26 per cent respectively) rather than in the longer term (21 per cent). Those who intend to
leave in the short term will do so, for example, “after obtaining MRCP qualification.”
More SpRs than SHOs stated that they intend to remain here in the long term and qualified
this statement with, for example, “until retirement” and “indefinitely”.
Twenty three per
cent of SpRs also indicated that they intend to stay only in the short term: and, on
completion of specialist training they intend to leave the UK.
It is possible to assess the
intentions of EEA doctors to stay in the UK by country of qualification. It is interesting to
note that overall, Greek doctors, in particular intend to remain for short periods in the UK
(1/12), with an even number of German doctors intending to stay for short and long periods.
Only 2 of 12 Irish SpRs anticipate long term stay.
The interviews.
We present the selected findings of both the doctors’ and Clinical Tutors’ interviews
together:
109
In terms of supply factors EEA doctors come to the UK because the job situation in their own
country is tight with an over-supply of doctors limiting the choice of options and career
progression - together with hierarchical systems in some countries. Factors specific to the
UK are the reputation of the UK training and that English is taught in most European
countries as the second language.
Two main routes into the application process were mentioned. First, through friends who
alerted EEA doctors to adverts/vacancies and second, through specialised employment
agencies. The latter route was seen as the more comprehensive and easy, because the
individual was guided through all the stages of the application to the acceptance of a job
offer. This was considered particularly useful in relation to validation of qualifications by the
GMC, which included the proper translation of documents.
The Clinical Tutors admitted that there is no separate policy for dealing with the induction of
EEA doctors and that they are treated the same as other junior doctors. Apparently are only
a handful of organisations with large numbers of EEA doctors have a tailor-made programme.
It was suggested that hospitals could get together, or that such a programme should be
offered at regional level.
In theory the career opportunities for EEA doctors are the same as for UK graduates. In
practice the picture is more complex. On the one hand there are doctors who testify that
they are satisfied and feel that there is equality of opportunity. They state that they are
treated the same as the UK graduates and that they feel well integrated and accepted. On
the other hand, a number of doctors expressed doubts as to whether an implicit hierarchy is
in operation, which goes as follows:
“First, British doctors, then EEA doctors and then Indian doctors. It all appears to depend on
skin colour” (SHO)
When comparing the EEA doctors’ perspectives with the opinions of the Clinical Tutors
interesting issues arise. At the formal level mutual recognition of previous training exists,
but in practice the Clinical Tutors describe concerns that they themselves and their
colleagues within the health service have about equivalence. The comments from the EEA
doctors and the Clinical Tutors point towards a problem of perception about the role of EEA
doctors and their aspirations. They all express the wish to take advantage of the same
career opportunities as UK doctors, yet do not all feel that these are available to them. This
can lead to an under-investment in professional development with possible negative
consequences for individual EEA doctors and the quality of the service provided by them.
The long-term career intentions of the EEA doctors differed between individuals and no clear
pattern could be ascertained in terms of nationality. The factors which determined whether
individuals wanted to pursue a career in the UK or at home were a combination of personal
considerations such as marriage and family, structural considerations such as changing
employment patterns and professional choices such as moving into new territories such as
practicing in developing countries.
Specific issues warrant further discussion. First, there was considerable confusion whether
qualifications such as CCST obtained in the UK would be recognised in the home country.
Most German and Greek doctors were confident that their UK CCST was recognised, while the
Dutch, French and Spanish doctors appeared uncertain. This is somewhat surprising given
that these doctors have embarked on training programmes and invested time and resources
in something that they do not know whether it will pay off in the long term.
Second, most of the German doctors want to stay in the UK, not only because of the poor
job prospects in Germany but primarily because they feel that they have been trained for the
110
UK context and therefore their career is geared towards the needs of the British health
service.
Conclusions.
EU regulation with regard to free movement of labour has resulted in easy registration for
EEA doctors with UK authorities to train and practice in the UK. Obtaining registration with
the GMC was not considered difficult, but finding an actual training position could sometimes
be more problematic. There is evidence in our study that a relationship with how prior
qualifications are interpreted exists. Whilst qualifications are formally recognised by the GMC,
and Trusts do generally not demand proof of qualifications, the recognition in practice is less
straightforward. The local medical establishments appear to perceive non-UK qualifications in
paradoxical ways: on the one hand formal recognition is espoused, but on the other hand a
lack of confidence in community-wide standards of basic medical and postgraduate
education becomes apparent when judging individual candidates. This leads to inconsistent
assessment of candidates’ suitability for training posts, with distinction made between
educational qualifications from Northern versus Southern European countries. The effect of
these localised, unsystematic judgements is a potential inequality of training opportunity for
certain EEA doctors.
The second issue relates to information concerning the training structure. The European
Commission’s Green Paper on Transnational Mobility (European Commission, 1996) and the
subsequent EU action plan on Free Movement of Workers that was adopted in 1997
emphasise this, because insufficient information in the member states can create obstacles
to mobility. At a local level this could be adapted to the needs of EEA doctors through
information sharing strategies, including regional booklets, Internet based material, induction
videos and so on. At a more personal level support networks for EEA doctors could be
helpful in breaking isolation, sharing information and experiences and possibly providing
guidance to local medical establishments about educational qualifications gained in EEA
countries.
In general terms, it is clear that the EU directives have influenced the UK health service in
that the free movement of labour allows the mutual acceptance of qualifications and thus the
uptake of training places for medical personnel. The reputation of British training and the
status of English as the dominant international language results in Britain being primarily an
importer of personnel. However, the attraction of the UK appears to be lessening for EEA
doctors while doctors from other English speaking countries (esp. South Africa and Asia) are
on the increase.
EU-wide policies and directives are in place and have been transposed in most countries, but
the key question now lies in their implementation at country-level. The UK case study has
illuminated the tension between formal and ‘real life’ recognition of medical qualifications,
and the lack of guidance throughout the training period for EEA doctors in the UK. It is vital
that the implementation discrepancy between formal and informal recognition and access to
information are tackled if equal access to medical training is desired as envisaged in the
Medical Directive 93/16/EEC.
Related to this is also the question of the quality of medical and nursing training. Even
though formal recognition exists, there is uncertainty as to the comparability of actual skills
and competencies. The differences in national curricula are difficult to ascertain because they
depend on a multitude of factors: clinical knowledge and content of educational
programmes, training context, cultural expectations, roles and responsibilities in different
health care systems and so on. Judgements as to what constitutes appropriate quality are
111
problematic and contingent upon specific structural and cultural conditions. An argument
could be made for the development of a minimum competency framework to be adopted
across the EU.
The (implicit) assertion underlying the EU legislative framework is that labour mobility is ‘a
good thing’. Clearly, in an economically and socially homogeneous Europe, which is a supernational political entity, such mobility is likely to be considered as a basic human freedom.
This study highlights the positive aspects of mobility which are both at the individual level in
terms of widening experiences and opportunities, and at the institutional level where
organisations are enriched through a wider range of cultural and educational inputs.
Yet, in a Europe ‘at the crossroads’, there may be unpredictable effects upon individual
countries. If, for example, doctors are in shortage Europe-wide or in certain economically
better-off countries, then free mobility may lead to shortages in economically poorer
countries. The migration of doctors from Greece to the UK would be a case in point. The
situation could be the other way round: surpluses in better-off countries could aid poorer
countries, or countries with shortages, or both. The recent (only temporary) surplus of
German doctors is a case in point.
What is clear, however, is that national manpower planning in the public sector may often be
inadequate to achieve its goals in the context of unpredictable international mobility. As a
result, there may be a politically difficult choice to be made between developing a European
manpower planning strategy for substantially publicly funded provision (e.g. of doctors); the
maintenance or even increase in regulatory restrictions on mobility to prevent national
strategies for being undermined; and the increasing privatisation of public planning (e.g.
leaving the supply of doctors to the private market with individuals investing in their own
training). The last is likely to be unattractive and inequitable – for poorer individuals and
also poorer countries. The second option goes against the grain of developing EU policy. Yet,
the first option is an attack upon subsidiarity within the EU as currently understood.
This overview on four EU countries has not begun to investigate these matters in any depth.
Yet, the pervasiveness of ‘informal’ barriers to implementation of free mobility perhaps
suggests that – in the absence of clear European policy compatible with member states’ own
policy and reality – member states will use informal policy, or barriers, to render national and
EU directives superficially compatible.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
References
Buchan, J., Seccombe, I. and Ball, J. (1992) The International Mobility of Nurses, A UK
Perspective. 230, Institute of Manpower Studies.
Buchan, J. (1998) Your Country Needs You. Health Service Journal 22-25.
Buchan, J. (2000) Pressure is on, Health Service Journal, 26-27.
Davies.J. (2000) The devil is in the detail, Health Service Journal, June 1, 18-21.
European Commission (1996) Education, training, research. The obstacles to transnational
mobility, Brussels, COM(96)462 final.
European Observatory on Health Care Systems (2000) Health care systems in transition –
Germany, written by R. Busse. Copenhagen: European Observatory on Health Care
Systems (in print)
112
Hurwitz, L. (1990) The Free Circulation of Physicians within the European Community,
Aldershot: Avebury.
Jinks, C., Ong, B.N. and Paton, C. (1998) Catching the Drift. Health Service Journal 24-26.
Lambert, T.W. and Goldacre, M.J. (1998) Career destinations seven years on among doctors
who qualified in the UK in 1988: Postal questionnaire survey. British Medical Journal
317, 1429-1431.
Lowry, S. (1996) Certify a Specialist. British Medical Journal Career Focus, 2-3.
Lyall, J. (1997) Doctors' Orders. Health Service Journal 12-12.
McKee, M. (1993) Workshop Discusion Report. In: Normand, C. and Vaughan, P., (Eds.)
Europe without Frontiers. Implications for Health, pp. 105-110. Chichester: John Wiley
and Sons.
The Permanent Working Group of European Junior Hospital Doctors (PWG) (1996) Medical
Manpower in Europe by the year 2000. From Surplus to Deficit. Copenhagen: PWG.
Annette Kennedy
Introduction
I am speaking on behalf of the PCN Standing Committee of Nurses of the EU, which is the
only independent EU organisation representing 750,000 nurses across the EU.
The
concentration in this session so far has been on the mobility of doctors. I will try and
represent nurses in the EU.
Despite the growing concern across Europe about the nursing manpower shortage, the
continually increasing international mobility of nurses and the ensuing difficulties in
healthcare planning and manpower determination, there is a lack of data on the nursing
resources at national, European and international level. This remains the greatest difficulty
in predicting nursing manpower requirements and in planning for the provision of the most
effective and efficient utilisation of the nursing resource.
There is a lack of basic information in all EU countries about the number of nurses:
registered in full-time employment / part-time employment; in other employment;
unemployed; immigrated; on leave for educational / family purposes and there is no accurate
information on the age profile or turnover of nurses.
Verbal reports from national nursing representatives across Europe would indicate that
countries likely to be recruiting nurses internationally have evidence to show that there may
not be shortage of qualified nurses, but insufficient numbers of registered nurses working as
nurses in the health service, e.g. Norway, Ireland and the UK.
Sufficient numbers of nurses have trained and registered over the last decade, but have
sought alternative employment, have immigrated or have decided not to return to work.
Many countries portraying a surplus of nurses or unemployed nurses may have shortages in
specialist areas, country areas or may not have filled nursing vacancies.
There are many difficulties in compiling data in order to make predictions for the future, both
nationally and at an EU level. These include:
1.
2.
3.
4.
5.
113
Different levels of aggregation of figures;
Differences in definitions;
Difficulties interpreting figures on staffing norms;
Diversity of health service delivery;
Statistics not drawn from – a) similar sources, b) similar years.
OECD figures for 2000, which are regarded as the most accurate, relate in many countries to
head count as opposed to whole-time equivalents (WTE’s).
•
What does head count mean? The number of nurses, irrespective of the
number of hours each nurse works?
The manpower data on medical and nursing staff is collected from professional registers in
most countries.
This register indicates that a nurse/doctor is registered as a nurse/doctor in that country, but
will not indicate if that nurse or doctor is in active full-time employment.
The Nurses’ Register in Ireland is a case in point. There are 57,000 nurses on the Register,
which, if this is accurate, would indicate that we have a surplus of nurses. However, we
estimate that only approximately 35,000 nurses are actively working in the health services.
This is equally true for other European countries.
THE QUESTION THAT MUST BE ASKED IS: WHY HAVE SO MANY NURSES OPTED OUT OF
NURSING?
European countries have extreme diversity in the delivery of healthcare and of those involved
in the delivery. The term ‘nurse’ may relate to a variety of workers, which may not be
compatible – 1st level nurse, 2nd level nurse, state enrolled nurse, nurse assistants, etc, which
has major implications for the collection of data on staffing norms.
Seeking data from individual countries is very difficult, not only in relation to aggregation
and definition, but also in relation to the source.
The sources may include Professional Registers, Departments of Health estimations, public
and private figures or separate figures, most of this data is out of date, being years older
than the survey, which has major implications on the accuracy of the research, particularly in
times of major changes.
The data on nursing manpower is extremely deficient. A study undertaken by the EU in 1995
in relation to nurses / midwives across Europe relied on data from sources compiled in 1990,
1991, and 1992, depending on the country of origin. No one year could be used across
Europe, as the data for that year may not have been in existence.
However, many predictors of such difficulties were in evidence ten years ago, but we failed
to pick up on the ensuing problems.
114
Although most countries, as can be seen in the table, had sufficient numbers of general
nurses, there was a shortage of nurses in speciality areas. In Ireland and the UK, two of the
countries currently with the greatest problems in relation to shortage of nurses, had an
oversupply in 1990 / 92.
However, Ireland did not have sufficient training places for specialist nurses and was reliant
on the UK for nurses to undertake specialist education. In all countries entry places for
nursing was restricted and countries indicated that there was a decreasing interest /
attractiveness in training for nursing.
•
On what basis did countries decide on the number of training places
required to meet service needs and to meet changes in the workforce
movement, e.g. retirement, emigration, education, shorter hours, different
opportunities?
There is no evidence to suggest that training places for either nurses or doctors were based
on accurate research data of service needs or changing workforce requirements.
115
As you can see from the chart, all the countries who ten years ago had sufficient nurses, now
have a shortage, except Germany and Spain.
These countries currently have an oversupply. Germany did have a shortage about 7 years
ago. However, rationalisation of the health services in Germany has increased the number of
nurses unemployed.
In Spain information from the National Nursing Association suggests that, although there is
an oversupply and unemployment of general nurses, there is a shortage of specialist nurses
and of nurses working in remote / country areas.
The Problem is Global
The problem of shortage of nurses and other health professionals is global, not just
European. It would be wise to take this into account in any strategy that may be developed
in the EU. Countries are currently competing in the recruitment stakes. The EU, America,
Canada and Australia have joined in recruitment and are all recruiting from the same sources
which are finite.
•
What does that signify for nursing and medicine worldwide?
It is clear that recruitment from other countries is not the answer. We are “robbing Peter to
pay Paul”, or in other words, recruiting from each other, recruiting nurses / doctors from
developing countries, taking the more experienced professionals from countries who have
surplus, but need these most experienced nurses to develop their own health service. This
116
is not the solution and is, to say least, unethical, and in many cases that surplus may be as
a result of an under-resourced and underdeveloped health service, e.g. India, Africa, Eastern
Europe.
How Did The Crisis in Nursing and Medical Manpower Arise? What went wrong?
The most common reasons cited by all EU countries include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Lack of manpower planning
Decreasing attractiveness
Low pay
Poor image
Restricted / reduced entry numbers
Increased career choices
Inflexible working arrangements
Lack of career progression
Perception of being undervalued
Poor conditions of employment
Heavy workload
Stress
As already stated, the single most common reason in all countries in relation to the current
labour crisis in all health professional groups was a lack of information in respect of the
number of health service employees and the future healthcare needs. There was no
monitoring of a changing climate among these workers.
An increase in the gender balance among junior doctors saw more women in medical practice
who would require time out for family reasons, job sharing, part-time work, who would have
more difficulty in career advancement and who were likely to change career or retire from the
service because the conditions of employment did not suit family responsibilities. This is
equally the case for nurses. The greatest influencing factor in decreasing attractiveness for
prospective students taking a career in healthcare is low pay, stress, workload, poor image
of the profession and shift work. Students over the last decade have been given a range of
very attractive career choices, which give them better pay for a less stressful occupation,
regular hours and better conditions of employment.
Changes in medical care: e.g. increasing technology and intervention, more dependant
patients, increasing elderly, changing health needs, e.g. road accidents, AIDS, unhealthy
lifestyle, drugs, smoking, alcohol abuse has led to a greater demand for healthcare and,
consequently, the need for more doctors and nurses.
Reasons for Mobility of Nurses:
1.
2.
3.
4.
5.
6.
7.
Economic / Employment
Recruitment
Travel
Education
Migration / Emigration
Career Advancement
Greater Opportunities
The single greatest reason for mobility of large numbers of nurses is economic i.e. improved
pay and conditions of employment. Nurses moved from Ireland to the UK, the United Arab
Emirates, USA, and Australia in the 80’s primarily to make money, and secondary to travel.
Many workers left Ireland for employment and economic reasons. However, when the
economic climate in Ireland improved the pattern changed and Irish people returned to the
117
country. Now Irish nurses, having trained in the UK are returning to Ireland. The nurses who
choose to emigrate are going to Australia primarily to travel and see the world.
Nurses have always travelled by choice to other countries; it is one of the attractions and the
marketing strategies for recruitment to nursing. Generally, nurses who are English-speaking,
travelled to English-speaking countries and, likewise, within other EU countries as speaking
the language of the country was an important factor. Now we see a major change,
recruitment agencies undertake to provide language education to nurses who wish to travel
to other countries to work.
In relation to doctors and mobility, it would appear to be related to education and career
advancement.
Nursing Registration
This bar chart reflects the situation over the last nine years in relation to the mobility of
nurses.
118
However it must be emphasised that these are registration figures and not actually nurses in
active employment. Both the EU and non-EU registrations have increased dramatically. The
EU registrations have doubled in five years from 700 to 1400 and non-EU registrations from
200 to around 1,000, and these figures have further increased in 2001 with active
recruitment.
It must also be noted that the highest figures for Irish nurses registering was in 1996 with a
gradual decrease since. Now all new graduates will register on the Irish Nursing Register, but
may choose to work in another country, work part-time or study.
The UKCC figures show an increase of 20% of overseas nurses on their Register and a
significantly greater increase in the London area hospitals, which have 3% overseas nurses.
119
Problems Associated with International /EU Recruitment:
1.
2.
3.
4.
5.
6.
Language
Culture
Emigration / Migration
Education
Cost
Retention.
The problems associated with international recruitment have led to PCN and ICN and
individual countries examining the issue with the objective of drawing up ethical guidelines
for the recruitment of nurses. PCN has held two workshops in Dublin with the aim of sharing
good practices in recruitment and retention at a national and European level.
Ethical Guidelines for best practice recruitment should include the following broad
categories:
1.
2.
3.
4.
5.
6.
Protocols for Recruitment Agencies
Information on the Country Recruiting and Employment Practice / Laws of that
Country
Rights of Employees
Details of Orientation / Induction Programmes
Integration Process
Support for Overseas Nurses both socially and within workplace.
This is where the Single European Market can assist countries to collaborate in good
recruitment practices. Information can be shared on disreputable recruitment agencies,
aggressive recruitment practices, recruitment from developing countries, unethical practices
of recruitment and poor or no support for overseas recruits.
Strategies for Retention:
A number of strategies for the retention of nurses have been discussed by PCN-member
associations and these are follows:
1.
2.
3.
4.
5.
Nursing pay is too low – systems promoting equal pay for equal work are valuable
– organisations should work towards promoting a level of pay reflecting workload
responsibilities.
National Nursing Associations to work with local Government seeking favourable
pay and conditions of work – pay is a priority in retaining nurses.
Consideration be given to funding career opportunities for older nurses.
Implement strategies to attract returnees to the profession – back-to-nursing
courses.
Support returnee nurses in the clinical areas.
Nursing is predominantly a female profession with a high proportion of members in
childbearing and childrearing years. These issues need to be addressed by:
1.
2.
3.
4.
5.
Introduction of family-friendly initiatives;
Provision of adequately staffed childcare and crèche facilities;
Flexibility in hours of work;
Marketing initiatives to recruit mature students;
Continuing professional development as a means of retention;
120
6.
Create ways to assist nurses undertaking further study – study leave,
reimbursement of fees and expenses incurred.
Development of management tools to assist nurse managers in terms of pro-actively
planning recruitment and retention strategies.
Recruitment of nurses from other countries could be supported by –
1.
2.
3.
4.
5.
Nationally agreed protocol on good recruitment practices;
Efficient national registration system for foreign nurses;
Recruitment using telephone 24-hour help line.
Orientation and induction programmes for overseas nurses;
Nurses from other countries have their education and experience gained recognised
in terms of pay and conditions.
Where To From Here?
It is inherently obvious that co-operation and collaboration is required, both amongst
countries within the Single European Market and the Eastern European Association (EEA).
Whilst recognising the difficulties encountered by EU countries in relation to nursing
shortages, PCN and its member-associations have concerns about recruitment practices which
militate against finding solutions, within individual countries, to the nursing manpower
shortage.
Policy implications should include:
•
•
•
•
•
Collaborative research into the nursing and medical resource across the
EU, future health service needs and recruitment practices in order to make
future predictions. Countries should be assisted / encouraged to collate
good quality data at local level first and then at national level. Guidelines
on the aggregation of data should be provided and research should be
both quantative and qualitative.
Setting up of an EU / National Manpower Forum.
Identification of successful recruitment and retention strategies and the
evaluation of their transferability across Europe.
Encouragement of countries to set up partnerships.
Ongoing monitoring of:
Health Service Needs
Employment Needs
Global / EU
Impact of Manpower
Changes for the Retention of Nurses
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
121
Public procurement of goods and services: a legal analysis of the
Spanish case:
Fernando Silio
1.Background
It is estimated that up to 15 per cent of the European Union's Member States economic
activity originates in the public sector to fulfil needs such as the execution of public works
and supply and services demanded by the public administration. Public procurement, as
well as being one of the essential tools of each administration for its own functioning, has a
great deal of influence in the evolution of the industrial and commercial structure of society.
For this very reason the inclusion of Spain in the European Community has provoked a
substantial change in the way public procurement is regulated. The legislative process was
begun in 1986 and concluded with the enforcement of the 13/1995 Public Procurement Act of
May 18th.
One of the backbone policies of the European Union in the construction of a single internal
market aims to "effectively open the public markets" with the purpose of ensuring
transparency of information and contract award procedures. This enables both suppliers
and businesses greater opportunities to develop and carry out their activities in the
community. The market expansion allows the reduction of cost through scale returns and
improved efficiency thanks to the positive effects of competition. Also, the diverse public
administrations benefit from greater choice which allows important budgetary savings.
Finally, consumers and users benefit from services at better value for money14.
The basic principles of public procurement which derive from the Directives are: equality,
transparency and competitiveness. These are basic principles which have to be complied with
in any contract. In the health sector the new legal framework has caused a revolution, as
there is a high level of public procurement in the health sector administration.
As in any other sector, deficiencies in the application of communitarian regulations in the
Spanish legal system have been immediately identified. First of all, the Directives on the
excluded sectors have not been implemented in time to our legal system. Secondly, the lack
of determination in our public sector, from the organizational point of view, has resulted in
the non-application of the law contracts, breaching the communitarian law. Thirdly, from a
technical perspective, we should point out that there is excessive formalities in the
enforcement of the regulations, a contradiction according to the communitarian principles.
Finally, we should also mention the infringement of a rule which has lead the European Court
of Justice to condemn Spain for putting into practice usages contrary to the freedom of
movement of people, goods and services. These are some of the reasons which have lead
the Spanish working party to make a study of the impact of the new legal framework on
Public Procurement one of their main objectives.
14
During the time we were doing our research, the European Commission has adopted a package of
amendments to simplify and modernise the public procurement Directives. The Lisbon European Council
acknowledged the importance of this legislative package for the competitiveness of European companies,
effective allocation of public resources, economic growth and job creation, and recommended its adoption and
implementation by 2002.
122
2. The impact in the health services. Public procurement in the Andalusian regional
government
Introduction
The system of purchase of goods and services by the Spanish health centres has undergone
a series of changes over the last years as a result of the Community Integration process. The
impact of European legislation on the system of purchase of goods and services materialises
in Spain through the Act 13/95 on contracts of the Public Administrations, currently in force,
and which derives mostly from Directive 93/36/EEC.
During this phase of our research, our objective has been to demonstrate the impact of
community policies on these services exploring the Spanish case in order to be able to
establish comparative objectives among the countries participating in this project.
We have started from the principle that in the public procurement of goods and services,
there is an interaction between the demand of the public sector and the supply of the
private sector. During the first stage of this project, we have identified the main legislative
transpositions carried out within the Spanish legal system.
The Spanish Act 13/95 regulates the process of purchase of goods and services by the
Spanish Public Administrations. The main stages in this process are detailed in the graph
that follows. This graph is the result of our field work in Spain and it is also the summary of
the process, as described by the persons interviewed:
123
124
Comparative analysis of real expenditure on goods and current services by the Andalusian
health service (A.H.S.) in relation to calls for tender
The following graph shows the real expenditure on goods and current services by the A.H.S
in 1998 and the calls for tender in order to purchase them. 15
As can be seen, the total value of tenders (525.07 millions of euros) represents 66.75% of
the total expenditure (786.66 millions of euros.
A description of the calls for tender by the Andalusian health service and their publication in
the European Communities Official Journal
The Spanish Public Procurement Act 13/1995 of May 18th establishes, in Book II, the
publishing regulations in the European Community for the types of contracts according to the
amounts involved and it lays down the following criteria:
Works Contracts :
To be published in the OJEC if the amount is equal to or higher than 4,090,831
euros.
Supplies Contracts:
To be published in the OJEC if the amount is equal to or higher than 163,633 euros.
Management of Public Services Contracts :
Publication in the OJEC is not compulsory.
15
.- Goods and current services expenditure does not include the amount for concerted health care, for this
reason it has not been included under type 62 "Health Care Services" of the analysis of tenders. The purpose of
this is to establish a comparison between the amounts for real expenditure and calls for tender.
125
Consultancy and Assistance Contracts:
To be published in the OJEC if the amount is equal to or higher than 163,633 euros.
The following graph illustrates the calls for tender by the ANDALUSIAN HEALTH SERVICE and
their publication in the OJEC as stated in the above mentioned regulation:
Calls for tender and their publication in the OJEC. ANDALUSIAN HEALTH SERVICE-1998
CALLS FOR TENDER
%
COMPULSORY PUBLICATION
482.30
89.57
NON-COMPULSORY PUBLICATION
56.18
10.43
TOTAL
538.47
100
Data in millions of euros
Source: Statistics and Information Service of the ANDALUSIAN HEALTH SERVICE
Note that 89.57% of the totality of calls for tender require to be published in the OJEC,
compared with a 10.43% that do not require compulsory publication.
126
Collection and analysis of the information obtained from the semi-structured interviews with
economic administrative directors
This information was collected in March 1999 in the different centres, in person and by a
trained interviewer. Each interview was recorded and subsequently transcribed.
The analysis of the information has been performed through a process of contents analysis,
complemented by an automatic analysis performed by the computer programme NUDIST.
Changes in the purchasing process:
In general, the proceedings are very similar to the ones existing before this law. The main
changes are shown in the following table:
European publication is required.
New criteria for the award of contracts.
Different costs to establish the type of procedure.
Positive aspects:
127
Negative aspects:
•
Improvement of the •
organisation in a short
period of time.
•
The objectivity of the
awarding
criteria
increases.
•
•
Better publicity and
more transparency.
•
The
procedures
to •
negotiate
exclusivity
contracts
become
quicker.
•
Increase in quality, rigor
and protocolisation.
•
•
•
Increase in red tape,
which affects quickness. It
is compulsory to go
through a long, hard and
difficult process.
The law fails to adapt to
the sector and to the
specific needs of health
bodies.
“For example, one can say:
“ how much am I going to
spend on sutures in the
year X? Or you can say:
“well, I am going to spend
money on a prosthesis and
you think: we are going to
buy fix prosthesis, but next
year the decision is to buy
rotative prosthesis, and
what are you supposed to
do with the contract
signed for the fix ones?”.
(ECONO1)
There is little clarity in
some aspects, such as the
framework agreement or
the proceedings required
for
the
negotiated “If you prepare the tender
well, it normally works
process.
well. Sometimes, doctors
It becomes more difficult have got used to a specific
to detect needs. There are type of trade mark and if
more information needs, the tender is not well
and this implies an defined, there can be
increase in services and problems. There have been
problems with needles and
personnel.
other lots”. (ECON02)
Extension of time limits to
“It has been a great effort,
make the purchases.
based
on
experience.
When you get to the
Discomfort
among technical committees, in
professionals.
which the technical aspects
are assessed, there are
mistakes
in
the
convocation which must
taken into account for the
following year” (ECON08)
Reasons for the changes in the purchasing system
Reasons for current changes in the purchase system are frequently attributed to the
European Union's influence in the integration process of its Member States:
Changes and improvements can also be seen as a result of the enforcement of the Spanish
Public Procurement Act which establishes the adaptation of services to the new situation:
128
Another argument given by the people we interviewed is to ascribe the changes as the result
of an evolutionary process towards the improvement of Public Administration, meaning more
budget control and a reduction of administrative arbitrariness.
Changes in tenders: Bi-annual tenders
The increase of paper-work is one of the main consequences carried by the new contracting
procedure, in particular when calling for a tender in order to purchase for the health sector.
Pluriannual tenders are a way of avoiding and delaying the increase of "bureaucratic tasks".
According to the people interviewed, pluriannual tenders have increased as a result of the
new Spanish Public Procurement Act. This type of tenders have more complex procedures
but also have more advantages. One is an increase of the contracting authorities' loyalty
towards the supplier who will supply the merchandise for longer periods of time. In return
there is an improvement of quality and better prices.
However, the interviewees have also pointed out some restrictions and problems arising from
this type of procedures: the impossibility of applying them to goods undergoing fast
technological development and that require changes in their definition when purchasing
them.
Among the procurement services we contacted, there are some that do not apply this type of
procedure to all the purchased goods and services. They are only applied for large contracts.
Sometimes the people interviewed have declared that this type of procedures already existed
and cannot be attributed to the new legislation. However, these cases have been
exceptional.
Contracts published in the Official Journal of the European Communities
The publication in the Official Journal of the European Communities (OJEC) varies in the
different health centres were we had staff interviewed. It varies between 11% and 80% of the
total of procedures submitted to tender.
In general, hospitals publish more if we compare them with the Primary Care Districts we
have studied. The reason can be found in the differences in the volume of procurement.
Among hospitals the Virgen del Rocio Hospital in Seville published more than any other
hospital in 1998, in the OJEC. However, we have to take into account that it has the biggest
assigned population, number of beds and budget.
To publish in the OJEC implies a prolongation of the time limit for the awarding of tenders.
Some interviewees have acknowledged that in some institutions the tenders are fractionated
in order to avoid compulsory publication at European level and therefore shorten the time
limits.
Criteria for the award of tenders: Changes introduced by the new law
The criteria for the award of tenders are different depending on the Andalusian health centre
studied. It depends on the type of goods and services to be purchased whether more points
are given to either price or technical quality. There is wide scope for case analysis. Generally,
the first distinction is made between supplies and services. When considering supplies,
prices are more important than in the case of services. In the latter the main considerations
are mostly technical.
These criteria are established according to the type of goods and services, based on the
decisions made by the departments in charge of the procurement services, and the usual
practices in the awarding of contracts. There seems to be a general criteria in each centre for
the different groups of items or services contracted.
129
In high-tech supplies and services priority is generally given to the technical report but for
those goods which have an established quality and technology, money is the main
consideration.
Occasionally in some tenders we have found considerations being made to specific aspects
that were not related to the technical report or price.
In other cases the department doing the purchase can fix the price before calling the tender.
In that way priority is given to the technical report because we start by fixing a "reference"
price according to market considerations.
In most of the cases studied the technical information is provided by the centre's specialised
staff. However that is not always the case and it depends mainly on the type of centre. In
the following quote we illustrate a case which corresponds to a situation where there was no
separation between price and technical report when calling for a tender.
The fact that you can't undercut prices in tenders in order to obtain the award of a hospital
service, means that prices have to be as fixed as possible. This is done well before the
preparation of a tender, then technical standards are taken into account .
In some hospitals we have worked with the impact of the European Union will have price
repercussions and therefore criteria will be established when purchasing goods and services
for health centres.
Adaptation to the new legislation
Procurement services tend to adapt themselves to the time limits established by law in order
to award tenders. That has been the most frequent opinion among the interviewees.
In hospitals or primary care centres where we interviewed managers, the first problem they
have mentioned were the formalities of the tender itself and the technical report which has
to be drafted by the centre.
The main inconveniences related to the processing of tenders are: the length of time, usually
long, the establishing of objective awarding criteria, the comparative analysis and the
definition of the technical characteristics. Also, it is necessary to obtain the consensus among
professionals, which is also difficult sometimes.
Once the formalities are fulfilled in their own centre, the external time limits are also
mentioned as an obstacle to ensure compliance with legislation. They are mainly legal
advice and publishing by the central services.
Sometimes, particular problems appear with some companies when is time to sign a contract
or deliver the goods. These problems also delay the fulfilment of the time limits. This is a
result of the exclusivity that some companies have, resulting from the negotiated procedure:
We have to take into account that the publication of a tender is a process for the planning
and scheduling of the services. This aspect is regarded as an advantage for the procurement
department's tasks.
As regards improvements derived from "better purchases", publishing increases the offer
from different brands and products. The increase in competition lowers prices and sometimes
there is even an improvement in the technological quality of some items. Also, service
managers are obliged to be better informed about the market.
However, there are also cases in which the procurement departments we have studied
consider the new directives as a path full of obstacles. Especially when they involve the
130
publication process and the compliance with time limits, which do not grant any advantages.
In our study these cases were very rare.
Consequences for the market variations in the type of providers
In general, the people we interviewed didn't remark on any substantial change in the type of
providers that submit to tenders called by the Andalusian health services.
In our study, we have noticed a larger presence of big companies and multinationals
compared to small and medium-sized enterprises. This is due to the market's own dynamics
and because of the latter's impossibility to tender.
The arguments put forward in order to explain SMEs' difficulties for tendering are mainly due
to debt but also because of not being able to prepare the required documentation for any
tender.
Among professionals there is a feeling of dismay because they had been used to working
with the same suppliers from smaller companies for a long time.
The change in the type of suppliers can also occur because of the improvements made by
the departments in the purchase proceedings. They take advantage of competition among
suppliers and try to avoid dependency as clients.
We have found a case in which the changes occurred only in a specific type of contract and
not in general.
One of the main achievements of integration in the European Union could be a greater
participation of foreign companies in tenders for health services. However, our data do not
reflect such a situation. In most of the cases, the main tenderers are multinational companies
with branches in Spain or they are simply the same companies as before the process of
European integration.
Subjective view of the impact of European legislation on public procurement departments
For most of the people we have interviewed, their purchase systems haven't registered any
impact as a result of the new European legislation. Some exceptions can be found in the
following; the obligation to publish in the Official Journal of the European Communities,
changes in the awarding criteria and in the procedures.
In some of the procurement departments where we interviewed the staff, they have received
phone calls from European companies interested in the tenders. No tenders by those
companies were submitted after the calls.
However, the impact can be perceived in the Spanish Public Procurement Act 13/95 which
reflects European legislation. It can also be seen in the new formalities for calling a tender as
established by law but not from the communitarian law.
Some of the professionals interviewed, who work in public procurement in Andalusia, said
that they felt they were under surveillance because the new law was brought into force to
avoid corruption. Thus, it has caused some lack of confidence.
For some of these professionals, in order to apply the law in the health services, its
implementation should be more flexible and adapted to the situation and objectives of
public services.
In some cases, there have been complaints about the lack of information that services'
managers have on the impact of the new European legislation on their departments. The
following is an extract of an interview that illustrates this situation.
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3. Effects derived from the transposition of the European regulations to the Spanish legal
framework.
Intended effects
The health sector's considerable amount of procurement emphasises the effects that the
Communitarian rules will have in this area. Without including all possibilities, in the health
sector there are important categories of contracts and it is worth mentioning the most
important ones. We will provide what will be only a descriptive and qualitative analysis.
Works contracts have a great deal of importance not only for building new health centres but
because it is always necessary to reform and extend existing premises. However there is a
great drawback in this type of contracts: insufficient formal budgets, as the investments
budget is scarce if not non-existent. Apart from those works financed by the European
Union's ERDF funds, this difficulty has been overcome with subsidies either from local
Corporations, companies or instrumental entities that are in charge of the negotiation of
contracts. These types of contracts do not have any repercussions in the peripheral
management of the centres. This is because the negotiation of contracts is normally
centralised due to the amounts involved. Over time a gradual externalisation of the
execution controls has also been observed. Before, the administrative services had their own
team of engineers and architects as well as project supervision departments. Nowadays these
services are provided by professionals who do not belong to the organisation itself. So far,
concerning the impact of the communitarian principles, there has been no effective opening
of the market. The reasons can be found in the need to have branches in the area where the
work is to be carried out or the need to purchase or transport heavy machinery and staff
belonging to a firm, hampering the participation of foreign companies with very few
exceptions. However, those exceptions are important as they have bided as temporary joint
ventures usually with the participation of a Spanish construction company.
The administrative award of public works has not yet developed greatly in the sector, but
now the need to improve access and equipment in health centres is starting to make this
type of contracts more commonly used, particularly in order to build and manage car parks
and co-generation power stations in large hospitals. Concerning tenders, they are also
applicable to works contracts.
Another important category of contracts is the management of public services, strictly
speaking concerted health care. This type of contract implies indirect management of public
services. This is the case when the Administration, holder of the competency to provide the
service, does not have enough resources to do it. In such cases it is necessary to hire
services from private firms working in the same activity. Thus, in concerted health care the
aim of contracts is always to provide health services, though we have to distinguish between
complete concerted health care, when a private hospital or clinic is contracted to provide the
totality of the services involved, and specific concerted services such as imaging diagnosis or
particular services in order to treat certain pathologies. This could be the case when
contracting services to operate on cataracts in a specific population group. In this category
health transport is also included. Concerted health care is categorised as an administrative
contract regulated by the Spanish Public Procurement Act and also, as established according
to its specific set of rules, by the Spanish Health Care Act 14/1986 of April 25th, article 90.
Despite economic and social importance, concerted health care contracts are irrelevant from
the perspective of this study, as this type of contract already existed in the Spanish legal
framework and is not subject to communitarian regulations.
However, there is a fact worth mentioning related to private health centres or institutions.
To study the running of such centres would be interesting as they are business activities
linked to free entrepreneurial activities or movement of capital, as far as the investment of
132
communitarian funds is concerned. From that perspective alone concerted health care would
be conditioned by the communitarian regulations.
In health services the supplies contract can be categorised as the most important one due to
the volume of activity that it produces. Among the purchase of goods electro-medical devices
can be highlighted. Such supply contracts have traditionally had the same financial problems
as the works contract, budget wise, as such purchases become an investment. New types of
contracts have solved this problem. Now it is the hiring without purchase option which
prevails, allowing not only the use of equipment but its fast renewal, an obligation due to
scientific and technological improvements and at the same time avoiding depreciation of
equipment that soon becomes obsolete. The introduction of new contract types such as
leasings and hiring with purchase option offer new possibilities for these purchases. These
sorts of goods are mainly supplied by European companies as well as American and
Japanese companies with branches in Spain, therefore the application of the communitarian
rules is not modified by the nationality of the supplier. These companies (communitarian
and those included in the European Economic Area and the World Trade Organization) could
benefit from the fact that they will be able to bid directly from their countries without the
need to establish themselves in Spain saving costs. But from the perspective of health care
services no change will be perceived in a short term.
Another important supply for health care centres is medicines. Traditionally health care
institutions purchased medicines for hospital dispensaries by direct contracting. This practice
caused non-favourable judgement by the European Court of Justice concerning case C328/1992 Commission versus Kingdom of Spain, Sentence of May 3rd 1994. The grounds on
which the Luxembourg Court based its decision are derived from the fact that the directive
does not exclude those products from its scope of application as well as being a
infringement of the transparency and competition principles. Also the supremacy of
Communitarian Law invalidates the ground argued by the defence based on the Spanish
Social Security Act which establishes that medicines and pharmaceutical items destined to
used in health centres will be directly purchased through an Agreement between the
Administration and the pharmaceutical industry. Also, the Spanish Medicines Act categorises
these products as mediatised therefore excluded from contract legislation. Regarding
suppliers we can also apply our argument to the case of electro-medical equipment. Large
laboratories keep a firm control on market forces which frequently makes free competition
difficult in the supply of these products. In any case, in order to comply with the
communitarian principles concerning the supply of medicines harmonisation techniques are
also necessary as the nature of the product demands that the corresponding authorisations
and administrative checking procedures be in tune with the fabrication and
commercialisation.
Everything we have said so far is also valid for the supply of all other health products;
reagents, medicinal gases, surgical equipment, and so on, due to the fact the their technical
features have already predetermined the market and therefore there is no variety in the type
of supplier, though logically purchase by tender could lower the product's prices.
In the case of ordinary supplies, generally due to their low cost, they are considered as
minor items with no communitarian participation. It is the local companies who take charge
of their supply.
In the section concerning services, as well as consultancy and assistance contracts, in which
the range of communitarian influence is modest, some important services required by health
centres are: cleaning, catering, maintenance and security services. Such services are
contracted through tendering and competition is fostered due to their high value. However, it
remains that because of their inherent characteristics requiring the availability of many
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workers mainly Spanish companies and groups bid for the tenders. The compliance with the
communitarian regulations has not attracted foreign companies. At another level we shall
mention the computing services where participation of foreign companies is greater due to
the sector's configuration.
Other contracted services, of less economic importance, are publicity for health promotion
campaigns, training services or legal services in which there is no communitarian
participation.
Insurance services are a recent addition to the Spanish health system. Communitarian
regulations have an influence on the contracting of civil liability insurance policies due to
their high costs which require advertisement at communitarian level. This sector, though
supervised, requires a mandatory administration authorisation in order to operate the various
insurance categories and has been influenced by the regulations established by the
communitarian institutions. This influence has forced the Member States to adapt their
internal regulations. In Spain such adaptation has been carried out according to the Private
Insurance Code and Supervision Act 30/1995. The contract type envisaged by the Spanish
State Contracts Act of 1995 revealed itself as inadequate. Which is why, after the reform, this
service is considered as a private contract, though its awarding should comply with the
contracting communitarian principles.
To conclude this brief description, we will mention a series of contracts with patrimonial
content and therefore excluded from the procurement legislation, but which have to be
awarded complying with the communitarian principles. They are the awarding of contracts for
the opening of cafes, press and lottery stands, cash lines and other business premises
appropriate to health service buildings. In this contract category, rather unclear regarding its
legal status, the communitarian regulations have not been applied and consequently there is
no communitarian competition.
UNintended effects
The analysis of the influence that public procurement has in the health sector demands that
we first look at some determinant regulations. First, the basic legislation on public
procurement, according to the Spanish Constitution -article 149.1.18-, establishes it as an
exclusive State competency. Being considered of a widespread nature, affecting the
Administration proceedings in various sectors and closely related to the market regulations,
the Spanish Regional Governments will only be competent with regard to its legislative
development. Although the Spanish Constitutional Rights Court in its sentence of April 22nd
1993, rendered for case 513/1987 regarding a conflict of competencies, established that
Regional Governments have broad competency in the sectors which affect the organisation of
their administrative proceedings and in those areas of competency which are granted by
statutory dispositions. For instance, some Spanish Regional Governments can regulate the
extent of competency of the contracting authorities, the guarantee that bidders provide as
financially and economically able, the securing and or exemption of guarantees in certain
contracts, the reasons for ruling on a public service management contract, the leasing of real
estate, payments in cash or other goods in a supplies contract, the summoning of Award
Tables, etc.
On the other hand, concerning the health sector, the Regional Governments have major
competencies in health service management. Together, the various Regional Health Services
form the Spanish National Health System.
It is probably in the health sector where the debate on new management forms and the need
to overcome the traditional model under the administrative law has had greatest importance.
The National Health System Analysis and Evaluation Commission appointed by the Spanish
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Parliament in 1990 advocated, in its summing up of the sector's problems, radical reforms
which included, amongst others, the granting of greater autonomy to the health centres in
order to transform them into public companies.
To put in Spanish jurisprudent, Muñoz Machado's, own words "...the trend for abandoning
Public Law guarantees and the infiltration of Private Law in every aspect of the public
services goes against the reality our times. Whilst we abandon some of those sorts of
guarantees the European Union, to which we belong as full members, is imposing the
necessary maintenance of a series of guarantees, that of course belong to Public Law, for the
functioning of certain establishments or in order to configure certain activities" (Muñoz
Machado: 1995).
Definitively, this is what is happening in spite of concepts or differentiated organisational
models in topics such as public procurement in which the working tools have to suit the
forecasts of Communitarian Law independently of the role of such rules as determining
factors in a management model. As we have said, independently of the management model
adopted, public procurement is fully submitted to Communitarian Law and the sometimes
difficult position health managers find themselves in, who have to combine effectiveness,
efficiency and legality in their task.
The previous legal analysis allows us to come to the conclusion that the impact of European
regulations in the purchase of goods and services is important because it has changed some
patterns in administrative management bringing about some legislative modifications in the
Spanish legal framework. These changes will be greater in the future. Planning for the
purchase of goods and services has become an essential tool permitting a greater
rationalisation of procurement. On the other hand such change, which has not been
welcomed by an important portion of the management staff, has contributed somehow to the
debate on new forms of organisation of the health services.
4. Conclusions and recommendations
The transposition of the European regulations to the Spanish legal framework on public
procurement started in 1986 after the accession of the Kingdom of Spain to the European
Economic Community. Since then, the extent of the influence of these transpositions has
been gradual, although from a substantial perspective we can assert that communitarian law
has been properly incorporated within the Spanish internal rules. However, such
incorporation has suffered delays in certain cases and formally has meant the noncompliance of the Spanish State obligations as stated by the communitarian Treaties. Such
was the case of the directives on supplies contracts in the utilities sector, as well as those
that modify and adapt the directives on services, supplies and works, both adapted beyond
the limit of the dateline.
The communitarian directives have put forward a new concept in public procurement. Due to
the diversity of legal frameworks in Member States, the administrative organisation or the
denomination of contracts is not an issue for the European regulations. On the contrary,
what is actually important is an effective opening of the public sector's market. Thus, any
contract, fully or partly financed with public funds, is considered as a public contract and
the contracting entities from the Public administration, or not, will be appointed as the
awarding body.
From this perspective, the impact of communitarian law in the purchase of goods and
services in health care services has been as important as in the rest of the public sector. This
135
is because procurement is a widespread subject that affects any activity involving public
expenditure and investment.
The impact of the communitarian regulations has been immediately perceived in its intended
effects. The incorporation of regulations within the Spanish legal framework has meant,
procurement wise, a reinforcement in the application of the communitarian principles of
transparency and competition, as well as the application of the equality and nondiscrimination principles. This is evident if we look at the new regulations concerning the
contracting proceedings, awarding proceedings, the fixing of time limits and datelines for
publishing in the official journals, as well as the new regime for establishing the essential
capacity and reliability qualifications of the contracted companies.
From the contracted parties perspective, partly because of the market's configuration, there
are no significant changes and because of this the supplier's features remain the same.
Generally speaking, the contracting possibilities have substantially changed. Now we have
new types of contracts and new possibilities in the purchase of goods and services that were
not externalised from the administration.
The unintended effects resultant from the application of the communitarian regulations have
stressed the existent differences between the trend set up by the European Union and the
need to provide health care management with alternative mechanisms.
Concerning the purchase of goods and services in the health care sector, the debate on the
wrongly called "privatising trend" has been heightened. We say wrongly called because in
fact, the trend does not imply the transfer or sale of resources and services to the private
sector. What is actually being questioned is a management model subject to Public Law. It is
into this context which we can fit the so called "escape of Administrative Law" searching for
alternatives that have to create instrumental entities subject to Private Law in their
proceedings.
When we deal with public service management public order in general and the inherent
nature of things establishes a series of limiting factors. Public Administrations, as opposed
to a private entity, can not without further questioning do anything that is not formally
prohibited. In fact, in the public sector, any activity always requires a qualifying rule. Every
proceeding carried out by the Administration is predetermined in rules according to the
classical principle of legality, therefore there is no possible management model aside from
the established rules and norms.
If the communitarian legal framework establishes a particular administrative concept in the
public sector, implying the existence of public law guarantees which are mandatory for the
functioning of certain establishments or for the configuration of some proceedings, it is
worth taking advantage of it. And it should be done with the right flexibility required for
managing public services with more effectiveness and efficiency.
The formal limitations that a regulation establishes can be compensated with more decision
power. In our case, when Public Administrations have to contract services they have to
comply with certain requirements and they are under constant supervision, not only political
but legal, financial and economic. However, when the Administration contracts a service
according to Public Law, it has a special regime not without advantages; it does not contract
as a private entity among equals. The Administration is in a prevalent situation justified
because it serves the general interest.
To sum up, the assessment we can give to this situation is positive, although the limitations
alluded to should be taken into consideration.
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Recommendations
General
Encouragement from the entities involved in the management of health care services should
be sought in order to foster legislative and ruling initiatives.
In Spain, the regulation proposals should be formulated by the competencies of the Regional
Governments as established in the Spanish Constitution and the Regional Governments
Statutes which grants them with competencies in the development of rules in contract law.
Specific
It is necessary to give managing entities mechanisms in the planning, co-ordination, and
homologation of proceedings for greater effectiveness in procurement.
In procurement it is absolutely necessary to previously define what we want to purchase and
which services are needed. A very important mechanism is the preparation of a product and
services catalogue. Catalogues define the technical features of the goods and services
included in it. These would be subject to constant modifications as the health care activities
are linked to scientific and technological progress.
Regarding the contracting systems, the simplification of administrative proceedings can be
achieved by creating centralised entities that would catalogue suppliers according to
contracting capacity. Contract forms would need to be approved, not for types of works
contracts, services or supplies but for specific contracts i.e. cleaning, supply of reagents,
security, hiring of equipment, etc. As well as the approving, within the entities, of provisional
and definitive security exemptions, the fostering of prototype contracts and tenders to decide
on them, the creation of contracting boards, the preparation of contracting guides and the
necessary moves to design management training courses.
Although budgets are issued on an annual basis which sets the pace of public expenditure,
it is important to fix a planning mechanism in order to establish the appropriate purchase
time.
Finally, a redistribution of competencies would be recommended in order to establish who
purchases. Despite the fact that autonomy in taking decisions has proved to be an efficient
mechanism in certain purchases more centralisation could save administrative costs and
some services could benefit from the effects of scale economy.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
5. References
ARIÑO ORTIZ, G. El concepto de contrato público en la CEE. Noticias/CEE 21, 1986.
BAÑO LEÓN, J.M. La influencia del derecho comunitario en la interpretación de la Ley de
Contratos de las Administraciones Públicas. RAP 151, 2000.
BASSOLS COMA, M. Aproximación a la normativa comunitaria europea sobre contratación
administrativa. Noticias/CEE, 21, 1986.
BORRAJO INIESTA, I. Las Directivas sobre contratación pública como manifestación de la
libertad comunitaria de circulación. Noticias /CEE 21, 1986.
GARCÍA GÓMEZ DE MERCADO, F. Contratos administrativos y privados tras la Ley de
Contratos de las Administraciones Públicas. REDA 95, 1997.
137
GARCÍA RUBIO, F. Agrupaciones de interés económico y la influencia europea como sujeto de
contratación administrativa en La armonización legislativa de la Unión Europea. Ed.
Dykinson, 1999.
GIMENU FELIÚ, J.M. Una valoración crítica sobre el procedimiento y contenido de las últimas
reformas legales en contratación pública. RAP 144, 1997.
GONZÁLEZ-BERENGUER URRUTIA, J.L. La incidencia de la legislación comunitaria en el
régimen de contratación de obras. Noticias/CEE 21, 1986.
GONZÁLEZ-VARAS IBÁÑEZ, S. La contratación de las Comunidades Europeas. RAP 142, 1997.
JIMÉNEZ-BLANCO CARRILLO DE ALBORNOZ, A. El impacto de la normativa europea sobre
contratación administrativa en la legislación de contratos del Estado. Noticias/CEE 21,
1986.
LÓPEZ BLANCO, C. La doctrina del Tribunal de Justicia sobre la contratación pública.
Noticias/CEE 21, 1986.
LÓPEZ FONT MÁRQUEZ, J.F. La apertura de los procedimientos nacionales de adjudicación
de contratos públicos a las empresas de otros Estados miembros de la Unión Europea
(Sentencia de 17 de noviembre de 1993 del Tribunal de Justicia de las Comunidades
Europeas) RAP 133, 1994.
MARTÍNEZ-CARDÓS RUIZ, J.L. La adaptación del Derecho español a las directivas
comunitarias sobre contratación administrativa. Noticias/CEE 21, 1986.
MESTRE DELGADO, J.F. La normativa comunitaria europea sobre contratación administrativa.
Noticias/CEE 21, 1986.
MONEDERO GIL, J.L. Criterios de adjudicación del contrato administrativo en el Derecho
comunitario. Noticias/CEE 21, 1986.
OLIVERA MASSÓ, P. La problemática sobre la delimitación del ámbito subjetivo de las
normas internacionales sobre contratación pública. RAP 145, 1998.
- VALERO LOZANO, N. El régimen de las actuaciones administrativas preparatorias de los
contratos en la Ley 13/1995. RAP 142, 1997.
VICENTE IGLESIAS, JOSÉ LUIS. Comentarios a propósito de la próxima reforma de la Ley
13/1995 de 18 de mayo, de Contratos de las Administraciones Públicas. Actualidad
Administrativa Núm. 31 de 1999.
VVAA. La reforma del Sistema Sanitario. Análisis comparativo de siete países de la OCDE.
ESTUDIOS DE POLÍTICA SANITARIA NÚM. 2 , 1998.
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Unido. ESTUDIOS DE POLÍTICA SANITARIA NÚM. 6, 1998.
VVAA. La reforma de los sistemas sanitarios. Una voluntad de cambio. ESTUDIOS DE
POLÍTICA SANITARIA, NÚM. 8, 1998.
6. An approximation to the public procurement of goods and services in other European
Countries: The case of England and Sweden
6.1 Public procurement of goods and services in the UK: NHS Supplies
In the UK a body called NHS Supplies (NHSS) provides a service to most NHS Trusts
(hospitals, community and mental health) for the procurement of goods and services. NHSS
has the following capability:
138
•
•
•
Customer services to Trusts: out posted teams which offer generic and specialist
advice for procurement (this includes everything from foodstuffs, stationary to
medical supplies and highly specialist equipment);
Contracts: the specification, negotiation and management of contracts;
Warehousing and logistics.
There are a number of private companies in the same business which can compete for
national contracts, especially in the generic business such as foods, stationary etc. Arguably,
NHSS has built up considerable expertise in the medical supplies business, but not all out
posted teams have this specialist knowledge available. Currently, there is debate about the
future of the customer services part of NHSS and strengthening the specialist, clinical
knowledge is one option.
In terms of procurement of goods and services Trusts are free to choose themselves which of
the following routes they choose:
•
•
•
Go through NHSS for the specification, negotiation and management of a contract;
Use NHSS customer services using their specialist knowledge to secure the best
contract, and then manage it themselves;
Directly access, negotiate and manage the contract themselves.
Decisions on the above options depend on what is considered best for the local organisation
in terms of price, quality, accessibility etc. Thus, in practice there is considerable variation
between organisations.
An important advantage of using NHSS is the already mentioned expertise they have in the
field, but also because they attempt to stay abreast of new developments in the field and
appraise the costs and benefits for Trusts. Because NHSS works across many organisations
they also build up incremental knowledge of what works in practice. They maintain a
database of the range contracts held by NHS organisations.
There is always the problem that consultants tend to believe the representatives of
companies, especially when they have a medical/nursing background. NHSS offers ‘nonpartisan’ advice, and it is important that they develop the evidence-based aspects of their
services in order to counterbalance the commercial sales talk of representatives.
The financial benefit of NHSS is the potentially lower overheads in comparison to operating
with a dedicated Trust-based supplies function.
The procurement process
There is no fundamental difference between the procurement of goods or services. When a
need has been identified within an organisation the size of the contracts determines the
process:
•
•
•
Below £25,000 the Trust can decide itself what and where to buy. This is mainly
decided by the Executive Team (esp. Director of Operations and Finance Director)
and put to the Audit and Performance Committee which is a sub-committee of the
Trust Board. Mostly, decisions are made on the basis of comparing competitive
quotations. At times smaller purchases are done as single tender actions.
Between £25,000 and £104,435 the Trust puts contracts out for tender. The length
of the contract can vary, but the total sum needs to be within these limits.
Above £104,435 the contract has to be put out to tender and advertised in the
European journal. This process takes a minimum of 77 days. If these are rolling
contracts over a 4 year limit they also have to be advertised in the European
Journal.
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For the contracts that have not been put in the European journal the rules in the Trust’s own
Standing Financial Instructions apply. These lay down rules for the tendering process and
management of contracts and the framework is developed by the Department of Health
(there is local variation about the size of the £25,000 limit depending on the total size of the
organisation’s budget).
A number of routes are possible:
•
•
•
NHSS may have a series of ‘packages’ which can be bought. NHSS maintains a
database of suppliers for a range of common services and can draw attention to
these ‘packages’, e.g. the management of maintenance for information systems or
ward supplies. NHSS manages the process of supplies throughout.
NHSS might offer advice for developing a service specification, manage the
tendering process and be involved in contract negotiations e.g. competitive
tendering for cleaning and portering services. Once the tender has been awarded to
a specific company the Trust manages the contract directly or NHSS does it on
behalf of the Trust.
The Trust organises a contract directly with a supplier.
The main difference between goods and supplies lies in the fact that. In general, it is easier
to specify the quality of goods than of services. However, there are notable exception such
as highly specialist equipment such as MRI or ultrasound that are influenced by medical
‘preference’. In terms of services, the issue of liability (health and safety) has to be
considered.
In general, procurement depends on foresight and sound planning, good negotiating skills,
credibility (expertise) and building up relationships within the organisation (visibility).
Impact of EU directives and regulations
Setting the financial limits has been one of the main influences, and the process for Europewide tendering has to be followed to the letter. Thus, it is difficult to procure things quickly
(77 days minimum) and long-term planning is essential. Safety issues concerning sterilisation
have been influenced, esp. regarding autoclaves. Another example is the storage of liquid
gases to comply with a 14 days supply requirement. This means the expansion of tank
capacity.
In the UK the Medical devices Agency issues up-to-date bulletins to NHSS and the NHS as a
whole on EU regulations. In general, everyone appears to be well informed of the latest
requirements.
At present, the procurement issue is becoming politically important as the new government
appears to want to move away from the ‘privatisation’ of services. The idea of developing
central coordination across all public services for integrated procurement is gathering
momentum.
6.2 Public procurement of goods and services in Sweden
In Sweden all the health care is decentralised to 21 regions. Because of this, all the buying of
goods and services are decentralised to the regions. In Sweden we follow the directive
93/36 so probably the procurement process is about the same in Sweden and Spain.
The total spending in goods and services during 1998 by your health services in your region
or country
For example, in Värmland during 1998 we spent about 500 millions in buying goods and
about slightly more than one thousand millions in buying both goods and services.
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The percent of this amount that your service buys using competitive tenders
All the buying of goods go though competitive tenders but it is about 700 millions of the
one thousand millions that go through competitive tenders.
The relation between the total number of competitive tenders and its publicity in the
European Official Journal
It is about 50 per cent that go through the European Official Journal.
Main regulations related to public procurement
Supplies
Commision Directive of 17 December 1969 concerning the supply of products to the State,
regional bodies and other legal persons in public law (70/32/EEC).
Council Resolution of 21 December 1976 coordinating procedures for the award of public
supply contracts (77/62/CEE).
Council Directive of 22 July 1980 adapting and completing Directive 77/62/EEC on the
coordination of procedures for the award of public supply contracts concerning certain
awarding entities (80/767/EEC).
Council Directive of 22 March 1988 amending Directive 77/62/EEC coordinating the
procedures for the award of public supply contracts and derogating some provisions of
Directive 80/767/EEC (88/295/EEC).
Council Directive of 14 June 1993 on the coordination of procedures for the award of public
supply contracts (93/36/EEC).
Public Works
Council Directive of 26 July 1971 concerning the abolition of restrictions on freedom to
provide services in respect of public works contracts and on the award of public works
contracts to contractors acting through agencies or branches (71/304/EEC).
Council Directive of 26 July 1971 on the coordination of procedures for the award of public
works contracts (71/305/EEC).
Council Directive of 22 August 1978 amending Directive 72/305/EEC concerning the
coordination of procedures for the award of public works contracts (78/669/EEC)
Council Directive of 18 July 1989 amending Directive 71/305/EEC concerning the coordination
of procedures for the award of public works contracts (89/440EEC).
Council Directive of 14 June 1993 on the coordination of procedures for the award of public
works contracts (93/37/EEC).
Reviews
Council Directive of 21 December 1989 on the coordination of the laws, regulations and
administrative provisions relating to the application of review procedures to the award of
public supply and public works contracts (89/665/EEC).
Council Directive of 25 February 1992 coordinating the laws, regulations and administrative
provisions relating to the application of Community rules on the procurement procedures
of entities operating in the water, energy, transport and telecommunications sectors
(92/13/EEC).
Excluded sectors
Council Directive of 17 September 1990 concerning the procurement procedures in the water,
energy, transport and telecommunications sectors (90/532/EEC).
Council Directive of 14 June 1993 coordinating the procurement procedures of entities
operating in the water, energy, transport and telecommunications sectors (93/38/EEC).
141
Services
Council Directive of 18 June 1992 coordinating the procurement procedures of public service
contracts (92/50/EEC).
Services, supplies, works
European Parliament and Council Directive of 13 October 1997 amending Directives
92/50/EEC, 93/36/EEC and 93/37/EEC concerning the coordination of procedures for the
award of public service contracts, public supply contracts and public works contracts
respectively (97/52/EEC).
Purchasing hospital services – the Swedish experience
Soren Berg
Abstract
The procurement process in Stockholm County Council
The presentation will consist of two parts: The first focused on political decisions, objectives,
legal conditions and the present state of the process. The second focused on evolving
challenges and dilemmas. The presentation will give an updated picture of issues like the
following:
Background and present state
The scope of this procurement is a contract period of five years (2004-2008), with the option
of a two-year extension, at a planned cost of ten billion Swedish kronor per year, which puts
this procurement in a class by itself as the biggest of its kind in Sweden.
A main objective is to increase the diversity among suppliers; to stimulate new solutions in
the ways in which health care is conducted.
The law on public procurement is not designed for such a complex object as acute health
care. Nor has such procurement previously been undertaken anywhere within the EU.
The procurement model is developing, but is not yet ready.
Challenges and dilemmas
The procurement raises many questions. Some of these have found their answer during the
process; some still remain open:
•
•
•
To what extent can and should itemised prising be used?
To what extent can and should objectives and incentives be tailored to fit different
situations and objectives?
How can dynamics in large-scale responsibility – with focus on integrated care – be
combined with openings for small size entrepreneurs?
142
•
How can the continuous flexibility and dynamics be strengthened under the
condition of five-year contracts?
How can purchaser-power be combined with patient-power?
Which openings for parallel services, with non-public financing, should be given to
contracted producers?
•
•
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
Matthias Wismar
Abstract
Regulation EEC1408/71 – which serves to coordinate social protection systems in the
European Union to allow the free mobility of workers and citizens – also provides the basis
for facilitating rather than restricting the free movement of patients or, to use a different
terminology, the consumer choice of cross-border healthcare goods and services.
The project identified four dimensions to consumer choice: i) access to the widest possible
range of services; ii) access with fewest possible restrictions (restrictions being authorisation
procedures or mandated referral patterns); iii) the maximum choice of provider; and, iv) full
reimbursement for any amount charged by the provider. (It may of course be desirable to
restrict some of them in pursuit of other social objectives such as equity.)
Potentially the impact of European legislation and ECJ decisions on cross-border consumer
choice is high, although the outcome to date has been very limited. Four factors account for
the limited numbers of patients actually taking advantage of cross-border choice: i) restrictive
handling of the E112 procedure whereby care abroad has to be pre-authorised; ii) differences
in the ‘healthcare baskets’ across Europe; iii) lack of cost reimbursement provisions in many
countries; and, iv) the nature of medical goods themselves and their distribution. The
political impact of the Kohll and Decker rulings, however, was substantial, since the ruling
resulted in the much-debated method to enable cross-border care (in addition to E111 and
E112), namely the ex-post patient reimbursement of unauthorised, but prescribed goods and
services.
Germany (the location for this case study) provides an illustration that there is potential for
cross border consumer choice in prescribed medical goods. During the brief period when
German legislation allowed free use of patient reimbursement instead of the usual
application of the benefit-in-kind principle, there were reports from sickness funds that bills
from abroad had been cashed in. Additionally, a strong claim in favour of the cost
reimbursement principle for the purchase of prescribed medical goods and services was
made by old age pensioners living abroad for long periods who did not wish to give up their
German residency.
As the Court ruling in the Decker and Kohll cases was restricted to 1) ambulatory care
services which are 2) included in the benefits’ catalogue of 3) patient reimbursement
143
systems, many Member States thought they would not apply to them. The recent GeraetsSmits/Paerbooms and Vanbraeckel judgements have, however, clarified that this is not the
case, have established further rights for patients to acquire goods and services across
borders, and provided a first hint towards a future standardisation of the benefits
catalogues.
Unrestricted access to services and providers outside the borders of the individual’s country
of insurance, reimbursed by public payers, would pose serious questions for national policy.
How could Member States deny choice inside their own country (for example, to restrict
access to a limited number of contracted providers) if these limitations do not exist for cross
border care? To what extent would such a new situation undermine national health policy
measures, such as rationing/prioritisation, or (more generally) cost-containment?
However, if the ECJ had decided against increased choice, i.e. in favour of a continuation of
the status-quo, this would raise the question whether – within a SEM – it is justified that
existing alternative methods of social protection institutionalise different methods to gain
access to different benefits, partially different providers and potentially different levels of
reimbursement.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
Alain Coheur
1. Introduction
With increasing European integration taking place in many areas (e.g. freedom of movement
for persons, goods, services and capital and also the advent of the single currency) and
because of the various cases dealt with at the level of the Court of Justice, cross-border care
is becoming an increasingly important question in the Member States.
Thus the border areas should lend themselves particularly well to policy action in the field of
health. In most instances, they constitute a geographical area with high worker mobility.
They were the first areas to benefit from agreements and conventions concluded between
neighbouring countries aimed at improving access to care, while the first pieces of social
legislation at European level were drawn up for frontier workers residing, in most cases, in
these territorial areas. However, these border areas have often been the result of a historical
heritage which has taken no account of cultural and social affinities.
At the present time, these areas offer new prospects and represent a unique area of
experimentation for Europe. In fact, it is not only a matter of reflections on worker mobility
but of pressure being exerted by each citizen in order to benefit from the care which is most
appropriate to his or her state of health. This constant pressure is the result of a European
process which has put the emphasis on freedom of movement for persons, goods and
services as a fundamental value in the creation of a single area. It would therefore be
144
paradoxical to encourage only the creation of a free trade area without accepting its indirect
consequences and thus to try to reduce mobility when it is not possible to manage all
aspects of it. This is particularly true in the field of health.
However, not all border regions lend themselves to the development of the same kind of
policy action project. Each region must, in fact, be evaluated in accordance with its
geographical, economic and demographic determinants and infrastructure capacity (excess
equipment or lack of equipment, medical oversupply, waiting lists etc.). Hence there are
areas with a low patient flow and underdeveloped health facilities, and there are areas with
a high flow linked to high worker mobility and highly developed infrastructures.
At the present time, we are only just beginning to obtain information16 on the social and
health characteristics of the Euregions and on the resident populations’ mobility potential. It
has to be said that the initiatives which have been undertaken are the result of the wishes of
grassroots actors, insurance funds, hospitals etc. And even though the legislatures seem to
be showing passivity invoking the principle of territoriality, this has not always been the
case.
2. Dynamics and evolution of the European context
To begin with, the legislatures’ interest was mainly shown through bilateral agreements. The
oldest Conventions of any importance in the field of cross-border health care were signed
between neighbouring countries such as Germany, the Netherlands, Belgium and France. A
typical feature was that they concerned care providers.
One of the first Conventions to be signed between neighbouring countries was the health
Convention of 12 January 1881 between Belgium and France which was revised on 25 October
191017 and which "authorised Belgian doctors of medicine, surgery and childbirth established
in the Belgium districts bordering France to practice their art in the same way and to the
same extent in any neighbouring French districts in which there is no doctor residing" and
reciprocally. Germany and Belgium entered into the same type of Convention on 28 October
1925.
The Convention of 28 April 1947 concluded between the Netherlands and Belgium covering
the practice of medicine in the border districts modified the Convention concluded on 7
December 1868 between Belgium and the Netherlands "on the reciprocal authorisation
granted to doctors and midwives to practice their art in the border regions of the two
countries".
This type of agreement was subsequently extended. Thus the origin of the Community
principle (applicable legislation geared to the country concerned) has its roots in the
simultaneous application of the Franco-Belgian Convention on social insurance of 23 August
1930. Under these provisions, French frontier workers and disabled people residing in
Belgium received Belgian benefits at the French rate: Belgian private insurance guaranteed
them at least the Belgian benefits and rates which, where relevant, would have exceeded the
French benefits.
16
"Le Nord-Pas-de-Calais Littoral, milieu, hospitalisation, médico-social et perspectives." Report
prepared for the Regional Nord-Pas-de-Calais Council. ORS Nord-Pas-de-Calais. O. Lacoste, L.
Spinosi, S. Le Niniven. Fourth Quarter 2000.
c
van
de
Euregion
Maas-Riin.
Werkgroep
Eureregionale
1 Gezondheidsbericht
Gezonheidsberichtgeving, R.J.M. Derkx, G.H.L. Franssen, J.H.Freund, Y. Pirenne. Fourth Quarter
1999.
17
This 1910 Convention was terminated only on 9 January 1998.
145
On 29 August 1947, the Netherlands and Belgium signed a Convention "on the application of
their reciprocal social security coverage legislation". Two agreements were later concluded in
1957 and 1965 concerning social security coverage in respect of sickness expenses. To the
extent that they related to benefits, these agreements ceased to apply on 1 January 1981
because of the entry into force of the agreement of 24 December 1980 on the coverage of
medical care.
In addition, Article 51 of the 1958 Treaty of Rome granting the Council the power to adopt
"such measures in the field of social security as may be necessary to provide freedom of
movement for workers" and which were introduced by Regulation 1408/71 did not do away
with the bilateral contractual arrangements. These have progressed by providing better
coverage and easier access to care.
•
The Grand Duchy of Luxembourg, in an effort to simplify the administrative
procedures for reimbursement of its costs, has entered into agreements with
medical establishments in the surrounding countries. Seven agreements have been
signed with different German university hospitals, including two in Trier. These
hospitals bill the Luxembourg health insurance funds directly for treatment provided
to Luxembourg patients.
•
The Belgian-Luxembourg Convention concluded on 24 March 1994, replacing the
one dated 16 December 1959. Any frontier worker and members of his family
receiving benefits in kind on Belgian territory are entitled, where necessary, to an
additional reimbursement under Luxembourg legislation. This additional
reimbursement is payable by the competent Luxembourg institution.
At European level the introduction of the coordination Regulations 1408/71 and 574/72 has in
no way restricted the room for manoeuvre by Member States, especially through the entering
into of bilateral agreements. However, there has been a gradual weakening of this instrument
for coordinating social security schemes which, on the one hand, was drawn up for the
purpose of guaranteeing rights to migrant workers and their dependants and which, on the
other hand, was subsequently extended18. On the one hand, it contains inherently restrictive
elements whereas, on the other hand, European integration has resulted in changing the
principle of freedom of movement for persons from an economic right to a personal right of
European citizens.
This weakening is all the more noticeable as Member States continue to claim a sovereign
competence as regards organising health and social protection by invoking, on the one hand,
Article 5 of the Treaty which defines the principle of subsidiarity and, on the other hand,
Article 152 (5) of the Treaty which provides that "Community action in the field of public
health shall fully respect the responsibilities of the Member States for the organisation and
delivery of health services and medical care". In fact, Regulations 1408/71 and 574/72 do not
rule out the principle of territoriality and their objective is not to ensure merely access to
health care for citizens in other Member States.
18
Article 51 of the Treaty of Rome entrusted the Council of Ministers of the European Economic
Community with the task of adopting "such measures in the field of social security as may be
necessary in order to provide freedom of movement for workers". The Council of Ministers first
adopted:
- Regulations (Nos. 3 and 4) covering social security for migrant workers;
- Regulations (Nos. 36/63 and 73/63) covering social security for frontier workers;
- Subsequently, the Regulations (1408/71 and 574/72) on the application of social security schemes to
employed persons and their families [foreign nationals from one of the Member States, refugees and
stateless people) moving within the Community
146
We are therefore faced with the paradox that, while the content of the Regulation has not
really changed since 1981, many changes19 have taken place in the various Member States in
the field of social security as the result of national legislation and bilateral agreements and
at the level of the European Union as a whole due to the case law of the Court of Justice (an
aspect to which we shall not return).
Following a relatively long period during which EU jurisdiction was based almost exclusively
on Article 51 of the Treaty of Rome (Article 42 of the Amsterdam Treaty) which was
strengthened, inter alia, in 1961 by Article 11 ("the right to benefit from all the measures
enabling him to enjoy the best state of health that can be attained") of the European Social
Charter (revised in 1996), it was not until the Maastricht Treaty in 1992 and the Amsterdam
Treaty in 1997 that a new dynamic was introduced into the fields of social protection and
health.
The Community speaks of a contribution to the attaining of a high level of health protection
(Article 3 (o)), ensuring a high level of health protection in the definition and implementation
of all Community policies and activities (paragraph one of Article 152 (1)) and of improving
public health, preventing human illness and obviating sources of danger to human health
(paragraph two of 152 (1)).
The Commission attaches growing importance to the development of health care systems20
and to the introduction of an information system21 which will enable the various health
systems to be assessed.
The European Union Charter of Fundamental Rights signed at Nice on 7 December 2000
recognises the right to social security (Article 34) and health protection (Article 35).
As far as social protection is concerned, the EU has also shown itself to be much more active
since the early 1990s on the basis of the Council’s Recommendations22 and the Commission’s
Communications23. The social dynamic involved was reinforced by the adoption of a
European strategy on employment at the Luxembourg European Council in 1997 and also at
the Lisbon Council in 2000.
Although the Community level has been assigned the competence to coordinate the various
national systems with a view to ensuring freedom of movement for persons while preserving
their social security rights beyond the borders of their affiliate home State, European
integration has left each Member State’s competence in organising its own social protection
system, define the conditions governing access to it and also entitlement to benefits intact,
whilst leaving it to the discretion of Member States to specify the degree of freedom
permitted to obtain care abroad or to negotiate the content in the context of any bilateral
agreements. However, developments which have taken place since the 1990s are giving rise
to new needs, new expectations, new possibilities and new hopes in the context of
enlargement.
19
Opinion of the Economic and Social Committee No. 2000/C 367/05; OJ, 20.12.2000
Commission communication COM (1998) 250 final, 15 April 1998
21
Commission communication on the health strategy of the European Community and Proposal for a
programme of Community action (2001-2006) (COM (2000) 285, 16 May 2000).
22
Recommendation 92/442/EEC of 27 July 1992, OJ 1992, L 245/49 concerning the convergence of
social protection objectives
23
Communication COM (1997) 102 final of 12 March 1997 entitled "Modernising and improving social
protection in the European Union" and communication COM (1999) 347 final, 14 July 1999 entitled "A
concerted strategy for modernising social protection"
20
147
3. Euregion dynamics in a restricted area of freedom
In the light of the above, do the Euregions have any real autonomy in the field of health?
Even if in principle the degree of freedom appears to be relatively small, it would
nevertheless appear to be sufficient to permit initiatives to be taken and for experiments to
be carried out which will promote freedom of movement for persons and will facilitate access
to cross-border care.
The border regions account for 15% of the Community's territory and 10% of its population.
These regions are extremely varied in terms of population density and economic
development. They also have to face a number of legal and institutional obstacles which do
not always have to do with the jurisdiction of the regions, in particular in the field of health
and health insurance, as we have shown.
In 1992, the European Commission launched a major Community initiative known as
INTERREG.
Community Initiatives are specific instruments of the Union's structural policy which the
Commission proposes to the Member States to support activities which contribute to solving
problems which have a special impact at European level.
The general principle underlying the Initiatives24 was and continues to be that national
borders should not be an obstacle to balanced development or to integration of the
European territory.
We can highlight three elements characterising and constituting the added value of the
Interreg Initiative:
•
support for the development of and complementarity in cross-border and
interregional cooperation;
•
their method of partnership and implementation of the "bottom-up" approach;
•
a grassroots visibility which it offers citizens.
Another original feature is the distinctive method of financing. Budgets are not allocated to
the individual Member States but by border, and this has the effect of creating and
strengthening cross-border partnerships at the level of regional authorities.
Although the priority areas25 for Community action are defined in advance by the
Commission, each Euregion has a great deal of leeway as regards applying these guidelines
within a specific field of measures suited to its own regional situation. For example, the
Meuse-Rhine Euregion26 has adopted eight priorities which include "improving cooperation
and cross-border accessibility in health care".
24
Interreg I-II-III
The priority areas defined in the communication to the Member States (COM (2000) 1101 include:
- sharing human resources and equipment relating to research and development, technology,
education, culture, communication and health for the purpose of improving productivity and
contributing to the creation of sustainable jobs;
- increasing human and institutional potential relating to trans-national cooperation for the purpose of
contributing to economic development and social cohesion;
26
Euregion priorities are in preparation in the PIC 200-2006 of the Meuse-Rhine Euregion, September
2000
25
148
In the light of the regional priorities thus defined, the local partners (public and private
institutions, associations etc.) have the same autonomy in preparing joint cross-border
projects27.
The most significant results and progress achieved as regards cross-border accessibility to
health care have been under the Interreg programme. The most relevant question relates to
the assessment of the deliberate mobility of patients when the prior authorisation procedure
is lifted. This assessment should make it possible to evaluate the scale of care flows even if
it initially gives little information on the cost of such liberalisation or on the behaviour of the
providers.
On the basis of the results involved, we shall be able to identify the motives for this mobility
and determine whether the Euregions can, within a geographical area, constitute a suitable
response to the needs and expectations of citizens. Thus, is a patient seeking local care as a
matter of priority? Are the language barriers an obstacle? Are medical services available and
if so for what types of care and with what technologies? Do external factors such as waiting
lists encourage people to resort to care abroad? And so on.
Apart from the European and national legal and institutional frameworks, these
complementarity projects have given rise to:
•
•
•
•
an easing in the administrative procedures for the authorisation of care abroad;
partnerships between care establishments;
bilateral agreements between neighbouring social security schemes;
exchanges of knowledge and know-how.
This kind of cross-order accessibility implicitly ensures de facto mutual recognition of medical
and hospital practices in the Member States concerned.
4. Cross-border experiments28
Many healthcare projects have arisen within the framework of the Euregions, these projects
have allowed the way in which European citizens can obtain better access to health services
to be analysed29. So, generally speaking, we can note two types of approach, one in relation
to contractual practices and the other to citizens’ cross-border mobility linked to an
administrative simplification.
4.1 Contractual practices
The agreement may relate either to a request for collaboration or a reciprocity convention
between individual service providers or hospital institutions and/or the insuring bodies in
order to supplement a range of care services which is insufficient on one side of the border
and/or plentiful on the other side or to reduce problems in accessibility for certain patients,
mainly connected to the distances to be travelled.
The development of these partnerships is built on the notion of complementarity and on the
search for medical cooperation. In practice this always requires a derogation to the principle
27
Coheur Alain, Final report of the cross-border project in the Meuse-Rhine Euregion "for the purpose
of guaranteeing greater access to health care in the cross-border region".
28
There are many experiments in progress in the border areas for instance the Gronau, Rhein Waal,
Ems Dollart, SaarLorLuxRhein, Bodensee and Inn Salzach Euregions. The cases mentioned here are
not exhaustive but we do not currently have any assessments or results obtained.
29
There are many experiments in progress in the border areas for instance the Gronau, Rhein Waal,
Ems Dollart, SaarLorLuxRhein, Bodensee and Inn Salzach Euregions. The cases mentioned here are
not exhaustive but we do not currently have any assessments or results obtained.
149
of the territoriality of the services which is based on the limits of the care infrastructure in
these regions.
Up until now, within the framework of these conventions, the impact of the rulings issued by
the Court of Justice has been negligible or even non-existent given the particularly welldefined framework, the target population and the negotiated nature of the terms and
conditions of payment for the services.
A number of elements are taken into account before it is possible to enter into a convention:
•
•
•
The drawing up of an exhaustive inventory of the capacities existing in each of the
border regions,
The analysis of administrative procedures and levels of reimbursement for the
services,
The defining of criteria for approval, quality and costs in order to obtain an
equivalence in the requirements in terms of public health in each of the countries.
The main actors in these processes may act in a differentiated manner according to the
specific context of the border regions in question, in this way we have been able to identify
4 modes of inter-hospital conventions negotiated between:
1.
2.
3.
4.
Hospitals only,
Hospitals, the national authorities who are competent on matters of health
insurance and the regional insurers,
Hospitals and regional insurers,
Hospitals, public administrations (national or local) and insurers.
•
Conventions between hospitals, essentially on hi-tech matters, for instance:
o
o
protocol of collaboration entered into for paediatric cardiac surgery and renal
dialysis between the Acadamisch Ziekenhuis Maastricht (NL) and
l’Universitätklinikum der RWTH in Aachen.
Collaboration entered into in the field of radiotherapy in the Schleswig region
(D) and Südjütland (DK) where the Danish inhabitants have the opportunity to
be cared for at the hospital in Flensburg whilst continuing to be monitored by
the Danish oncology department at the hospital in Sonderborg.
•
Conventions between hospitals, the national authorities who are competent on
matters of health insurance and the regional insurers: there is the example of the
cross-border cooperation between the hospitals in Tourcoing (F) and Mouscron (B).
So French nationals suffering from renal insufficiency are cared for by the CH
(Hospital Complex) dialysis department at Mouscron. Belgian patients suffering from
immune deficiency syndrome are cared for by the infectious diseases department at
the Tourcoing CH. The assessment of the number of beneficiaries shows that on the
French side 20 patients have been monitored since the signing of the convention in
1994 and for Belgian patients benefiting from care at the CH in Tourcoing, since the
beginning of the convention (1994) 17 people have been monitored.
•
Conventions between hospitals and insurers: for example, since 1 March 197830,
Dutch people insured under the Zeeland-Flanders and West Brabant health
30
This Convention was modified and extended in 1998. The number of person benefiting annually
from this regulation is around 2,300, which corresponds to approximately 4% of the persons insured
by OZ in this region. Oral communication sources, 15 January 1999, Mr A.F.M. Bootsma, Medical
Manager of OZ)
150
insurance fund (OZ) have been able to receive medical care at the expense of the
Dutch social security system at two Belgian hospitals: the University Hospital of
Ghent and the Saint-Jean Hospital in Bruges.
Thus, when a patient's state of health requires immediate treatment, on the basis of
the treating physician's opinion (scheduling of treatment) and after obtaining
(administrative) approval from the competent health insurance fund (which issues
an E112 for identification of invoicing details), the patient is sent to one of the
above two Belgian hospitals. In other cases, the normal procedure (E 112) for
requesting health care abroad is followed. The patient pays the portion of the cost
of clinical care not reimbursed by the Dutch social security scheme. The health
insurance fund reimburses the cost of any hospital treatment.
•
Conventions between hospitals, public administrations and insurers
o
o
Public health administrations: there is the example of the agreement
signed between the transfusion centres in Liege (B) and Maastricht (NL)
allowing the blood products with a short storage life to be delivered in
connection with emergency care at the Hermalle-sous-Argenteau hospital.
This hospital is located 20 minutes from Maastricht and had to obtain its
supplies from the transfusion centre of the Liege University hospital
located more than 40 minutes away. Following a detailed examination of
the GMP31 conditions and the standards laid down by Netherlands
legislation and in accordance with the quality requirements relating to
blood products under Belgian legislation, a memorandum of agreement
was signed which had received the approval of the Belgian Ministry of
Public Health. The assessment made between May 2000 and March 2001
shows that a total number of 130 packs of blood were delivered
representing 46 trips between the transfusion centre and the hospital in
Hermalle.
Municipal administration: emergency transport agreement (in force since 1st
July 2000) signed between the municipality of Riemst (Riemst, Kanne,
Vroenhoven, Lafelt) (B) and the Belgian insurance bodies in order to allow
Belgian nationals involved in accidents on the territory of Riemst and
urgently transported to the AZ in Maastricht (NL) to benefit from
reimbursement at the Belgian tariff, the difference with Dutch tariffs being
paid for by the Municipality of Riemst.
4.2 Experiences with cross-border mobility :
These experiences are based on an overall approach to the situation in the border region,
the steps taken allow the following:
•
•
•
31
The supply of and demand for care can be used as a basis with the aim off
providing better efficiency in the use of the resources so as to improve the state of
health of the populations involved and to take account of the needs of people
covered by insurance who reside in border regions.
The creation of an institutional dynamic thanks to the direct involvement and
agreement of the authorities.
Thanks to cooperation with the public authorities, to encourage greater flexibility in
the procedures for access to care and mechanisms for authorisation and, if
necessary, to bring about an adaptation of the national legislative framework in the
countries in question.
GMP = Good Manufacturing Practice
151
The regulatory reference is still, however, the European regulation (1408/71) given that it
guarantees pricing security but contrary to inter-hospital conventions, the rulings of the Court
of Justice, in particular Kohll and Decker,32 have encouraged the setting up of projects using
the definition of a functional framework which does not require any prior authorisation from
the health insurance fund as a reference, thus giving rise to an administrative simplification
of the request for authorisation.
The authorisation to use an E 112 form depends not only on the legal framework but also on
the discretionary power of the consultant or the doctor from the insurance fund. So, the
more centralised the authorisation decision is (e.g. France, Denmark) the more the control
exercised over the conditions for eligibility is strictly respected 33 and vice versa, the more
decentralised the process of authorisation is (Belgium, Netherlands, Luxembourg) the more
the appropriateness of care provided abroad is taken into consideration.
So therefore it is logical that the most advanced cross-border projects with regard to mobility
have developed in Euregions where insurance bodies and the national environment both
work in favour of a cross-border dynamic. This does not necessarily mean that citizens have
total freedom in their choice of medical services. In most cases, projects relate to medical
specialties available in hospitals, up to now general practitioners and dentists have not been
involved, deeming that the populations’ needs are met by the services currently on offer.
Given that this is an overall approach where national elements may interfere with the
content of the projects developed, such as the over or under capacity of the infrastructures,
whether or not there are any waiting lists, etc. there may be two situations:
•
•
a restrictive policy on access to cross-border care: the public authorities are looking
to make investments and to use the domestic medical infrastructure, which results
in a reduction in the use of E112 forms;
a liberal policy: cross-border care is no longer considered as a burden but as a
contribution to the objectives of health policy resulting in far greater use of E 112
forms.
These elements do, effectively, assign the management bodies a function as the main
contact for the needs of individuals but also for the political authorities in the search for
innovative and appropriate solutions in border regions.
The results of the experiments described below shed light on the potential in border areas in
terms of innovation and accessibility to health services.
4.2.1. Hainaut (B) and Nord Pas de Calais (FR) regions: the aim of the Transcard project is to
facilitate access to the care provided in particular hospital establishments34, whether this is
outpatient care or care provided in hospital for Belgian or French employees and to check
the interoperability of health cards from each of the two countries (Vitale for France and SIS
for Belgium). This project disregards certain provisions made under regulations 1408/71 and
574/72 given that it does not require any prior authorisation from the health insurance fund
doctor in the country of affiliation. The experiment offers both Belgian and French people
living in the border region the opportunity to use their cards, SIS or Vitale respectively, in
precise cases requiring the E111 or E112 forms. The SIS and Vitale cards replace these forms
32
The Smits and Paerebooms, Vanbraekel rulings being too recent for their impact to be measured.
Luca A Crivelli, Cross border care between Swiss cantons: a testing lab for the single European
market, in
34
For the Belgian part, the Fagnes Health Centre in Chimay, for the French part, the Pays d’Avesnes
Hospital Complex, Felleries Liessies Departmental Hospital, Fourmies Hospital Complex, Brisset
Hospital Complex in Hirson, Nouvion Hospital in Thiérache, Vervins Hospital Complex, Thiérache
Private Hospital in Wignehies.
33
152
with regard to the identification of “cross border” patients and the monitoring of their
insurability. The information contained on the cards is used by the parties involved (the
hospital establishments and insuring bodies) in order to be able to invoice for the care and
obtain the reimbursement of the monies owing35.
From the first exploitable data36 it emerges that, during the period from 17 May 2000 to 30
April 2001:
•
22 people insured in Belgium received care in France
•
250 people insured in France received care in Belgium
Distribution by age: A majority, 66 %, of these insured people are between 20 and 60 years
of age, which is the age range of the active population. The remaining one third is
essentially made up of people aged over 60 (27%)
AGE
WORKFORCE
PERCENTAGE
0-10
8
3%
11-20
13
5%
21-30
23
8%
31 41
54
20%
41-50
62
23%
51-60
38
14%
61-70
32
11.5%
71 and over
42
15.5%
TOTAL
272
100%
Distribution by sex: 61% women as against 39% men
Distribution according to place of residence: we can see a flow of patients whose place of
residence is located within a radius of 20 km from the hospital attended for people insured
in Belgium and France.
Distribution according to the nature of the care: For people insured in France who were
treated in Belgium this is mainly outpatient care; nevertheless we can see the emergence of
a flow of hospitalisation (8 patients recorded at 31/12/2000). On the other hand the cases
listed in France correspond to stays in hospital.
35
In practice, for instance, the Fagnes Health Centre reads the French insured person’s Vitale card
using the “Transcards Vital” software application. If the insured person is part of the experimentation
region, the card contains the Transcards zone, which allows a special E112TF form to be printed out.
This is then automatically filled out with the information from the Vitale card, the hospital personnel
complete the form by entering the insured person’s address and send the E112TF with the request for
payment to the Belgian mutual insurance system which assigns an identification number to the French
affiliated member.
36
Final report Transcards project November 2000 until May 2001, 17/07/2001.
153
Types of services recorded
The year of experimentation has allowed us to record the following movements of patients:
CARE
French patients
Receiving care in Belgium
OUTPATIENT CARE
173 patients / 273 examinations
Belgian patients
receiving care in France
Scanner = 28%
Other medical imaging = 14%
Neurology = 18%
Nuclear medicine = 12%
ONE DAY CLINIC
12 patients / 59 fixed cost
Intra-vascular perfusion = 24
Chemotherapy = 29
Surgery = 5
Scanner = 1
INPATIENT CARE
8 patients
18 patients
Functional rehabilitation
= 13
Haemodialysis = 2
Other = 3
TOTAL
193 patients
18 patients
So we can conclude that, a posteriori, the project has allowed the following
complementarities to be fulfilled:
•
Patients residing in France travelling to Belgium for nuclear medicine and medical
imaging services plus neurology consultations. So these are mainly outpatient
services.
•
Patients residing in Belgium travelling to France for haemodialysis and functional
physiotherapy, so these are mainly inpatient services.
This can be explained by the fact that the care establishments may be some
considerable distance away, whereas they are available by simply crossing the
border.
Financial flows for Belgian patients
Belgian patients cared for in France (period from 15 May 2000 to 30 April 2001)
Outpatient care
Cost paid by Health Share to be paid by Total
Insurance
the patients
107.70€
46.33€
154.03€
One day clinic
1,281.74€
0€
1,281.74€
Inpatient care
114,133.62€
3,319.30€
117,452.92€
TOTAL
115,523.06€
3,365.63€
118,888.69€
154
Financial flows for French patients
French patients cared for in Belgium (period from 15th May 2000 to 31st December 2001. This
data is incomplete due to normal invoicing times).
Cost paid by Health Share to be paid by Total
Insurance
the patients
Outpatient care
25,257.25€
2,969.19€
28,226.44€
One day clinic
23,259.50€
1,551.22€
24,810.72€
Inpatient care
15,411.34€
1,115. 64€
16,526.98€
TOTAL
63,928.09€
5,636.05€
69,564.14€
Although we can see an imbalance in the flow of Belgian patients heading for France (a small
flow), on the other hand the imbalance is inverted with regard to the financial flow, which
can be explained by the nature of the care provided and the length of stays in hospital. This
shows a complementarity in the range of care available.
We can see a considerable difference in the sums remaining to be paid by the patients: in
Belgium, the share to be paid by the patient is 8.82% of the total to be paid by the Health
Insurance Policy whereas this is only 2.91% in France. These values have been calculated for
all forms of care as a whole.
Using the same indicator and making a distinction between the types of care (outpatient
care/one day clinic/hospitalisation), we can see that in both France and Belgium the shares to
be paid by the patients are the highest for outpatient care and are the lowest for One Day
Clinics.
Still according to the type of care, the share to be paid by the patient is between 0% (one
day clinic) and 43% (outpatient care) whereas in Belgium it is between 6.6% (one day clinic)
and 11.7 % (outpatient care).
This data is supplied for information only, it has not been possible to carry out a comparison
between prices for identical services.
In addition to the medical aspects, this experiment shows that it is possible to use a social
identity card from one country to another and it also shows the interoperability of the
systems in the medium term. For the social security bodies, this system of transmitting data
solves the problem of the heavy administrative load required for the management of forms
for access to care and financial regulation.
This project is in addition to another experiment with the reading of the NETLINK card
between France (Strasbourg) and Germany (Bad Wurtenberg) for dialysis patients.
4.2.2. Liege (B) region, Limbourg (B), Limbourg (NL), Kreis Aachen (D) Meuse-Rhine
Euregion: the aim of the IZOM project which brings all of the insurer bodies together is to
facilitate access to care for all populations residing in this geographical area for general care
provided by specialist doctors, on both the diagnostic and the therapeutic levels, the
prescribing of medicines within the framework of this treatment and the relevant hospital
care. This unique experimental project is implemented within the framework of international
agreements (EEC Regulations CEE 1408/71 and 574/72), as a result the legal provisions on
health insurance, the tariffs and the procedures in each country are applicable. In practice,
155
the insurer authorises the cross-border care with the aid of a specific form, IZOM EMR E112+
without prior agreement from the consultant. This project is based on the results of a
previous experiment carried out in the region under the name of Zorg op Maat.
4.2.2.1 Results of the Zorg op Maat project. This is a Dutch ZOM project monitored by the
NZI37 in the Meuse-Rhine Euregion. This latter, on the basis of a form, E 112+, allowed Dutch
patients to receive outpatient care from specialists in Belgium or in Germany. The project ran
from April 1997 to December 1998.
On the scope of the mobility: the regional insurer (CZ) assessed the number of insured
persons who benefited from the project in relation to the total population of the CZ in the
region (4% in Zealand Flanders cf. note above) at less than 1% on an annual basis and
estimated the number of potential beneficiaries at 3%.
On the type of medical specialties (n=989): in the league of medical specialties, the results
show that ophthalmology comes in first, followed by gynaecology and orthopaedics.
Medical specialties on the basis of the E 112+ form (period from 1 January 98 to 1 December
98) CZ.
Belgium
Germany
Total
1
Ophthalmology
50
119
169 (17%)
2
Gynaecology
1
120
121 (12%)
3
Orthopaedics
8
101
109 (11%)
4
Internal medicine
2
100
102 (10%)
5
Dermatology
40
53
93 (9%)
6
Scan
5
75
80 (8%)
Etc.
These figures have been compared with the national data for waiting lists. They do, in fact,
show that ophthalmology is in first place and orthopaedics in second place for the
specialties on waiting lists, gynaecology only comes in 6th and dermatology in 10th. On a
regional level, there are no waiting lists for gynaecology and for dermatology, only one
hospital (AZ Maastricht) has this specialty available, hence the congestion effect.
On the main reason for recourse to cross-border care (n=280) first comes the existence of a
waiting list (88.7%), then comes a detailed examination of the state of health (77.8%). In
third place (71.7%) is a different system of medical care. This latter point can, for instance,
be explained for orthopaedics by a more organic system of care, so in Germany
physiotherapy care is part of the treatment as a whole, for oncology Germany offers a
number of therapeutic alternatives and not only hospital establishments, for ophthalmology
Germany is quicker to use the laser treatment technique. The insured person’s knowledge of
the treatment plays a positive and considerable role in recourse to cross-border care
On geographical accessibility: the further away the beneficiary lives from the service provider,
the more he tends to have recourse to these services. So, in the Zuid Oost Limburg part,
proximity is mentioned in 73% of cases. The inhabitants of Maastricht tend to travel within
Belgium and the inhabitants of Vaals, Kerhade, Heerlen choose to go to Germany. In the
37
Grensoverschrijdende zorgproject Zorg op Maat report. Zienkenfondsraad, Minister van
Volksgezondheid, Welzijn in Sport, 25 March 1999
156
Midden Oost Limburg region geographical proximity is only involved in 9% of cases.
According to the type of population, in particular for German cross-border pensioners
residing in the Netherlands, there are other factors involved, such as a system of payment
which is appropriate to their own circumstances (43%), having already benefited from care
abroad (32%), the language used also reinforces these two latter factors (23% of cases)
For other groups such as the elderly and the disabled, only having to travel a short distance
to obtain care is an important qualitative element.
On the consumer profile: more than half of beneficiaries had received care abroad on one
occasion and more than a third had received care at least five times. There are three groups
of people which emerge from this. Pensioners who used to work across national borders and
who continue to travel due to the fact that they trust the service provider, a group based on
the existence of waiting lists and a third, looser group of people who travel because care on
offer abroad can offer more value or for reasons related to discontent or in order to obtain a
second medical opinion.
5. Euregional divergences, convergences and perspectives.
In spite of the trends, developments and results sketched out above, the practical and legal
hindrances to cross-border circulation will still remain considerable for the time being. The
convergence of healthcare systems can only be viewed as a long-term objective within the
European Union. The points of divergence are based upon the following:
•
•
•
the historical and legal development of European social models,
the organisation and financing of social security and health insurance,
the role played by the public authorities, the social partners and private
organisations in the decision-making process and the implementation of health
systems. For complementary systems, the differences are even greater.
The room for manoeuvre within the Euregions is very small, since we have to plan, build and
collaborate on the basis of a whole patchwork of differences.
Nevertheless, we can note that independently of their differences, all of the systems are
faced with analogous problems and challenges which will require a greater degree of
convergence. This potential convergence will be influenced by a number of factors.
The consequences of the rulings made by the Court of Justice, even though the Euregional
impact remains low within the framework of contractual agreements, have played a not
inconsiderable role in cross-border mobility projects. In addition to this, following highly
marked developments on a national level, certain Member States are thus being forced to
think ahead. Waiting lists in the Netherlands, which are creating a new dynamic in particular
in Germany and in Belgium, are a good example of this.
The uniqueness of the Euregions shows that there are various possibilities for continuing
with the development of the practical results obtained up to the present. The unique
geographical location of the Euregions means that we can experiment here on a small scale
with projects for complementarity or full mobility, where this does not yet appear to be
possible on a European scale. The Euregions are in fact a field for experimentation in the
development of new cross-border initiatives on European territory.
One interesting development which can be seen is the trend towards a growing diversity in
cross-border circulation. When the European regulations on the coordination of social
security were established, the legislature had only made provision for a very limited number
of categories of insured persons within the framework of cross-border circulation, insured
157
persons who, at the time, also had to be employees. Since then, the diversity of the types
and categories of insured persons and patients who can obtain aid abroad with or without
the prior authorisation of their insuring bodies has become extremely large. However, it is
not a question of a growth in cross-border circulation in all of the existing categories. The
studies carried out in the Euregions show that, in many cases, patients receive
complementary care abroad which is either not available at all or else scarcely available in
their own countries.
Cross-border circulation is becoming more and more a matter of guaranteeing that insured
persons who live in the Euregion can receive care which is “nearby over the border”. In many
cases, the care which the insured people require is available just over the border in the
neighbouring country, in the bordering part of the Euregion, whereas, in their own country,
these insured persons would have to travel further in order to obtain the same care. For
services which are also covered by the social security system in the insured person’s own
country, the obtaining of aid abroad, when this is either not available or not sufficiently
available in his own country, does not generally pose a problem.
It is important to underline the fact that the composition of the population plays an
important role in the establishing of the dynamic. Amongst the inhabitants of the various
Euregions, we find many insured persons who are originally from another country. For
instance, in the Meuse-Rhine Euregion many people of Dutch origin live in the Belgian
Limbourg area near the border, insured persons of German origin live in the part of the
province of Sud-Limbourg close to Germany and people of German origin also live in the
German-speaking part of the province of Liege, in Belgium. These insured persons have
greatly encouraged and stimulated the particular dynamic of the Euregion, especially recently.
As the image obtained in this way is extraordinarily complex and as the results are specific
to each Euregion as such, they cannot be generalised to cover all of the Euregions, and even
less so to cover the systems in general.
On the basis of the above, the future prospects for cross-border health care in the Euregions
could entail:
•
•
•
a relaxation in cross-border care arrangements, with accessibility for all insured
persons, and with the highest common denominator as regards the provisions laid
down in the arrangements (for two or three countries, depending on the Euregion
involved) for social security cover in respect of health care;
the emergence of cross-border traffic for local care, where necessary supplementing
that which can be provided to insured persons in their own country;
an extension of cross-border care to cover patients and insured persons from other
Euregions, in the context of bilateral and multilateral (experimental) arrangements.
At the outset this will only be available to the residents of a single Euregion and
mainly for high-technology care.
Finally, the last point to be underlined is the need to ensure that the populations are better
informed and to get to know the socio-demographic characteristics and the potential of the
range of healthcare services available in border regions better. There have been a number of
specific examples. Since October 1997, insurers in the Scheldemond Euregion have opened
up information booths. The aim of these is to provide citizens - workers and heads of
companies - with information about the specific problems of border regions, in particular on
the financial and administrative aspects. In addition to this, specific training for personnel
from the insurers is organised so that they can get to know the health insurance system in
the neighbouring country better.
158
The year 2000 saw the creation of a Franco-Belgian regional Health (OFBS) watchdog in the
Hainaut (B) and Nord Pas-de-Calais (F) geographical area. In 2001 this latter has been
extended to cover the Luxembourg (B) and Champagne – Ardennes (FR) area.
7. Conclusions.
On the basis of an analysis of the various projects, we have been able to show that there is
a not inconsiderable potential demand for cross-border care in the Euregion areas and
therefore a high level of intentional mobility. This demand corresponds to a real need among
the populations involved but is conditioned by a large number of parameters deriving from
the characteristics of such populations and from the health infrastructure specific to each
region. Taken separately, these factors do not have any impact, and this conveys an image
of a highly complex cross-regional mobility in relation to health care, although it also ensures
that each Euregion is unique.
These Euregions are therefore becoming partners in the search for appropriate solutions in
the light of populations' needs and in accordance with existing health care capacity. We can
therefore reject the argument which is regularly put forward regarding the risk of
destabilisation of the organisation of health services due to uncontrollable movements of
citizens, especially because, on the one hand, such intentional mobility continues to be
supervised by the partners from the legal and institutional point of view and, on the other
hand, the geographical and attraction area is limited. This kind of mobility should be
accompanied by a wider process providing the inhabitants of these regions with information.
The Euregion projects should receive greater support from the European authorities. A
complete listing of all cross-border initiatives should be drawn up, a survey of Euregion
infrastructure should be carried out, and a profile of the populations involved should be
drawn up. This process of capitalising on information would allow a specific programme of
action to be drawn up so as to allow the development of cross-border health projects.
As for the revision of Regulation 1408/71, it could benefit from the work and the practical
results obtained by the carrying out of the experiments and offer new perspectives in the
health field because it is no longer a matter of providing a regulatory framework for the
mobility of workers but also for the mobility of citizens.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
The SEM and health care – policy conclusions from the EHMA project
Reinhard Busse
1. Context and overall significance
In political terms, there appears to be a contradiction between the purpose of the Single
European Market (SEM) and the manner in which statements in article 152 of the Treaty
Establishing the European Community are widely interpreted (“… excluding any
harmonisation of the laws and regulations of the Member States. … Community action in the
159
field of public health shall fully respect the responsibilities of the Member States for the
organisation and delivery of health services and medical care.”).
This study investigated the impact of SEM Regulations and Directives as well as respective
European Court of Justice (ECJ) rulings – taken together as “interventions” – on the health
services of the Member States. It demonstrates that the relationship between health services
as a major sector of Member States’ economies and the SEM are intertwined in such a
complex manner that it is virtually impossible to separate them. The argument, therefore,
that subsidiarity applies to health services is not fully sustainable within the context of the
SEM.
Thus, the SEM may rightfully be seen as a challenge for health services, adding a further
complexity to the principal driving forces such as changing healthcare needs, increasing
patient expectations, the development of e-health, a regionalization of political decision
making in a context of economic globalization. This is particularly true because the SEM
inevitably regards the patient as an individual consumer rather than as a citizen with
collective rights and responsibilities.
2. Markets and the European social model
At a European level, the SEM requires health services to adapt to market rules, while at
national level, governments seek to adapt market rules to ensure the effective delivery of
health services within a social model.
Differing views on the future structure of health services in Europe underlie much of the
debate on health in Europe. These differences are based on two principal, divergent models
– the European social model and market forces.
SEM Regulations and Directives, while stressing the market, have not been exclusively aimed
at achieving economic objectives – indeed some SEM interventions have a social purpose in
terms of consumer and health protection (such as the Directive on medical devices
93/42/EEC). Some directives are, arguably, even geared to regulating or limiting market forces
(for example the Directive on pharmaceutical price control and regulation 89/105/EEC).
Nevertheless, there is a need to recognise that market forces and the European social model
have differing objectives.
There is, however, no option for simply ‘exempting health from the Single European Market’.
There may however be significant cases where regulation of the market is required in order
to achieve health objectives. Paradoxically, this requires a new coherence and prominence for
EU health policy – not just to draw a sustainable rather than accidental line between Member
State policy and EU-wide policy, but also to make the aspirations of both these actors more
coherent.
3. Intended and unintended effects
SEM interventions have both intended effects (principally to create a single market with free
movement of goods, services, people and capital) as well as unintended effects.
Intended effects include providing the basis for a range of European activities in healthcare,
e.g. a common public procurement system for goods and services, Europe-wide mobility of
doctors and nurses, a common system for regulating medical devices, common licensing and
market access procedure for pharmaceuticals as well as a European system to provide health
160
services for tourists, and provisions to ensure healthcare coverage for persons working in
other EU Member States.
Unintended effects on the purchasing, supply and delivery of health services often result
from the fact that these have not been sufficiently taken into account when the Regulations
and Directives were drafted. For example, SEM interventions have sometimes led to
increased health service bureaucracy. Small and medium-sized enterprises were also effected
negatively by such requirements. SEM interventions may also lead to patient/citizen
movements from one country to another in order to obtain treatment, thus undermining
attempts at priority setting within the publicly-funded systems of member-states. Movement
of doctors and other professionals may create shortages in poorer - especially accession countries.
The different political or organisational settings of health services, as well as countries’
geographical settings within the EU, may lead to differing effects of SEM interventions within
Member States. Policy-makers (and judges) should be aware such of differences.
4. Impact on health services
While the actual impact of some SEM Regulations, Directives and ECJ rulings on health
services may currently be marginal, the inherent conflicts behind many of the directives and
ECJ rulings may have a significant impact and may cause unexpected systems turbulence.
For example, should the cases which are currently pending at the ECJ be decided in favour of
free choice of healthcare goods and services, then the patient-provider relationship would be
more firmly embedded in the range of European activities in healthcare – with free choice of
provider dominating other objectives. Should such free choice be permitted across national
borders, it might also have to be mandated within countries – with potentially major
consequences for healthcare systems.
The thrust of such policy is to emphasise individual rights as opposed to the collective
priorities (and collective rights) of public healthcare systems. While it is generally the betteroff who can currently take advantage of such individual rights, the extension of free choice to
healthcare within Member States would make the benefits more widely available. On the
other hand, collective priorities may be undermined by mobility which prevents effective
national planning. Basic characteristics of Beveridge (NHS) systems in particular may be
threatened.
5. Implications for health policy-making
Even if the impact of many SEM interventions is small in terms of numbers of patients or
professionals affected by these interventions, the systems turbulence caused by these
interventions, particularly those resulting from ECJ decisions, may be greater than the
numbers involved. SEM directives and ECJ rulings have the potential – in a “worst case”
scenario – to undermine Beveridge systems if ‘managed competition’ in compliance with
other aspects of European law leads to the spread of sickness funds in the context of the
insurance model. Equally, there could be considerable turbulence in Bismarckian systems if
the rules were to be changed away from a “social” health insurance model.
To address such problems, arising from the unintended consequences of European Union
regulation on health services, it is therefore time to raise the profile of health policy at the
European Union level – but in a manner consistent with the aspirations of Member States.
161
Based on the future scenarios conducted as part of the study, neither total integration of
health services at a European level nor the exclusion of health services from the SEM are
probable. The third option, “muddling through”, does not provide easy solutions, but doing
nothing is not a sensible option.
An honest and explicit debate on the advantages and disadvantages of “muddling through”
must take place. This first requires an acceptance of the intertwining between the SEM and
health services. Such an acceptance would enable the development of a proactive role for
health policy-making – as opposed to the current decision-making which is all too often
reactive, especially to ECJ rulings. While different objectives and interests will no doubt
continue to be the subject of compromise, an overt healthcare strategy to manage the
relationship between the SEM and healthcare should be developed.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
Acknowledgement: This presentation is based upon the BIOMED project “Impact of European
Union Internal Market Regulations on the Health Services of Member States” in which the
author participated jointly with Philip C. Berman, Pauline Ong, Calum Paton, Clas Rehnberg,
Barbro Renck, Nuria Romo, Fernando Silio, Mona Sundh and Matthias Wismar.
A summary of the conclusions has been published under the title “The European Union and
Health Services – The Impact of the Single European Market on Member States” by the
European Health Management Association. The full report is available as a book published
by IOS Press (edited by Reinhard Busse, Matthias Wismar and Philip Berman).
Summary Report of Forum III
Philip Berman
1. Introduction
Forum III was hosted by the European Commission, DG Health and Consumer Protection, and
organised in association with the European Health Management Association (EHMA). Mr
Michael Hübel of DG Health, who chaired Forum III, was responsible for the design of the
meeting, together with Philip Berman and Paul Belcher of EHMA.
The purpose of Forum III
was to explore the impact that the Single European Market (SEM) is likely to have on the
ways that health services function. The forum explored three principal aspects of the SEM
as it may affect health services:
•
•
•
The development of the labour market for doctors and nurses
Public procurement of goods and services
The free movement of patients.
The forum also considered the recommendations of a major EU-funded study on the impact
of SEM regulations on health services, recently published by the European Health
Management Association.
162
Three major questions dominated both the papers and the discussions among the forum
participants:
•
•
•
What are the policy implications of the SEM both for national and regional health
services, and how should legislators – at European and national levels – respond to
these issues?
Will the impact of the SEM change the way in which European hospitals are
managed, and how should managers respond to these developments?
Will the impact of the SEM lead to better services for patients?
2. Labour market for doctors and nurses
There was widespread acceptance that the free movement of health professionals will be of
considerable benefit to countries with specialist shortages while, at the same time reducing
the problems of countries with an oversupply of doctors and nurses. Evidence was shown of
the extent to which the UK relied on EU doctors and nurses, as well as the (temporary)
oversupply of German doctors that had helped to ameliorate the UK shortage.
It was emphasised, however, that in the context of a European market in specialist areas
where there are shortages (such as anaesthetists or paediatric intensive care nurses)
countries seeking such specialists from other European Member States may have to pay the
“market rate” (i.e. the top rate) for those specialists. This will make it easier for the wealthy
European countries to recruit specialists, and will make it much more difficult for poorer
countries, paying lower salaries, to retain their specialists.
It seemed probable that, particularly for nurses, the development of a European market
might drive up salary scales within hospitals, since employees may not be willing to accept
that a co-worker from another country, performing the same functions, is paid at a higher
rate.
Concerns were also expressed that such movements of professionals might have an adverse
effect on medical and nursing education in poorer countries. What incentive, it was argued,
would there be for poorer countries to invest in medical and nursing education if their
doctors and nurses then emigrated to other EU Member States? Some poorer countries
might even, it was suggested, be tempted to abandon medical and nursing education to the
private sector which, in turn, could lead to the growth of the private sector in healthcare.
The forum concluded that, although workforce planning is rarely successful, nevertheless
there is a need, at a minimum, for the provision of better information on the numbers of
doctors and nurses moving between EU Member States, as well as better information for
their motivation in moving. It was suggested that the European Commission might have a
role in providing such information or in sponsoring such research. It was even suggested
that medical schools might need to begin to exchange information, and even to coordinate,
their recruitment policies.
3. Public Procurement of goods and services
Evidence was presented that the public procurement process has been to the advantage of
health services, providing greater objectivity and transparency in the procurement process,
and improved planning and organisation of services. The Stockholm experiment, in which
the provision of hospital services for much of Stockholm may be put out to public tender,
was alluded to as potentially the largest public procurement process within the European
163
Union. The question as to whether these opportunities for entrepreneurship would be good
for the citizen was discussed but not resolved.
It was also clear that the EU’s public procurement processes had problems as well as
benefits – increased bureaucracy and personnel numbers, and a slower purchasing process.
There was evidence that healthcare organisations were using techniques, such as splitting
the size of contracts, to avoid the EU’s complex public procurement process, and that there
had been a decrease in the number of Small to Medium Enterprises (SMEs) competing for
tenders because of the complexities involved. Disturbingly, it was demonstrated that – at
least in Andalusia – the EU’s public procurement process had had little or no effect on the
system – the same companies were winning contracts as had won them in previous years.
4. Free movement of patients
The effect of the Kohll/Decker and Peerbooms cases were much discussed in this forum, and
it was felt that it was necessary to distinguish between the effects on the “home country”
(i.e. where patients live) and the effect on the “host country” (i.e. where patients receive
treatment)
The scope for resolving waiting list/waiting time problems was a clear benefit for the “home
country”, which would be able to transfer patients elsewhere for more rapid treatment.
However, it seems likely that the effect of the Peerbooms case may be to require Member
States to redefine their healthcare baskets if patients are to have the right to go elsewhere
for internationally accepted procedures which are not available in their own country. The
benchmarking of hospital procedure costs will almost inevitably follow.
If patients are to move more freely across Europe, this will inevitably lead to demands for
comparisons of quality standards. Patients will want to be reassured that the hospital that
they wish to attend has similar standards, if not better, to their local hospital. While it is
unlikely that the European Commission will wish to become engaged in the accreditation
process, it may well wish to accredit accrediting agencies in the Member States in order to
ensure consistency in quality standard-setting across Europe.
It was acknowledged that the principal benefits will be to patients at border areas, but that
there is considerably greater potential benefit than has so far been realised. Concerns were
expressed that this freedom to choose is more likely to be used by the well educated and
mobile, but not by those with greatest need – the poor and those with little education.
As far as the “host country” is concerned, overcapacities (such as in Germany) could be put
to good use by countries with undercapacity (such as Norway). On the other hand, the free
movement of patients might exacerbate waiting times if patients seek treatment in countries
with pre-existing waiting lists. It is also possible that some systems may seek to recruit
patients in an aggressive manner, which could have negative effects on the home country.
As far as the Applicant States are concerned, the free movement of patients to and from
those countries is likely to trigger a debate on the financial differences between Central &
Eastern European and Western European healthcare, which may lead to some turbulence
among professionals. Where there is acknowledged expertise and lower costs, there may be
an influx of patients from Western Europe. Again, there is significant potential in border
areas, which could to be activated through EU regional cooperation initiatives such as
Euregio.
164
5. The significance of the SEM for health systems
It is important that the tension between the objectives of the Single European Market and
those of the European social model should be recognised and managed proactively. At the
European level, the SEM requires health services to adapt to market rules, but at national
level, governments seek to adapt market rules to ensure effective delivery of services within
the social model. The SEM, if it were not held in check, might threaten the widely held
European values of solidarity and universality.
If the values of the European social model are to be protected, greater prominence will have
to be given to health issues vis-à-vis market priorities both at national and especially at the
EU level.
Policy-makers and judges should be made aware that the different political, organisational or
geographical settings of the health services of Member States will be affected in different
ways by SEM interventions. European Court of Justice (ECJ) rulings may, for example, have
different effects in Bismarckian countries than in Beveridge systems, just as the impact may
be different where countries have long land borders from more isolated countries.
6. Enhancing opportunities and diminishing threats: Some recommendations
The Commission, the Member States and healthcare providers all have roles to play in
enhancing the opportunities provided by the SEM and diminishing SEM threats:
•
•
•
•
•
At the European level, health experts and policymakers should be involved in key
discussions that impinge on health. Thus, when there are – for example –
negotiations on competition regulations, it must be recognised that these
negotiations will have a significant impact on health. It is not acceptable that
decisions are taken without, at the minimum, an effective “vetting” function by
health experts and policymakers during a process which should be open and
transparent.
Article 152 seems inadequate to deal with the reality that the Community must have
the legal basis to deal with the “intertwined” consequences of the SEM for health
systems specifically from the health perspective, and the inherent contradiction
between the SEM and the European social model is just one of these consequences.
The time has now come to revise Article 152 to recognise these realities.
It must be recognised that the likelihood is that Member States and the
Commission are most likely to adopt a “muddling through” approach, rather than
taking a radical approach to resolving these contradictions. Member States,
though, should replace their current reactive behaviour with a proactive approach,
seeking to use ECJ judgments to benefit European citizens, while preserving the
financial basis of health services.
Citizens should be informed of their (equal)
rights; technical innovation should be encouraged; more cross-border activities
should be developed; best practices should be fostered; and quality should be
guaranteed across Europe through a process of accreditation.
It should be recognised that health is a minor actor in the macro-economic play
called “globalisation”, and that the globalisation process is the extension of the
Single European Market on a global scale, affecting our health services, particularly
in relation to health professionals, pharmaceuticals and the increasing prevalence of
market forces.
Managers and policy-makers must recognise that health systems are no longer
bound entirely by national boundaries. They need to look across borders for both
165
•
•
opportunities and threats. It is important that the voice of the providers, who will
be particularly affected by these developments, should be clearly heard.
The European Community should explore the potential impact of workforce
movements and, at a minimum, should ensure that there is reliable and comparable
data on the extent of the movements of doctors and nurses.
Research will continue to be required at a European level to understand the
implication of all these issues.
Presentation
slides
are
available
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166
Forum IV: Building a healthy Common
Agricultural Policy (CAP)
Shifting CAP's objectives to the provision of healthy, sustainable food
production and safeguarding the health and vitality of rural
communities and landscapes
Aileen Robertson
Agriculture policy, health and nutrition
This article argues that public health workers need to pay increasing attention to agriculture
policies. Agriculture can provide employment, food security, healthy diets and a healthy
environment, but it will only do so when its current practices are challenged.
The major nutritional problems related to the food supply in Western Europe are not caused
by a lack of protein (our diets are rich in meat and milk products) nor a lack of energy (we
consume high levels of fats and sugars) but primarily by an inadequate consumption of
vegetables and fruit.[†]
Appropriate policies – for example to encourage greater investment in horticultural
production – can help to resolve this imbalance, and simultaneously improve prevailing
environmental and social conditions. Vegetables and fruit can be made more accessible to
the local population, improving food security and nutrition, enhancing the local economy and
strengthening social cohesion in rural areas. In this way, food policies can be geared towards
socioeconomic and environmental goals as well as improving public health.
Health authorities, especially, can promote intersectoral collaboration to address the
determinants of public health. We look at the links between agriculture and health, especially
nutrition, and describe some opportunities for changing agriculture policy.
Nutrition, food and agriculture
Recent experience in Europe (such as dioxin contamination in Belgium, BSE in Britain, and a
decline in wildlife across Europe) has shown how food contamination and environmental
pollution are directly linked to agricultural production methods. These links can be given
financial costs: for example, an assessment in the UK suggested that the environmental and
health costs of agriculture were as high as $6bn annually.[1]
This assessment excluded any links between nutrition and agriculture, for which
documentation is less well established. More research is needed in this area, but there are
several reasons why the nutrient quality and diversity of our diets are linked to agriculture
policy:
Forum IV: Building a healthy Common Agricultural Policy (CAP)
•
•
•
•
167
The biodiversity of our diet has declined dramatically. One estimate suggests that
just 15 crops supply 90% of the world´s human food and livestock feed.[2]
Supermarkets may appear to have a great variety of foods, but a wide range of
brand names does not mean a diversity of nutrients and other valuable
biochemicals.
The selection of species for commercial crops has favoured productivity (high yields,
fast growth, response to fertilisers etc) over nutrient diversity and nutrient density.
Stocks of wild foods (fish, wild edible plants, wild game) with high nutrient density
and an abundance of protective phytochemicals and polyunsaturated oils are
threatened.[3]
Policies which lead to the mass destruction of vegetables and fruit in the EU reduce
access to these foods, in turn reducing the nutritional content of the European diet.
Besides antioxidants (carotenoids, vitamin C & E, selenium), vegetables and fruits contain
dietary fibre and other phytonutrients, such as quercetin, which are biologically active
compounds in human metabolism. There is now clear evidence of the health benefits of
eating more vegetables and fruits. Estimates suggest that 30-40% of certain cancers (colorectal, gastric and lung) are preventable by increasing daily intakes of vegetables, fruit and
fibre.[4] A low intake of vegetables and fruit is also associated with micronutrient
deficiencies, hypertension, anaemia, premature delivery, low birth-weight, obesity, diabetes,
and cardiovascular diseases.[5]
As a result of these observations, the World Health Organization recommends the daily
consumption of more than 5 portions (> 400g) of vegetables and fruits per day.[6] This does
not include potatoes but does include eating an average of 30 grams of legumes every day.
The supply of vegetables and fruits varies considerably throughout the European region. The
greatest supply is in Greece where there is over 1000 grams of vegetables and fruit available
per capita per day.[7] Greece has the lowest rate of premature mortality from cardiovascular
disease.[8]
In contrast most other EU countries do not have enough vegetables and fruit to ensure
nutrition security for the population. Accession countries are in an even worse state. It has
been calculated that levelling up the intake to the highest consuming groups could result in
tens of thousands of lives saved each year in the EU.[9]
What should the objectives of food production be?
A reformed agriculture policy should incorporate the following elements:
•
•
Following the Rio Summit and Agenda 21, there is an overriding objective to
encourage sustainable forms of agriculture. This includes producing foods that
mirror the population’s needs, as set out in dietary guidelines for EU member
states. All dietary guidelines stress the need to increase intakes of vegetables and
fruit and to decrease saturated fats, which come mainly from meat and milk
products. In addition, to meet wider public health needs, agriculture policy should
stimulate social cohesion and enhance socio-economic status for rural populations.
Publicly financed subsidies for agriculture should aim to achieve the above goals.
For example funding should go to support promotion of increased consumption of
vegetables and fruit, instead of promoting the consumption of meat products and
full-fat milk. In contrast , intervention price support for cereals (the bulk of which
are used for animal feed) has encouraged farmers to convert land from vegetable
and fruit production to cereal production.[‡]
168
•
Resources for research and development into sustainable agriculture and health
impact assessments should be provided. At present, most agricultural research
resources are devoted to the needs of conventional methods of production
(including biotechnology), and most resources for impact assessment are devoted
to a narrow range of environmental concerns.
Opportunities: 1. Health Impact Assessments
Health cannot be protected, sustained or promoted by the action of the health care sector
alone. There is a need to assess and change the impact of other sectors on the health of the
population, and to do this through the development of intersectoral health policies.
This need has given rise to a call for the development of a systematic approach,
methodology and procedures for Health Impact Assessment (HIA).[10] The significance of
human health and its determinants has been emphasized as an aspect of Environmental
Impact Assessment (EIA), particularly in the USA, Canada, Australia and New Zealand as well
as in the World Bank.[11]
Research into the health impact of agriculture policy is urgently needed. Under the
Amsterdam Treaty, the European Union is committed to ensuring that ’…a high level of
health protection shall be ensured in the definition and implementation of all Community
policies…’ (Article 152). The single largest policy operating in the EU, responsible for around
half the overall budget, is the Common Agricultural Policy (CAP). As has been discussed in
several documents, many of the measures under the CAP act to reduce the potential for high
consumption of fruit and vegetables, and promote the consumption of meat and dairy
products, sugars and fats.[12]
Opportunities: 2. Enlargement
As we have suggested, the EU's system of compensatory payments to farmers distorts
agricultural markets and, in our view, encourages poor diets. If the EU's intention is to apply
these payments to the countries of Eastern Europe currently applying to join the EU, then the
implications for social cohesion and public health in these countries are serious, with the
following likely distortions:
1.
2.
3.
4.
5.
Land prices will rise, which will make it harder for young farmers going into
agriculture.
Production of crops and livestock will intensify, with concomitant burdens placed
on the environment.
Absentee ownership is common in accession countries, and much of the income
from EU subsidies would be invested outside agriculture. Thus, payments will be of
little benefit to those working on the land, resulting in an agricultural policy that
transfers wealth to a substantial number of non-farming landowners.
Agricultural productivity in 2000 in the accession states was only 11% of the EU
level.[13] Increasing productivity will mean that less labour will be required, creating
high levels of unemployment. In Poland the agriculture policy calls for the
percentage of the working population engaged in agriculture to be cut from 28% in
1998 to just 5-7 % before joining the EU.[14]
Food production policies during the 1970s and 1980s led to the consumption of
high levels of fats and meat products but low levels of fruits and vegetables. An
extension of the present EU agricultural policy would perpetuate these eating
patterns and discourage healthier diets.
169
In many accession countries, the price of foods has increased more rapidly than income
levels, and in some countries between 30% and 60% of household income has to be spent
on food, compared with less than 20% in the EU.[15] In response to this household food
insecurity, supplementary food production and small-scale farming has increased, and
appears to be more efficient than larger-scale farming methods.[16] A rapid change due to
high levels of capital investment may jeopardise the food security being developed in the
region.
Opportunities: 3. the General Public
In 2000 the total support for agriculture in the EU was some Euro 40.2 billion [17] (nearly
50% of the total EU budget) creating a tax burden on EU citizens of some Euro 130 per
capita. The protective measures also raise the price of food compared with world market
prices, adding another Euro 120-150 per capita cost to the consumer.[18] The average family
is thus paying some Euro 1000 annually as a result of EU agricultural policies.
Consumer expectations will be an important consideration in the CAP discussions. In order to
assess public perceptions, two Eurobarometer opinion polls were carried out among farmers
and the general public in 2000. The surveys were carried out by telephone interview on
16,000 members of the general public and 3,500 farmers and revealed a widespread interest
in agricultural issues and a wish for more information.[19]
Whilst 92% of the general public think that agriculture is important, only 50% had heard
about the CAP. Both farmers and the general public were asked to rate the importance of a
list of 12 policy objectives, including food safety, environmental protection, the improvement
of rural life, the protection of farm incomes and the competitiveness of European agriculture
on international markets. (Questions on nutrition and diet were not asked.) A clear majority
of people thought that all the objectives were important (ratings varied between 76% and
97%) but the levels of satisfaction with how they were being met ranged between 16% and
57%.
The protection of farm incomes and small farms was seen to be badly served, by both
farmers and the general public. Food safety and environmental protection were considered to
be the top priorities but the survey revealed an acute need for information about agriculture
policy. With respect to enlargement, only half of the respondents in both groups had heard
something about it and only 10% of the general public felt well-informed on the subject.
Indirectly, consumers are already protesting against agriculture policy because they buy less
meat. Since the BSE crisis demand for beef dropped by around 27% on average and in
Germany by 50-80%. This is damaging for agriculture policy, but, from a nutritional health
perspective, this trend may prove to be healthy if the dietary changes include the
consumption of more fruit, vegetables, wholegrain cereals or fish.
Opportunities: 4. The First Food & Nutrition Action Plan for the WHO European Region
In September 2000 the 51 member countries of the European Region of the World Health
Organization unanimously endorsed a resolution to implement the region’s first Food &
Nutrition Action Plan.[20] This document makes the case for combining nutrition, food safety
and sustainable food production concerns into an overarching, intersectoral policy, and offers
support to member state governments to develop, implement and evaluate such policies.
Progress with implementation, both by WHO and member states, will be reported to the
Regional Committee in September 2002. In addition, a more comprehensive evaluation of the
170
impact of this first Action Plan will be reviewed during the first Ministerial Conference on
Food & Nutrition in 2005.
This political commitment gives public health experts an extraordinary and important
opportunity to lobby both at national and European level for an agriculture policy that
explicitly promotes health.
Conclusion
Unsustainable agricultural systems have grown out of the narrow focus on productivity that
has monopolized agriculture policy. Their economic costs are already becoming apparent but
their human health costs – including their nutritional impact – have not received sufficient
attention.
A number of opportunities for changing agricultural policy are becoming available, and public
health experts are urged to ensure that their views are fully expressed in this process.
Notes
†
This has been the finding of several WHO reports over the last decade: Diet,
nutrition and the prevention of chronic disease (WHO Technical Report Series 797, Geneva,
1990); Preparation and use of food-based dietary guidelines (WHO internal document
WHO/NUT/96.6, Geneva, 1996); Countrywide Integrated Noncommunicable Diseases
Intervention (CINDI) dietary guidelines (WHO Regional Office for Europe, Copenhagen, 2000).
‡
Between 1960 and 2000, the countries of Mediterranean European saw a reduction
in the land used for fruit and vegetable production by nearly a quarter (2.1million hectares)
and an increase in land devoted to cereal production by a similar amount (1.5 million
hectares).
References
1.
Agriculture and the Environment: An impact statement prepared by the
Environment Agency, Consultation draft, UK Government Environment Agency,
Bristol, October 2000.
2.
D Pimentel et al, 1974, cited in RD Sainz, ‘Livestock-Environment Initiative, Fossil
Fuel Component: Framework for Calculating Fossil Fuel Use in Livestock Systems’,
Livestock, Environment and Development program (LEAD), FAO, Rome 2000
[http://www.fao.org/WAIRDOCS/LEAD/X6100E/Intro.htm].
3.
For game, see MA Crawford, Fatty acid ratios in free-living and domesticated
animals, Lancet, 22 June 1968, p1329-1333; for plants, see A Trichopoulou et al,
Nutritional composition and flavonoid content of edible wild greens and gren pies:
a potential rich source of antioxidant nutrients in the Mediterranean diet, Food
Chemistry, 70, 2000, p319-323.
4.
World Cancer Research Fund, and American Institute for Cancer Research, Food,
Nutrition and the Prevention of Cancer: a global perspective, WCRF/AICR,
Washington, 1997.
5.
World Health Organization Diet, nutrition and the prevention of chronic diseases,
Technical Report Series 797, WHO, Geneva, 1990.
171
6.
World Health Organization Diet, nutrition and the prevention of chronic diseases,
Technical Report Series 797, WHO, Geneva, 1990.
7.
Food and Agriculture Organization Statistical Database: Food Balance Sheets, FAO,
Rome [www.fao.org] annual.
8.
World Health Organization, Health for All Database [www.who.dk] annual.
9.
Joffe & Robertson, The potential contribution of increased vegetable and fruit
consumption to health gain in the European Union, Public Health Nutrition (in
press).
10. J Lehto and A Ritsatakis Health Impact Assessment as a tool for intersectoral health
policy, a discussion paper for a conference: Health Impact Assessment: From Theory
to Practice, Gothenburg 28-31 October 1999.
11. See, for example, WHO and CEMP, Environmental and Health Impact Assessment of
Development Projects. A handbook for practitioners, Elsevier, London, 1992; British
Medical Association, Health & environmental impact assessment. An integrated
approach, Earthscan, London, 1998; The World Bank, Environmental Department ,
Health Aspects of Environmental Assessment. Environmental Assessment
Sourcebook Update, July 1997.
12. Agra Europe, page 7, March 2000.
13. Agra Europe, page 12, May 1998.
14. M Bobak, D Blane and M Marmot Social determinants of health: Their relevance in
the European context draft paper for the Verona Initiative, 1998
[www.who.dk/Verona/Publications/Bobak1.htm].
15. G Hughes, working papers 2/7 and 2/10, in Agricultural Implications of CCEE
Accession to the EU, FAIR1 CT95-029, Wye College, University of London, 1998. E
16. European Commission [http://europa.eu.int/comm/agriculture/survey/index_en.htm].T
17. The First Action Plan for Food and Nutrition Policy: WHO European Region 20002005,
WHO
Regional
Office
for
Europe,
Copenhagen,
2001
[www.who.dk/Document/E72199.pdf].
This contribution is a revised version of an article by Tim Lobstein and Aileen Robertson
which originally appeared in Eurohealth Vol. 7, No. 2, Summer 2001
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
172
Local level: Using urban agriculture and local sustainable food
production to safeguard food security, reduce health inequalities and
preserve cohesion in rural communities
Jeannette Longfield
Abstract
For many, sustainable food production and consumption automatically incorporates all the
elements listed in the title of this presentation, and more besides. Given the growing
evidence, and groundswell of public support for sustainable food systems, the question
remains, why do we not yet have this? Unless we have a clear view of the obstacles, as well
as the opportunities, our efforts will fail. How, for example, can local, small-scale
experiments in sustainable food systems help to tackle:
•
Global organisations with major financial interests in keeping the current,
unsustainable system in place.
these include not only major sectors of the agriculture (including
agrichemical supplies) and food production, processing and distribution
(including advertising) industries, but also transport and associated
businesses
•
Governmental inertia, intellectual dishonesty, cowardice or corruption.
even sympathetic governments tend to move only slowly towards reform
many profess powerlessness in the face of the “inevitable” results of
increasing global food trade
others refuse to acknowledge the financial vested interests outlined
above, couching reform efforts in terms of “partnerships”
some suspect (though find it hard to prove) collusion between some
governments and parts of the agri-food business to prevent reform
•
Consumer ignorance and sense of helplessness.
because of the lack of social cohesion exacerbated by the current food
system, many consumers are unaware of the damaging consequences of
their buying habits
those consumers who become aware often feel powerless in the face of a
complex, global food system and therefore fail to make the transition from
passive consumer to active citizen
Taking the last point first, sustainable food projects can:
•
•
•
•
demonstrate what can be done. Urban food projects are particularly important in
Europe since that is where most people live. Seeing improvements in the food
system, however modest, empowers people.
help raise awareness. While information and education is often assumed to be a
necessary precondition for action, “action speaks louder than words”.
show government that change is possible and popular. Practical projects can also
help generate more tangible evidence that sustainable food systems have health
and environmental advantages.
provide a direct economic challenge to the dominance of unsustainable food
systems by offering people the opportunity to Buy Something Else – an alternative
BSE!
173
However, sustainable food projects alone are not “the answer”. Their very advantage for
citizens i.e. that they are local and human-scale, makes them too small, individually, to affect
government and business. To increase their influence food projects need to:
•
•
form groups or federations of similar projects from local to global level
form links between these federations and other, like-minded networks
National level: Austrian farmers call for a radical change in CAP to
provide healthy food
Elisabeth Baumhoefer
Society and the environment need a new agricultural policy
The Coordination Paysanne Européen (European Farmers Coordination, CPE) is convinced
that the EU´s Common Agricultural Policy (CAP), within the Agenda 2006 programme, needs
to be redesigned. Stories of nitrates and pesticides in ground water, antibiotic residues in
meat, dioxins and salmonella in poultry, the risks of genetic engineering, and not least BSE
and MFD , far too often make sad headlines in the media and have given a bad image to
agriculture. All these problems and crises are a consequence of industrial farming and under
this now all farmers have to suffer. Small and medium sized farms still constitute the
majority of farming enterprises and they are far more environmentally friendly than industrial
agriculture. In the actual situation small farms run the risk of being sacrificed in the interests
of multinational companies and global trade.
Society´s real needs
The CPE wants an agriculture that focuses the real needs of society like production of high
quality and healthy foods, protection of the environment and biodiversity, regional
markets,... The so called European model of Agriculture is full of contradictions. How can it
be environmentally friendly and pollute the ground water or produce healthy food and have
the antibiotics and dioxin scandals at the same time?
It is high at the time that the CAP will be changed to a „farmers„ agriculture which respects
the environment. Also the subsidies shouldn’t be linked to the number of hectars and
animals. It should be linked to the labour and working places. Also subsidies should be
limited and linked to an ecological minimum standard. We think, that the society will accept
this better than the actual programme. In the long run food prices should cover production
costs. The prices should take into account the consequential cost of environment, transport
and so on.
Food Souvereignity
Under Food Souvereignity we understand the right of every region and nation to produce its
own food and it is the fundamental basis for Food Security. This unites the farmers in the
North and the South. The orientation of the CAP towards the world market instead of
focusing on internal needs has negative consequences beyond Europe. Export dumping not
174
only undermines food production and, in turn, the existence of farmers in many regions of
the world, but it threatens food security and the environment.
The CPE and the Austrian Mountain Farmers Association are convinced that to ensure the
nutritional value of our food and to preserve the ecological balance worldwide, this can only
be possible with a non-industrial and responsible agriculture.
EU level: Interpreting the multifunctional role of agriculture and rural
development across Europe
Elisabeth Guttenstein
In discussions with Génon Jensen of EPHA last summer she suggested to me that the
environmental movement in agriculture can today reap the fruits of its success. European
Leaders such as Schröder and Blair now speak about the need to reform the CAP along the
same lines we have been promoting over the last ten years. It clearly is a success.
However, I replied, our new challenge is even greater.
We now have to achieve
environmental standards and the provision of environmental services through a policy which
is still based on the objectives of productivity and security of supplies.
The concept of ‘multifunctionality’ in agriculture has not been around for very long. The
different aspects of multifunctionality have been around for much longer, of course, the
environment, food security and safety, consumers, landscapes and rural economies.
However, in Europe we champion the concept of multifunctionality because we recognise the
need to bring these different issues into a coherent framework. Articles 2 and 6 of the
Treaty of Amsterdam are arguably an expression of this. These two articles stipulate the
need for all community policies, including the CAP, to integrate sustainable development and
environmental protection. I will not list all the different functions we want integrated in the
CAP to make it more sustainable. The recent crises in the agricultural sector have once again
provided us with clear evidence of the depth of public concern about the future of agriculture
and rural areas. I will instead analyse the example of environmental integration in the
process of CAP reform, and whether CAP reform is contributing to environmental protection.
WWF is the first to agree that the management of natural resources is at the heart of the
daily work of farmers. Nonetheless, evidence shows that when environmental constraints
pose a challenge to productivity, achieving environmental protection through agriculture
creates tensions. The tensions can be competing demands on natural resources such as
water; on finances available to deliver agricultural and environmental services; or
contradictory incentives provided for the two sectors.
These are just the most common conflicts that occur between the environment and
agriculture. If we then add the need to respond to consumer demands, to maintain fragile
rural economies, not to mention a sustainable impact on the economies of developing
countries; multifunctional agriculture seems doomed to failure from the outset.
Policy may not be able to resolve all those conflicts alone. Today we recognise the
increasing role played by the market, global trade and the consumer. The question I would
like to address is the following: which policy model for a future CAP is most likely to deliver
on multifunctional objectives?
175
Many people think of the WWF as being a ‘visionary’ organisation, campaigning for radical
overhauls and global solutions. Far be it from me to dispel this image. Later in my speech I
will tell you about our requirements from a future CAP. But we also believe that much can
be done within the current framework to improve the sustainability of agriculture.
The first step in achieving environmental integration is to define the objectives. These are
well known: to manage natural resources (water, soil, forests…) habitats and biodiversity
sustainably. Most of these objectives are addressed through specific EU legislation, such as
the Water Framework Directive, the Nitrates Directive, or the Habitats and Wild Birds
Directives. Under the CAP we have a better funded agri-environment scheme since the
Agenda 2000 reforms, which aims to support those environmental services which are best
provided through farming.
However, having specific instruments to achieve environmental objectives is not the same as
integrating environmental protection in the CAP. Very little has been done to integrate the
environment into the core of the CAP, into the basic incentives and obligations of the market
regimes, which after all still account for 90% of the total CAP budget. Without integration
into the very structure of the CAP, environmental objectives will not be achievable, let alone
achieved.
It is clear what could be done to improve environmental integration in the CAP. Let me give
you the example of the olive oil sector. Olive oil is possibly the most antiquated regime in
the CAP. The environmental problems it is driving have been widely documented, including
by the Commission itself. In fact, we know that olive farming is one of the major causes of
one of the biggest environmental problems affecting the EU today: widespread soil erosion
and desertification, in terms both of land and people, in Spain, Italy, Greece and Portugal.
Over the last three years the regime has been twice through Commission and Council for
reform. Twice the proposals of the Commission and the final decision of the Council have
fallen short of even attempting to steer the sector towards better environmental, and social,
integration. Yet the means are clear: change the current production-based subsidy into a
standard flat-rate payment per hectare; stop new plantations from being eligible for funds, to
halt their current expansion; establish local codes of good agricultural practice and make
farmers’ receipt of payments dependent on them respecting these standards. Similar
changes have been successfully implemented in other sectors and would provide immediate
benefits in reducing the degradation of natural resources caused by intensive olive farming.
It would also improve the viability of marginal or low-input farms.
Last December the Commission proposed to delay reform again for another two years, and
our Ministers, at their Council meeting last June, played heed to the political pressures of the
producer countries, and to those production and supply interests they still believe to be
over-riding all others.
The MacSharry reforms launched in 1992 represented a new departure for the CAP, and were
overall beneficial in strengthening the environmental dimension of agriculture. Since then
there has been little concrete willingness to pursue that move. Although there is a lot of
rhetoric about how to make the CAP greener, we seem to have reached a stalemate.
WWF considers this regrettable particularly with respect to enlargement. WWF also believes,
however, that enlargement provides the best opportunity the CAP may have ever had to be
reformed in favour of greater sustainability.
We can only extrapolate the specific effects exporting the CAP would have on the Candidate
Countries. Nonetheless, we can learn lessons from the CAP’s impact on the Member States.
We must also recognise the economic forces of the global market. Beyond the effects the
176
CAP might have on the natural environment of the Candidate Countries, the reason why we
believe enlargement could lead to CAP reform is, of course, financial.
We now know that the current model of the CAP has frozen production patterns in many
regions of Europe, pushing for specialisation to the detriment of mixed farming systems and
local distinctiveness. Those farmers that could have adapted through economies of scale.
They have either increased the size of their farms or intensified their production to maximise
yields. Those who could not have left farming. Compensation payments, with no agreement
as yet to phase them out, maintain the strong link to the farming patterns the CAP has
traditionally supported.
None of this bodes well for enlargement. According to Commission calculations if full direct
payments were paid today to Candidate Countries this would represent roughly Euro 7-8
billion per year. This would already exceed the ceilings laid down for the CAP in Berlin in
1999. But enlargement is of course a political rather than an economic choice, and I have no
doubt that when enlargement will happen, our politicians will find the means to pay for it.
What we need to ask is should they pay to extend a CAP we are already unhappy with in the
current Member States?
Let me speak briefly to you about a project which clearly demonstrates the model of farming
and CAP support that WWF would wish to see as a basis for a reformed CAP in the
Candidate Countries.
At the end of the 1990’s WWF launched the Väinameri project in Estonia. Our aim was to
manage valuable coastal eco-systems by ensuring economic viability for farmers living in
these traditionally sparsely populated areas, so that they would not abandon them. Both
goals, as you will know, are central to the rural development policy of the Union. The
approach we adopted was to enhance the financial opportunities of farmers through
developing recognition for their ‘natural grazing meat’ as added value to consumers. We
also were able to identify financial support for the provision of the grazing patterns and
mowing services required to manage the semi-natural meadows of this coastal area. The
financial security this gave farmers had the knock-on effect of creating further economic
opportunities, developed from the recognition of the natural values of the area: small-scale
green tourism developed, the local cultural heritage was revived and new crafts developed
from using local materials. Väinameri’s coast is now under active management, and the
environmental and economic future of the region is secured.
What lessons can we draw from this? Not all farming areas would benefit from this type of
approach, nor would it be relevant to many of the more favourable farming regions.
However, this indicates to us that maybe, in the medium to longer term, we really do need
to reconsider what the CAP must support and what instead can be left to the market. There
is no longer any doubt that over time, as market liberalisation is pursued, it will become
increasingly difficult to support either market stability or farming incomes. The CAP must,
therefore, reconsider its basic objectives.
WWF believes that both the 1992 and the 1999 reforms of the CAP were insufficiently
focussed on delivering environmental protection through agriculture.
On the one hand, because they attempted to manage the environmental impact of farming
and provide positive environmental services under the same means, and therefore were
insufficiently focussed or resourced for either;
On the other hand, market developments and the economic choices within the CAP have
continued to push farmers and governments to choose between productivity and the
environment. This generally still results in the environment losing out;
177
Finally, the reforms did too little to define and remunerate those environmental services
which may not be a simple by-product of farming, and that are not automatically provided
for by the market.
From WWF’s perspective a future reform of the CAP needs to take these issues into
consideration and address them. In particular, WWF calls on the Member States and the
European Commission to:
Pursue the reforms of the market regimes. Respecting the environment must become an
integral criteria of all commodity payments;
Agri-environment measures must be better focussed and strengthened. This will require
further funding but also ensuring that those regions and sectors where the environmental
problems are the greatest are included;
In the longer-term, however, it may be necessary to reconsider altogether the objectives of
CAP payments, to redirect them towards supporting those services which are not provided
for by the market;
Before this can be done, the objectives we are aiming for need to replace those of
productivity and supply management. For this we will need an honest assessment of what
farming can provide, and what it cannot;
I have spoken to you about multifunctionality from the perspective of the environment. The
lessons I have drawn are, however, applicable within other spheres. I hope we will be able
to discuss them further throughout the day.
The EU farmers’ views on the development of the CAP
Anton Reinl
Ladies and Gentlemen, Chairman,
Thank you very much for the invitation to present you today the position of European
farmers and their cooperatives on “Obstacles to changing the CAP and the farming industry’s
vision”. However, I did not have any influence on the topic of the Forum. I would have
preferred to discuss “Building a healthy European food policy” (instead the narrow CAP)
together with representatives of medicines, consumers, food industry and retailers who are
missing today.
Therefore, I choose the title “The EU farmers’ views on the development of the CAP”. I will
try to show you some incoherent aspects in the European policy and would enjoy to hear
your opinion on that issue.
BSE, dioxin crisis, food and mouth disease, classical swine fever etc. demonstrate –
according to the general public opinion – that “there is something wrong in agriculture”.
Although these incidents really only involved a few European countries, the impression in the
mass media was that despite the strict regulation of the agricultural sector, these above
mentioned incidents occur regularly all over Europe.
178
While the public often criticises politicians for their inept handling of such situations, the
recent political solution to scandals and crisis seems to be to tighten up existing legislation
(new regulations) - rather than focusing on the practical control of existing rules. A recent
example is the ban on the use of meat and bone meal in animal feed for pigs and poultry as
a result of the lack of control and illegal use in cattle feed.
As you may know, the Common Agricultural Policy, created already in 1958, has changed
through its reforms in 1992 and 1999 (Agenda 2000). Progressively, support prices have been
reduced, increased direct aid to farmers have been introduced, which are becoming more
decoupled from production and where environmental considerations are coming more and
more to the forefront.
Taken together, these reforms amount to a major change in direction for our agricultural
policy. The new focus is now on the multifunctional nature of agriculture rather than on its
food producing role.
The second large reform, Agenda 2000, decided by the European Council in Berlin, is being
implemented over the period 2000 to 2006. Now, only one year after Agenda 2000 was
introduced there are moves in some quarters to press for yet a further wide-ranging reform
of the CAP before well before 2006.
COPA and COGECA are keen to engage in a debate about the direction agricultural policy
should take once the current CAP reform has been implemented. However, they believe that
a further reform before 2006 is not only unwarranted but also unwise. When deciding upon
Agenda 2000 the European Council requested the Commission to submit a series of reports
over the period 2002 and 2003.
The only possible justification for changing the CAP prior to 2006 would therefore be if
budgetary expenditure in the agricultural sector was at risk of exceeding the ceiling set by
the European Council in Berlin and/or there was a serious deterioration in the overall market
situation.
This is clearly not the case since the agricultural budgetary situation and the market outlook
are sound. COPA and COGECA consider that the European Union must maintain a strong
position in the forthcoming WTO round and farmers and their co-operatives need stability
and a coherent policy.
There is an attempt in some circles to use the above mentioned crisis to press for further
reform of the CAP prior to 2006. Some, for example, are pressing for yet more reform of the
CAP along the lines of the 1992 and Agenda 2000 reforms. This means increased
liberalisation, greater price competitiveness and more rapid productivity growth.
In contrast some others are calling for a move in a totally opposite direction –blocking the
trend towards larger farms and encouraging more extensive farming which will inevitably
reduce productivity and the competitiveness of European farming.
These opposing views are also increasingly reflected in EU policy: on the one hand trade
policy is pushing towards lower prices, forcing farmers to cut costs while internal policy is
resulting in increasingly restrictive regulations on agriculture which lead to higher and higher
costs.
In economic terms, this development means that European society has imposed conflicting
demands on food production at the agricultural level:
While the European society demands
more productivity at lower prices to meet the WTO trade concerns
It also demands
-
179
stricter environmental, animal welfare and food safety standards, thus often higher
costs leading to a loss of international competitiveness.
Examples:
-
Antibiotics (ban of 4 antibiotics as additives in feeding stuffs 1999; imports not
covered)
ban of meat and bone meal for internal production, imported products can be
produced with meat and bone meal
animal welfare (higher standards for European producers, imported products are not
covered; e.g. Ban of battery cages for laying hens)
Whatever farmers try to do they are squeezed and their attempts to meet society’s
expectations are thwarted. This conflict must be resolved but the path of the past CAP
reforms has clearly not brought the solution. It is evident therefore that another quick CAP
reform along the same lines is not the solution. To our opinion, the current contradictions
have to be solved beforehand.
Consistent objectives must be pursued in the policy approach to the current WTO
negotiations!
EU farmers wish to respond to the expectations of society to develop the quality of products
and production methods but trade and other policies, as well as market conditions, must
make this possible.
The agri-food sector should never be treated in the same way as other economic sectors, and
equal account must be taken of the very special and important role of non-trade concerns in
the case of agriculture.
Agriculture differs from other economic sectors in several critical ways:
•
•
•
farmers work directly with the environment: their production is dependent upon the
climate, soil, water and sunlight.
food is a vital necessity – all governments must be able to guarantee their
population secure and stable supplies of safe food. This is too important to be left
solely to market forces: agricultural commodities are subject to significant
fluctuations in supplies and prices due to climate, economic fluctuations and
international strategic considerations. In an increasingly global market these
fluctuations are becoming more rather than less acute. An effective agricultural
policy is therefore essential;
farmers (and their co-operatives) supply services to society which provide a public
good over and above the production of commodities. They contribute towards the
economic viability and employment in rural regions and the maintenance and
enhancement of the countryside. Agriculture also has the capacity to make a
significant contribution towards reducing pollution – through the production of biodegradable industrial raw materials and bio-fuel.
It is therefore essential that the European Union follows a trade policy in the current WTO
negotiations which takes account of the wider role of agriculture compared with other sectors
and ensures society’s expectations of agriculture are met. This concern is not restricted to
the European Union. Fewer and fewer societies, throughout both the developed and
developing world, are willing to move towards freer trade without taking into account its
impact on other issues of equal or greater concern. This was illustrated very vividly in Seattle
and is now presenting WTO members with their most important challenge. The forthcoming
negotiations must achieve a balance between trade and non-trade concerns and enable
180
agriculture to fulfil its multi-functional role. If not the credibility of the WTO will be seriously
eroded.
The rules concerning market access must ensure that the concerns of European consumers
are met and that there is fair competition between EU and imported products.
Let me draw your attention also to one aspect which is seen quite controversial by the
public. The agricultural budget: The Common Agricultural Policy has been the first really
harmonised common policy at European level and is still mainly financed by the European
budget. Imagine a Brussels financed pension or public health system! The current European
agricultural budget would be a very small part of this total budget. Concerning the famous
50 percent discussion: If you count all 15 national budgets and the European budget
together the expenditure for agriculture is less than 2 percent of all expenditures!
Europe has to have the means of its ambitions. And its ambitions eventually have to be
translated in policies.
Farmers (and co-operatives) are determined to meet EU regulations concerning food safety,
quality and environmental protection, sustainable production methods and animal welfare
but it must be ensured that this is compensated either via the market or through the budget
so that they do not lose markets to competitors. In this respect 3 items for the further
development of the CAP are important:
1.
2.
3.
food safety and animal welfare rules applied to domestic production must also be
applied to imports;
it must be possible to apply the precautionary principle in the case of legitimate
concerns about food and environmental safety when scientific assessment is
inconclusive or incomplete. Therefore, the precautionary principle should be clarified
at the next WTO round;
Farmers' (and co-operatives') positive contribution to the environment, rural
development as well as the maintenance, of a countryside and landscape must be
recognised as a public good which can be remunerated under WTO – green box.
European level: European supermarkets set standards for their
suppliers in response to growing consumer demand for
environmentally sustainable and pesticide free products
Nigel Garbutt
181
Summary Report of Forum IV
Mike Rayner
In reporting back on Parallel Forum IV: ‘Building a healthy Common Agriculture Policy’ I will
firstly summarise the most important issues discussed at the Forum, secondly I will mention
some controversies that arose and finally summarise the four recommendations that were
agreed.
Issues
Firstly the Forum discussed, in some detail, what the health objectives of the Common
Agriculture Policy (CAP) should be.
The issue of ‘food safety’ has generally been the focus of thinking about incorporating health
objectives into European food and agriculture policy and the Forum agreed that one
objective of the CAP must be to ensure that food is free from microbiological and chemical
contamination.
However it was noted that diet-related chronic disease - particularly cardiovascular disease
and cancer - are a larger cause of mortality and morbidity than acute food-borne diseases.
The Forum therefore considered that those setting health objectives for the CAP needed to
consider how the CAP could help to reduce the burden of chronic diet-related diseases as
well as acute food-borne diseases.
The Forum noted that the European Commission had recently funded the Eurodiet Project to
develop dietary goals for European populations which if achieved would help to reduce the
burden of diet-related diseases. The Eurodiet Project had taken two years and involved
over 200 experts from all over Europe. The report of the project had just been published 38.
Eurodiet sets out 17 population dietary goals which if achieved would significantly improve
the health of the European population. A priority goal is for an increase in consumption of
fruit and vegetables.
The Forum noted that the CAP has other effects upon health other than upon food
consumption – through its effects on the environment, employment, etc. These effects are
complex but nevertheless need to be considered when setting health objectives.
The Forum noted that, under the CAP, tobacco farmers are paid subsidies for growing
tobacco. The subsidised tobacco is for export and therefore its consumption does not affect
the health of Europeans, but its consumption is highly damaging to the health of people
living in the countries to which it is exported.
The Forum noted that the European
Commission had agreed to the phasing out of subsidies for tobacco farmers.
The second issue discussed by the Forum was the relationship between health and other
objectives – particularly environmental objectives. The Forum noted that it is increasingly
recognised that what is good for human health is generally good for the environment. The
First Food and Nutrition Action Plan for the World Health Organisation European Region –
agreed at the WHO Regional Assembly in September 2000 – proposes that there should be
three strands or pillars to food and nutrition policy: food safety, nutrition and sustainable
production.
38
Eurodiet Project (2001) Eurodiet Reports and Proceedings. Eds A G Kafatos and C A Codrington.
Public Health Nutrition 4.2(1) 325-336.
182
The third issue discussed by the Forum was how health objectives could be incorporated into
the CAP. The Forum noted that CAP reform is already being considered in order to achieve
other objectives in relation to the liberalisation of international trade and to enlargement of
the European Union.
Broadly speaking there are three policy options currently under
consideration:
•
•
•
little or no change to the existing system of agricultural subsidies (there is virtually
no support for this option in view of the enlargement process);
a ‘two-tier’ system where the subsidy system remains largely unaltered and
subsidies remain high in current members of the EU, but are lower in accession
countries; and
a reduction of subsidies across the whole of the EU with a re-direction of subsidies
- away from subsiding production to subsidising rural development and
environmental protection.
Controversies
There were four main issues which where not resolved at the Forum.
Firstly in speaking of health objectives, whose health objectives are we talking about? Do
we mean the objectives that consumers would want if asked? Consumers seem to be more
concerned about food safely – not only in relation to chemical and microbiological
contamination of food but also in relation to genetic modification of foods – than about dietrelated chronic disease. Or do we mean public health objectives – with a greater focus on
reducing the burden of diet-related chronic disease than of food-borne diseases?
Secondly to what extent do health objectives conflict with other objectives such as economic
or environmental objectives?
In the case of the olive oil regime there appears to be a
conflict between health and environmental objectives. Most nutritionists would agree that
an increase in consumption of olive oil in Northern European countries would be beneficial
to the health of people living in those countries. However environmentalists suggest that
increasing the production of olive oil in some Southern European countries is already having
adverse environmental effects in those countries. Would the health benefits of consuming
more olive oil in Northern European countries outweigh the environmental costs in Southern
European countries? It was agreed that this would seem unlikely and that conflicts between
health and other objectives are often more apparent than real.
Thirdly if we want to build health objectives into the CAP should the focus be on supply or
demand? Reducing the burden of diet-related chronic disease would mean changing the
food consumed by Europeans and this would inevitably change the food supplied. Some at
the Forum thought that the CAP should aim to shape the supply of foods, others thought
that it was consumer preferences that should shape that supply.
Fourthly should the CAP seek to influence the price of foods and if so what should that price
reflect? It was generally agreed that farmers should receive a fair return for their labour but
should the costs of consumption in relation to the health and the environment be
internalised to reflect the true cost (e.g. to health and other services funded through
taxation) and if so how?
Recommendations
The Forum agreed that an increase in fruit and vegetable consumption would be desirable in
most European countries. The Forum considered that the CAP should help to promote the
consumption of fruit and vegetables but did not agree on how, precisely, this should be
achieved.
183
It was agreed that the relationship between the CAP and health needed further and more
systematic investigation though ‘Health Impact Assessment’ and that the issue was of such
importance to warrant the formation of an Inter-service Working Group on the CAP and
health within the European Commission.
The Forum agreed that the European Commission needed to be clearer about its policy
objectives in relation to food and nutrition and that this would be helped by the publication
of its proposed Action Plan on Nutrition Policy.
In summary the Forum’s recommendations were:
1.
2.
3.
4.
Everyone should affirm that a multifunctional agriculture should incorporate health
objectives.
The Commission should publish its Action Plan on Nutrition Policy by the Spring of
2002.
There should be an Inter-service Working Group on the CAP and health.
The CAP should promote the consumption of fruit and vegetables.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
184
Forum V: The informed patient /
citizen: a new partner in the political
health arena
What are the information needs of citizens? Results from research &
academia
Angela Coulter
Abstract
Patients in all European countries have a great thirst for health information. They want to
understand how to prevent illness and how to cope with diseases and disabilities. Access to
appropriate information can empower patients to express their treatment preferences and
help professionals to improve the appropriateness of clinical decisions. Information to
support patients’ involvement in prevention, treatment choice and self-care should therefore
be a central part of any quality improvement strategy.
The paper will discuss the evidence on patients’ information needs and look at ways in
which these can be met. Issues raised by widening access to the internet and to commercial
sources of information will be outlined together with the implications for national and
international health policy.
The Right
assessment
to
Health
and
Patients’Rights:
Population-based
Anne Brunner & Manfred Wildner
Patients’ rights from the citizens’ view: areas for improvement*
*See also:
•
Brunner A, Wildner M, Fischer R, Ludwig M, Meyer N, Crispin A, et al.
Patientenrechte in vier deutschsprachigen europäischen Regionen. Z f
Gesundheitswiss 2000;8:273-286.
Forum V: The informed patient / citizen: a new partner
185
in the political health arena
•
Wildner M, Kerim-Sade C, Fischer R, Meyer N, Brunner-Wildner A. Regionale und
geschlechtsspezifische Unterschiede in der Erfüllung von Patientenrechten:
Ergebnisse einer repräsentativen Bevölkerungsumfrage in München, Dresden, Wien
und Bern. Soz Präventivmed 2001;46: 248-258.
Abstract
Patients’ rights as part of a human rights framework are of considerable importance for
future medical and public health practice. So far little empirical evidence has been provided
on the status of patients’ rights and especially not from the citizens’ perspective. The
European Office of the World Health Organization formulated the Amsterdam Declaration in
1994, demanding thereby the realization of the principles of a humane health care. These
principles relate to the protection of dignity of personhood, to self-determination, the right of
information and the right of quality, continuity and equality in health care. Goal of our study
was a population-based assessment of the perceived fulfilment of these rights.
Computer-assisted telephone interviews were conducted during the months February and
March 2000 in four German speaking European cities (Munich, Dresden, Vienna and Berne).
The questionnaire was derived from the framework of the WHO-sponsored Amsterdam
consultation. 125 persons randomly drawn were interviewed in each city (total 500
interviews). A paragraph of the Declaration on the Promotion of Patients’ Rights was
regarded as fulfilled if there was at least 80% agreement.
High grades of fulfilment were found for respect, self-determination, humanity of treatment,
free choice of care providers, confidentiality and issues of consent. Some problematic areas
of fulfilment of patients’ rights were found consistently across all four regions: patients‘
information rights, inpatient/outpatient transfers and humane terminal care. Deficiencies were
most pronounced for the provision of community and domiciliary services after hospital
treatment and for the right concerning humane terminal care and dying in dignity. Moreover,
regional differences were found between Munich, Dresden and Vienna on one side and Berne
on the other side, with degrees of fulfilment being higher in Berne. These regional
differences are more pronounced than gender-specific differences.
Although in general fulfilment of patients’ rights was high, problem areas could be identified.
This provides an evidence base for further research, targeted action and monitoring of
patients’ rights within complex and technologically advanced health care. We conclude that a
health rights framework contributes to a patient-centred assessment of health care systems.
Key Points
•
•
•
•
Patients’ rights are of increasing importance for medical care in the “era of the
patient”. The legitimate representation of the patients’ view is a controversial issue
between stakeholders in health care. Population surveys on the patients’
perspective hence were conducted in four cities in Germany, Austria and
Switzerland.
This empirical evidence suggests high degrees of fulfilment in areas like dignity,
respect and equal access in these regions.
Low degrees of fulfilment were found for information rights, continuation of care at
the inpatient/outpatient interface and humane terminal care.
Further research may target different regions or specific diseases, health care
settings or population subgroups
Patients' rights have advanced to a topic of high priority in health politics. The discussion on
patient's rights is being led in many countries and at the European level. It has been claimed
that the "era of the patient" has begun. Founding principles of contemporary health care
186
ethics are beneficience, nonmaleficience, distributive justice and patient autonomy. Patient
autonomy is also an essential principle of patient advocacy with its meanings of free action,
effective deliberation, authenticity and moral reflection. Free action focuses on health rights
such as the right to decide on one’s treatment options, effective deliberation on the
rationality of the decision making process in view of information levels and cognitive ability.
Authenticity requires consistency of a choice with personal preferences and life plans while
moral reflection makes reference to consistency with beliefs and values.
Patients' rights as health rights can be linked to the human rights legislation. Health rights
can also be found in the new rights charter of the European Union
(http://www.europarl.eu.int/charter/). Protection of human dignity, and health protection and
health promotion have been discussed recently with an explicit reference to rights. This
approach reflects a comprehensive understanding of health promotion as expressed for
instance by the Ottawa Charta. There are voices in favor and against elaborating patients'
rights further.
The legitimate representation of patients' interests has been claimed by several groups:
consumer organizations, patients' self-help groups, self-made patients' representations,
sickness funds, political organizations and medical professional organizations. Not
surprisingly these different organizations are motivated by different interests: citizens'
empowerment, consumer rights, market transparency and fair market competition, costcutting by informing consumers or lobbying professional interests. Correspondingly a
confusing number of labels can be found: consumer, customer, user, client, citizen, insured,
patient.
The traditional label "patient" reflects a special situation of the sick individual: An
extraordinary situation which is characterized by illness, functional impairment or disability
and increased vulnerability. Impairment ranges from a limited rationality due to pain and
anxiety over somatic and cognitive functional deficits to a complete loss of consciousness.
The patient-doctor relationship in this context is characterized by a special need of the sick
individual to be protected and is best describe as a trust relationship.
The European Office of the World Health Organization (WHO) has issued in 1996 a
Declaration on the Promotion of Patients’ Rights in Europe as a common European
framework for action following the Amsterdam Consultation on Patients’ Rights. This
document contains specific sections concerning human rights and values in health care,
information, consent, confidentiality and privacy, care and treatment and their application.
Patients’ Rights and citizens’ views were endorsed by the Ljubljana Charter on Reforming
Health Care of 1996.
It is evident that patients’ rights will play an increasingly important role in medical practice
in the 21st century. Causes are manifold. The need for the development of patients’ rights
emanates from a new role informed patients want to play, from scientific, ethical and moral
concern and the human rights movement in health care, including experience with
(mis)managed care.
Much conceptual and legal work has been done in the context of patients’ rights and their
advocacy. However, in the at times competitive efforts towards a legitimate patients'
representation the view of the key agents, i.e. the past, present or future patients, hardly
ever has been assessed in empirically. Empirical evidence however is essential for the
rationale setting of health targets to guide health policy. As this is an obvious deficit in the
current discussion over patients' rights, our study aimed at a systematic, populationrepresentative assessment of the perceived fulfilment of patients' rights from a patient
perspective as detailed by the Amsterdam Declaration on the Promotion of Patients’ Rights
in Europe.
187
Methods
A survey questionnaire was constructed using standard questions on demographics (age, sex,
occupation, marital status, insurance status, hospital stays, German as mother tongue),
health status (SF-12), a previously developed and validated Human Rights questionnaire (HRQuestionnaire) and questions derived from the WHO document Declaration on the Promotion
of Patients’ Rights (PR-Questionnaire). 30 of the 49 articles were reformulated as statements
for the interview, so that respondents could express their agreement with their content. The
wording was kept as close as possible to the original wording of the document. For example,
article 5.6 of the document was reformulated as „I can choose and change my own physician
or other health care provider and health care establishment“.
The questionnaire was worded in German. In order to maximize comparability of study
regions and to avoid language bias four German speaking cities were selected: Munich in
former West Germany, Dresden in former East Germany, Vienna in Austria and Bern in
Switzerland. A simple random sample of telephone numbers were drawn from available
telephone directories on CD-ROM. Interviewed household members were selected with the
nearest birthday method to enhance representativity. Only persons between 25 and 78 years
of age were included. A total of 502 interviews were conducted from February 15th to March
8th, 2000. The response rate was between 43% (Dresden) and 60% (Vienna), which is a
normal response for telephone interviews.
Statistical analysis was descriptive and based on the proportion of respondents who agreed
with the statement out of all interviewed persons. A distinction was made between „I don’t
know“ and „no answer given“. About half of all rights had a fulfilment below 80% in German
study regions. Hence special focus is given to fulfilment below about 80%. This threshold of
80% fulfilment was set to define potential for improvement. It must be noted that low
fulfilment consists of both low agreement and high uncertainty („don’t know“). Results were
analysed after direct standardization for the New European Standard Population. The regional
differentiation was kept and results were reported separately for men and women. No
statistical hypotheses were tested.
Results
In Munich (West Germany), areas with relative potential for improvement were found for
access to health care and prevention, information about health services, information about
one’s own health status, the right not to be informed and the right to have someone else
informed about one’s health condition (men only), information about health care providers
and rules and routines on hospital admission, written summary on hospital discharge,
continuity of care and especially coordination of care after discharge out of the hospital,
humane terminal care, ability to seek legal redress and access to information on patients’
rights.
In Dresden (East Germany), areas with relative potential for improvement were found for
access to health care and prevention, information about health services (men only),
information about own health status, the right not to be informed, the right to have
someone else informed (men only), information about health care providers and rules and
routines on hospital admission, written summary on hospital discharge, the right of access
to one’s own medical files (men only), continuity of care (men only) and especially
coordination of care after discharge out of the hospital, humane terminal care, ability to seek
legal redress and access to information on patients’ rights. In general, patterns of perceived
patients’ rights were similar to those seen in former West Germany.
In Vienna (Austria), areas with relative potential for improvement were found for information
about health services, the right not to be informed, the right to have someone else
188
informed, information about health care providers and rules and routines on hospital
admission, written summary on hospital discharge, access to medical files (men only),
coordination of care after discharge out of the hospital, humane terminal care, ability to
seek legal redress (women only) and access to information on patients’ rights (men only).
Although the pattern was in many aspects similar to German patterns, better fulfilment was
observed for access to health care, continuity of care and ability to seek legal redress.
In Bern (Switzerland), perceived fulfilment was generally superior compared to the other
German speaking regions. Areas with relative potential for improvement were found for the
right not to be informed (women only), information about health care providers and rules
and routines on hospital admission, written summary on hospital discharge, coordination of
services after discharge and humane terminal care (women only) and ability to seek legal
redress (women only). There was a general high agreement between sexes.
Discussion
Occasionally, empirical studies have been done on patients’ rights before, which were
however either restricted to special topics like information rights, were limited to special
professional groups, or both. The importance of patients’ rights for future medical practice
underline the need for a systematic evaluation of the status of patients’ rights in the
population. As the aim of our study was the assessment of a representative population
perspective, the citizen’s perspective in their role as former or current patients was chosen.
As the survey was based on judgement and subjective experience, only those persons who
ever have had a hospital stay were included for the hospital questions. Because citizens role
as tax payers or insurance payers is different from their role as sick individuals, this focus on
the citizen as a patient is essential and was made clear in the wording of the questions to
the interviewees. The selected representativity for households ensures a basic information
base for urban populations. Focussing on special patient groups defined by illness (e.g.
AIDS), setting of medical care (e.g. long-term care), demographic (e.g. old age), social
characteristics (e.g. migrants) or other regions (e.g. with high penetration by managed care
plans) would have been a valuable extension of this study. Subset analysis of the study data
base is limited by power considerations.
The comparability of the study populations appears satisfactorily from the demographic
variables, and was enhanced by the calculation of age-standardized results, stratified by sex.
For a graphical representation, it was chosen to visualize a theoretical patients rights „space“
with indentations corresponding to human rights problem areas. The 80% alert line serves as
a visual anchor for the comparison between countries and represents lack of fulfilment
perceived by one out of five interviewed persons, although any judgement on what degree of
fulfilment is regarded as satisfactory in principle is arbitrary.
This approach identifies in all four regions generally perceived deficits or uncertainty in the
areas patient information, continuity of care on transition between the inpatient and the
outpatient sector, and humane terminal care. More specific are deficits regarding access to
health care and prevention (Munich and Dresden), information about own health status
(Munich and Dresden), right of access to medical files (Dresden and Vienna men) and ability
to seek legal redress (both German study regions). The latter deficit corresponds to the lack
of a patient ombudsman system or patient advocacy, that the other study regions have
implemented. The deficits recorded in Vienna and Bern are reported by women only and may
be spurious. Uncertainty regarding access to one’s own medical files may be a late sequel of
the former East German political system in Dresden. Again this consequence may be spurious
in Vienna as it is only found for one sex. Similarly, deficits regarding access to health care
and prevention were only reported by Bernese women and may hence be due to chance.
Alternatively, this may reflect concern stemming from several managed care experiments
189
being currently in place in Switzerland. However, the proportion of the Bernese population
insured in managed care plans is about 4% only.
Differences between the responses of men and women were generally small and were more
pronounced in Dresden than in the other study regions. Again one could speculate that this
latter finding is due to social adjustment processes taking place currently in former East
Germany, with high rates of unemployment and resulting dissatisfaction among men.
Moreover, the perceived health status was considerably lower in Dresden compared with the
other study regions, more persons were currently receiving medical care and less patients
could afford private health insurance.
The areas patient information, continuity of care on transition between the inpatient and the
outpatient sector, and humane terminal care require further research and potentially
corrective action. Any perceived lack of fulfilment of patients’ rights has a considerable
proportion of respondents stating „I don’t know“, reflecting a general uncertainty regarding
these rights in all study regions. If the analysis of such surveys excludes these statements of
uncertainty, then higher degrees of fulfilment of patients rights will be calculated, which
however must not be reported or interpreted without information on the proportion of
uncertain responses ( „I don’t know“).
On the positive side respect, self-determination, humanity of treatment and connectedness
to family and friends while in the hospital, free choice among health care providers and
confidentiality of data and issues regarding consent to treatment, study participation and
participation in teaching ranked high in all four study regions. These are certainly valuable
achievements of the systems under investigation.
Generally, the study design does not allow to differentiate between existing differences in
deficits between study regions from differences in the subjective perception between regions.
For example, perceived dissatisfaction with the information about the own health status in
Munich may reflect the unmet demand for information of an urban, well educated population
rather than a true deficit relative to Dresden. It is possible that education on patients’ rights
sensitises a population on existing deficits and may lower perceived fulfilment of these
rights. An answer to this hypothesis, however, requires a different study design, e.g.
longitudinal analysis concurrent to informational intervention.
Other perspectives, e.g. the perspective of caregivers, legal experts, patients or patient
organizations have the potential to add to the understanding of this area. We found a
number of patients rights in the Amsterdam Consultation Charter which were not suitable for
assessment by a population-based survey. For example, article 3.6 states that cases of
dissent between health care providers and legal representatives regarding necessary medical
interventions should be referred to a legal court or some form of arbitration. Evaluation of
the fulfilment of this right requires the knowledge and experience of legal experts and
professional bodies.
There is no doubt that in all four study regions modern and effective health care systems
were in place, which are maintained with allocation of considerable financial resources, and
with professionals working with high ethos within these systems. The essence of our study is
the identification of problematic areas within these complex, technology-intensive and human
resource-intensive care giving systems with the aim to further improve the quality of health
care systems. Basis of our analysis were the articles of the Amsterdam Consultation on the
promotion of patients’ rights. The pattern of deficits is in part consistent across study
regions (information rights, transition between inpatient and outpatient sector and humane
terminal care), in part it is regionally specific. There is no doubt that further research is
required to evaluate further patients’ rights strengths and weaknesses, e.g. among vulnerable
subgroups defined by illness, health care setting, demographic or socioeconomic
190
characteristics. Nevertheless, fields for action are mapped by the presented empirical
evidence from a patients’ view and may contribute to the formulation of health targets, to
the formulation of human rights-based strategies to reach them and to the impartial
monitoring of progress. It has the potential to strengthen both the scientific basis, the
democratic legitimization and the acceptance of calls for action.
Acknowledgement
The presented study was supported by a grant of the MSD Merck Sharp & Dohme European
program on Health Targets 1999. We would like to thank Dr. Michaela Moritz from the
Austrian Federal Institute for Healthcare (ÖBIG), Professor Thomas Abel from the Department
of Social and Preventive Medicine of the University of Bern and Professor Georg Ress, Judge
in respect of Germany at the European Court of Human Rights at Strasbourg for their
support.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
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Albert Jovell
Abstract
Goals:
To highlight the main findings of quantitative and qualitative research carried out in Spain on
information needs in health care
Method:
1.
2.
Review of health care surveys carried out at country level since 1989 based on
population random samples
Focus groups structured across different patients and citizens characteristics carried
out in July 2001
Main findings:
Health surveys:
Lack of public opinion studies in Spain
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Data were not found dealing with issues such as patient's rights and responsibilities,
consumer empowerment, policies and participation by the public in health policy
decision-making, medical errors, shared decision making, and doctor-patient relationship
The most important source of information was the patient-physician relationship
Population expressed a wish to obtain clear and understandable information on
diseases, prognosis, and treatment
Population expressed concerns on the impact of genetic and biotech research
Qualitative study:
Participants expressed lack of appropriate information in health care
Internet appeared as a source of information although there were concerns on the
quality of the health information in the net
Internet did not replace the patient-physician relationship
There were multiple sources of information for patients, which resulted in different levels
of expectancies in the population. Doctors were valued as the best source of information
Participants valued positively to get information on sources of quality of health care
Smart cards might be helpful as sources of information in health care
Theresa Petrangolini
1. Traditional and new citizenship
Recently (Politeia, Conference on “Citizen Participation in Europe”, November 2000) Giovanni
Moro, the general secretary of Cittadinanzattiva, has presented a very useful definition of
new citizenship that I want to report in this conference. It may be a synthetically way to
present the aim of my speech: citizen participation in health policies.
Our starting point has to be the traditional idea of citizenship. It can be defined as follows.:
Citizenship is the belonging to a national identity, witch is realised through a set of
rights and duties that rule the relationship between the state and individuals or
social groups.
Two elements of this definition:
•
•
Voting is the highest expression of citizenship. The background idea is that citizens
don’t’ have sufficient time, information, capacity and self-identification with the
general interest to participate actively in public life. Consequently, they have to
choose, through voting, persons that are competent, free of time, and really linked
to general interest.
There’s a primacy role of state and public institutions. In the “Standard View” on
public participation, citizens can ask, but it is the state that has to answer; citizens
can express loyalty, voice or exit, but always in respect of the state; citizens can
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criticize, but the power to really manage things and solve problems is in the hands
of public institutions only.
This traditional idea of citizenship is hardly questioned because of:
•
•
•
•
•
The double process of globalisation and localisation, that imply a weakening of the
national state;
The migrations (it is difficult to say precisely “who is in” and “who is out”);
The crisis of effectiveness of public institutions in the implementation of norms and
in the protection of rights;
The lack of consensus of representative institutions (the so- called anti-politics and
the mistrust in the ability of political leadership to represent people);
The crisis of traditional welfare systems, since there are new needs without rights
and old rights without funds.
Otherwise it is emerging a new feature of citizenship and civic participation: This new kind of
citizenship can be defined as follows:
Citizenship is the exercise of powers and responsibility of citizens in the arena of
public policies, in the context of governance.
A comparison of this two concept of citizenship may be useful
TRADITIONAL CITIZENSHIP
NEW CITIZENSHIP
Rights and duties
powers and responsibilities
In civil society-state relation
in public policies
In the government context
in the governance context
Electoral participation
civic participation
Firstly, while rights and duties characterize traditional citizenship, powers and responsibilities
characterize new citizenship. Second, the new citizenship is exercised in the field of public
policies (i.e. the everyday life politics). This is a relevant difference: in the traditional
approach we are citizens when we relate with the state; in the new approach we are citizens
when we face the public problems that affect our life (i.e. health programs). Thirdly,
traditional citizenship is part of the context of government, i.e.: the context in which the
responsibility for the management of public life is assigned, in an exclusive way, to
executives and administration directly linked to elected bodies. The new citizenship, on the
contrary, works in the context of governance (Commission on Global Governance, Prodi,
2000). This is an approach that sets off the cooperative role of public, private and social
collective \ comunitarian actors of public policies, in logic of interdependence, in an
interactive modality of policy-making and overcoming the traditional distribution of roles. In
other words, governance in a way to manage public affairs shared out between a number of
public, private, and social actors that exercise their own powers and responsibilities in
policymaking and that interact with each other in forms based on co-operation or conflict.
2. Active citizens in public policies
The main expression of this new way to be citizens is what we can define as active
citizenship:
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Active citizenship is the capacity of citizens to self-organize in a multiplicity of
forms, to mobilise resources, and to exercise powers for the protection of rights, to
achieve the end of caring for and developing common goods.
About this phenomenon there is a sort of “Standard View”, with a reductive vision of civic
participation:
•
•
•
•
•
•
It has no institutional or political definition;
The scheme is “demand of citizen – answer of the state”;
The activity is only pushing, protest, claim, without any constructive aim or
capacity;
It is a problem making and not a problem solving activity;
It implies no own power of citizens, but dependence on the others’ power (of
market, of the state);
Il appears as a “temporary post” in front of the financial crisis of welfare systems.
The wide diffusion of active citizens organisations is a trend that contradicts this vision.
Looking at the common operational modality of the various experiences of civic participation,
it is evident that they exercise many powers, a kind of new powers, very different of
traditional ones.
•
•
•
•
•
the power to produce information and interpretations of concrete situations that
affect people (i.e., new needs not considered as rare illness or immigrants health’s
condition, quality of services in formations);
the power to change the field of perception and the conscience of actors involved
in public policies by using symbols;
the power to promoting the consistency of institutions with their mission (e.g. an
hospital must serve users and not workers, the health service must create a net of
in formations services);
the power to change material conditions (door to be opened, architectural barriers
to be destroyed, services to be built, etc.)
the power to promote partnerships and collaborations between the stakeholders
and to combine their different interests (alliance promote with general practitioners
to improve the outpatients services).
As for the result, in a very partial and incomplete way, we could say that the action of
organized citizens has reached objectives such as:
•
•
•
•
•
•
•
New laws
Mobilitation of human, technical resources,
Changes in the behaviour of social and collective actors,
Modifications of mass culture and common sense,
Modifications in political agendas, styles and languages,
Modification in market rules and functioning,
Etc.
Until now, in its daily life democracy has prevailingly considered citizens as beneficiaries of
programs and public interventions, and consequently often as a problem. The time has come
to affirm that they are actually a resource for democracy.
3. The European citizenship
In the European environment there are many official documents regarding citizen’s rights,
citizens/consumers/patients participation and involvement in public policies. They are
197
finalized to reduce the lack of confidence of citizens in EU institutions and to make citizens
closer to the European Union. There is still an underestimation of the role and the meaning
of citizen’s initiatives and organizations, but something has been done in the direction of
understanding this new phenomenon.
The main documents in this direction are:
•
•
•
•
Maastricht and Amsterdam treaties (EU)
Ljubljana Charter on health care (WHO)
Charter of fundamental rights (EU)
Recommendation adopted by the Council of Europe on the development of
structures for citizen and patient participation in the decision –making process
affecting health care.
This last document is important because recognize the fundamental right of citizens to
determine the goals and targets of the health care sector and the role of civic and self-help
organisations in representing users interests.
… patient empowerment and citizen participation can be achieved only if basic
patient’s rights are implemented and …, in this turn, patient participation is a tool
for the full implementation of these rights in daily practice (Rec 2000/5)
4. The experience of Cittadinanzattiva/Tribunale per i diritti del malato
identity and mission
“Cittadinanzattiva” is a civic Movement that was established in 1978 and whose
members - individuals, groups and networks - share a commitment to ensure that
the general public affirm and play an active role in governing society.
The Movement identity is comprised of two closely linked aspects. The first involves
promoting civic participation. The second aspect is a commitment to protecting rights, that is
the main objective of participation exercised through civic powers.
Therefore, the Movement works to enrich the democratic system with a new protagonist - the
active citizen - who can thereby take on government responsibilities at local, regional,
national and international level - along with the actors that have been established
throughout the history of democracy.
the organization
From a legal viewpoint, the Movement is a non profit-making organization of social interest,
and acknowledged as a consumer organization, with representation in the National Council of
Consumers and Users.
The Movement is democracy-based, comprising Territorial Assemblies of Active Citizenship
linked to regional Congresses. An Assembly of Active Citizenship requires the membership of
at least 50 citizens for establishment. There are currently over 180 Assemblies throughout
Italy with 53.000 members.
Any individual or association interested in supporting the Movement’s mission is welcome to
join. Membership is free, occurs on a voluntary basis and is affected through the Territorial
Assemblies. The Movement is mainly organized and run through voluntary work, although the
National Headquarters and various regional centres employ qualified people to carry out
programs and activities.
198
The Movement has always adopted three procedures for collecting funds - public funding (at
local, regional, national, and community level), private funding (partnerships with private
enterprises for specific programmes) and donations and contributions from the general
public.
networks
The Movement since its foundation has always adopted networks to ensure that individuals
or organizations join forces. The Movement could be best described as a “network of
networks”.
The main networks operating at the national level are as follows:
•
•
•
•
•
•
The Tribunal for the Rights of the Patients;
The Chronically Ill Associations Coalition;
The Citizens’ Advocates;
Justice for Rights Coordination;
The School for Active Citizenship;
A network of employees applying good practices in public services and public
administration.
Except the network there are other important fields of commitment. One of these is the
programme on Corporate Citizenship that aims to support and distribute information
regarding the renewal of social responsibility in private Italian and European enterprises. In
June 2000, a “Manifesto of Corporate Citizenship” was prepared and distributed by a group
of the Movement’s partners, while a project to research and design ways of labelling
corporate citizenship in the four south-European countries and Great Britain - sponsored by
the European Commission - is currently underway.
tribunal for the rights of the patients
The Tribunal for the Rights of the Patients is an initiative that began in 1980 to protect the
health and welfare rights of citizens and to help achieve a more humane and functional
health service. The Tribunal is comprised of ordinary citizens, workers from the sector and
professionals who provide their services on a voluntary basis. It involves local units
throughout Italy and over 10,000 citizens working in hospitals and territorial services, a
central structure to co-ordinate the network activities. The ongoing programmes and
campaigns implemented by the Tribunal for Patients’ Rights include the following:
•
•
•
•
•
•
•
•
•
•
The “Safe Hospital Campaign”;
A programme for good practices in the health sector, for which the “Andrea Alesini
Award” is given;
An experimental project to reduce waiting lists;
A programme on safety and quality in medical practices;
A project on the “surgical path and citizens’ rights”;
A campaign on pain therapy;
A campaign to sponsor generic drugs;
An oncology campaign following the so-called “Di Bella” case;
A campaign for compensation for damages through the transfusions of infected
blood;
Experimental implementation of a network for “PIT” services at the local level.
The Tribunal for Patients’ Rights is linked to the Chronically Ill Associations Coalition, which
has around one hundred member Federations and Associations for patients suffering chronic
diseases. The Coalition aims to intensify action implemented by each individual Organization
through a common policy for all chronically ill patients and thereby receives greater attention
199
and care from the National Health Service, especially with regards to free prescriptions for
pathological patients and access to pharmaceuticals. In 2000, the Coalition began publishing
an annual report on the policy regarding chronically sick people in Italy.
The Tribunal for the Patients’ Rights is linked to “PIT Salute”. This service was created in
1996 to offer all members of the general public information, advice and mediation in the
protection of their rights in the welfare and health fields for both public and private
structures. This service that is carrying out at national level and on 35 local provinces also
receives and manages reports on how the health sector works and the quality of services
offered. “PIT Salute” acts on any request regarding both public and private medical and
health sectors and more specifically with regards to the following:
•
•
•
•
•
•
•
•
•
Hospitals and assistance in the home;
Assistance for elderly and chronically ill patients;
Diagnoses;
Provision and use of pharmaceuticals;
Bureaucratic issues such as reservations and waiting lists;
Free prescriptions and disabilities;
Relations with health workers;
Efficiency and effectiveness of structures;
Emergencies.
“PIT Salute” prepares an annual report on “Citizens and Health Services” based on the
reports and cases they deal with, which is presented on the National Day for the Rights of
the Patients (the 21st such occasion to be held in 2001).
operational procedures for rights protection
Cittadinanzattiva - as mentioned above - aims to ensure that citizens assume a leading constructive rather than destructive - role in public policies. At operational level, this is
affected via a commitment to ensure that rights set forth in the law are effectively
implemented. It is exceedingly difficult to guarantee such rights and the Government bodies
responsible often do not guarantee them at all when left alone to do so. On the contrary, it
often occurs that the bodies responsible for protecting rights actually violate them - the Law
being a prime example of this.
Every project, programme or campaign implemented by the Movement and the Tribunal uses
one or more of the following tools and strategies for rights protection:
•
•
•
•
•
•
•
•
•
•
Charter of Rights, such as the Charters for the Rights of the Patients;
Structures designed to listen, provide assistance and advice, such as “PIT” services;
Monitoring aspects such as safety in hospitals or service quality levels;
Mobilizing and making the general public aware (by distributing leaflets, collecting
signatures, initiating petitions, etc.);
Symbolic and demonstrative actions (such as those against wildcat strikes in the
transport sector, etc.);
Roundtables or other forms of negotiation (such as the Conferences on services
offered by Local Health Service Units (ASL) or workshops on security in hospitals);
Protocols of Intent and agreements with other parties (such as health service
units);
Alliances and partnerships (for example with family doctors and hospital doctors on
the management of risks of malpractice);
Implementation of the protection tools set forth in the law (Ombudsmen,
committees for the appropriate use of blood, etc.);
Legal action (civil action in criminal proceedings; inhibitory measures; etc.);
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•
•
•
•
•
•
conflict management (Conciliatory commissions, Alternative Dispute Resolution,
etc.);
Collecting and encouraging best practices (awards, catalogues, etc.);
Planning new services (for example house services);
Civic use of the Internet (for example for pressure campaigns);
Training (such as experimental programmes for the reform of civic education);
Lobbying (for the passing of laws, changes to the financial law and so forth).
some results
The Movement got important outcomes at the time, including the following:
•
•
•
Reform of the health sector (Section 14 on Citizens’ Rights);
Reform of local self-governing bodies (introduction of the Ombudsman and citizens
participation procedures in City and Province Council statutes);
Reform of public services (rules on participation from citizens in the Ciampi-Cassese
Directive regarding Service Charters).
More recently and regarding health sector:
•
•
•
•
•
•
•
•
•
•
A policy of good practice for professionals and operators.
Built risk management units in twenty pilot-hospitals.
Reinforced its nation-wide network of civic safety monitors.
Bought and put at citizens’ disposal equipment for checking the level of
electromagnetic pollution.
The new law on pain therapy.
The introduction of generic drugs in the national health system.
The zero costing of new drugs for certain categories of chronically ill patients.
The increase of investments in radiotherapy and in mental health services.
The suing for damages in several important criminal proceedings (most of them
regarding malpractice and environmental issues),
Improvement of policies on transplants and on mental illness
Regarding the promotion of civic space in Italy, Cittadinanzattiva has contributed to the
reform of paragraph no. 118 of the Constitution, which now states that the State, the Regions
and the local administrations have to enable citizens to freely and independently carry out
activities of general interest.
the European dimension
The Movement has been working at the European level for a number of years, including
cooperation with the European Commission for programmes concerning the protection of
consumers, access to justice, training and information for citizens. It has participated - and
still participates - in the public forums on institutional reform in the European Union.
The Movement is a member of the “European Forum of Civil Society” - a coalition of
organizations that act to expand and strengthen democracy and citizenship in Europe.
The Movement laid the foundations for the creation of a “Centre of Documentation and
Initiative on the Rights of Consumers in Southern Europe” in 2000, which currently involves
30 organizations from Greece, Italy, Portugal and Spain.
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5: Closing remarks
•
•
•
•
•
•
•
How to reduce the gap between the underestimate vision of civic participation by
institutions and the growth and the effectiveness of active citizenship;
May civic participation helps the health care system to overcome his actual crisis
(funds, organisation, new needs, general public consensus, new knowledge);
How to introduce civic participation on decision-making process without confining
this practice to resolving problems and simply choosing between solutions, which
have already been drawn up?
It is necessary to create favourable conditions, both in the legal and fiscal system,
for the founding and operating of the civic organisations and civic programs. It Is
also necessary to create favourable legal conditions to support financing of these
kind of programs by the industry while avoiding conflict of interests;
In every European country policy makers are seeking to strike a better balance
between state intervention and the intervention of other partners (fund holders and
care providers); this change (liberalisation and privatisation of public services)
requires a new definition of patient rights, explaining the meaning of solidarity,
equity and efficiency in health system. In this scenario the participation of
consumers can be considered a means of harmonising out market mechanisms.
Civil society and patients associations have high expectation of participatory
process. At the same time, the health system lives a lack of consensus (confidence,
compliance, transparency, gap of information). Participation (open doors) may be a
way to reduce this distance and rebuilt a relationship between services and citizens.
Empowerment of citizens is a goal by a modern health organisation. At the same
time, citizen well informed and conscious of their opportunity can introduce new
inputs (new technologies, new drugs, change in models of professionals, different
planning of services, etc.). Is the health system (hospitals, doctors, providers, fund
holder, authorities, etc.) disposed to accept this challenge?
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
Rodney Elgie
Europe, in geographical terms, is made up of 51 countries and approximately 870 million
citizens. It comprises some of the richest and some of the poorest nations on Earth. Despite
this diversity, all governments across Europe wrestle with the insoluable problem of squaring
the circle of need versus cost. We are experiencing rapid changes in the manner in which
health care is delivered and this will continue unabated due to the advances in medical
science. Need can never be fully satisfied in the health field. Currently, we have needs and
wishes. If all needs are satisfied, what were formerly wishes become needs, and what were
just thoughts, become wishes, and so on. EU citizens are intelligent enough to appreciate
that some form of rationing is inevitable. What is lacking is a sufficient feeling of
involvement or partnership between state and citizen, coupled with confidence that
government has a viable long-term plan.
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The problem for patients is that governments tend to think short term as the average
administration lasts for around four years. This produces two consequences. Firstly, there is
an automatic preference to treat acute conditions rather than chronic illnesses. The return
and impact is almost immediate thereby producing political capital for the party in power.
Secondly, governments tend to look backwards after two years in office to examine what
election pledges have been fulfilled, which are half way to fulfilment and which ones require
a radical review before the next election to keep faith with the electorate. Any long-term
health programme might only enjoy success when the implementing government is no longer
in power, presenting the former opposition, as the party now in office, with the opportunity
to claim credit at the expense of its opponents. For these reasons it is vital for the
patient/citizen to become involved as an equal partner in the political health arena.
Patients with a chronic medical condition will often become an expert in their particular
illness. Whilst this expertise is extremely narrow in comparison to health professionals, it is
nonetheless valid. The knowledge will not only include treatment options, be they
pharmacological, psychological or complimentary, but also first hand experience of what it is
like to live with the illness, to experience the side effects of medication and to combine
family and work life with the condition. It has been estimated that there are around 30,000
illnesses/diseases known to the medical world. It is inconceivable that a GP can possess a
detailed knowledge of more than 10% of such conditions. Hence, the patient is a valid
partner when discussions centre on his or her specific condition. After all, that condition is
the same across Europe. The symptoms are the same and so should be the available
treatments.
In the UK in 1998, the government of the day sought to introduce an initiative known as
PRODIGY. The concept was excellent and potentially of tremendous benefit to patients. It
revolved around GPs prescribing rationally. The initiative would compensate for a doctor's
lack of expertise in certain disease areas and also guard against contra-indications.
Regrettably, the whole concept appears to have been cost driven. Almost without exception,
the medicines recommended as first line treatments under PRODIGY for any given condition
were the cheapest available. But the notion of cost containment was fundamentally flawed.
For example, in the case of depression, the text published by the Department of Health
acknowledged that between 400 and 600 patients committed suicide annually whilst taking
the old antidepressants recommended by PRODIGY. It is well known that such medications
are highly toxic! So when governments talk about the quality, safety and efficacy of
medicines their views should at least be scrutinised and validated by the informed patient.
Experience shows that clinical effectiveness and cost effectiveness frequently represent a
contradiction in terms.
Health is, perhaps, the most important single factor for all citizens. There is a very real
prospect that we shall all become a patient at least once in our lifetime. It has been
interesting to note the development of pan European patient groups over the past decade.
As the concept of the European Union has gathered strength with the enlargement process,
so has the notion of patients joining together across national boundaries to press for better
healthcare and equality of access to newer medicines. There is a realisation of strength in
numbers and how "divide and rule" tactics can be overcome by this approach. In my own
field of mental health, Gamian-Europe has brought together over 50 national patient
organisations in 27 European countries covering the whole spectrum of psychiatry. The
principle has been followed by those affected with a neurological condition who, earlier this
year, created the European Federation of Neurological Associations. We have now come
together with health professionals to form The European Brain Council. Slowly but surely,
patient groups are abandoning their old territorial concerns and the preference for working in
isolation. There is a growing realisation that we can all learn from one another and, all too
often, we share the same problems, such as non-diagnosis, mis-diagnosis, failure to seek
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treatment and stigmatisation, to name but a few. We now have the concept of a European
Patients Platform becoming a reality in 2002 with the support of DG SANCO. This will
certainly hail the advent of patients taking a key role in many decisions affecting health.
With the introduction of the Internet, better developed patient organisations and the more
extensive use and availability of patient leaflets, the "informed" patient is becoming an
increasingly educated and sophisticated being when it comes to debating health issues.
Coupled to this is the fact that no government generates income of its own; its income is
only derived from the fiscal measures it implements. Accordingly, it is only equitable that
citizens, as taxpayers, should automatically become a partner in one of the largest spending
areas of government. Patients/citizens are able to provide a valuable insight into the
provision of health care, not only in terms of its efficient delivery and offering value for
money, but also in setting standards and priorities. After all, what multi billion Euro industry
does not spend a proportion of its revenue on market research? Citizens and patient groups
represent a rich seam of knowledge, skill, resources, experience and expertise that could
prove of immense benefit to national and supranational governments.
It is difficult for patients to accept that within the EU there are the four basic freedoms and
very soon there will be a shared currency for the majority of Member States, yet at the start
of the 21st century we are still no nearer to creating a freedom for health. Perhaps a chink of
light is beginning to shine through as a result of the recent judgement by the European Court
of Justice. But should the judiciary, rather than the European Parliament and the European
Commission, be leading the way? Some may well answer in the affirmative and advance the
view that the judiciary is more in touch with the views of European citizens than elected
politicians. Perhaps too great an emphasis is placed by the EU Institutions on the cost of
medicines and the alarmist views promulgated by some at the prospect of Europe
introducing a form of Direct to Consumer Advertising (DTCA).
It seem highly unlikely that Europe will adopt wholesale the system in use in the USA for
DTCA but what is wrong with patients being included in the debate before any decisions are
reached? Evidence within the EU tends to suggest that pharmaceutical products account for
less than 10% of the total cost/disease burden for the majority of conditions. Again, using
the UK as an example, it is estimated that cost of medicines used to treat mental illnesses in
1999 amounted to £460 million. Yet the total cost of these illnesses to the Exchequer was
estimated to be in the region of £20 billion. In other words, over 95 % of the cost was
attributable to welfare and social security payments, days off work, unemployment,
attendance at hospital for attempted suicide, successful suicides, drug and alcohol abuse,
crime and housing problems. Excluded from the calculation is the social and economic cost
on carers and other family members. If better and more appropriate medicines are used,
perhaps the "indirect" cost of mental health in the UK and elsewhere would be
correspondingly less. In other words, it is unsafe to advance an argument using limited or
selected facts.
The point can be further underlined by the examining the terms of reference for the High
Level Group on Health, the G 10. One such term required the Group to examine drugs that
either saved lives or cured people. Without the citizen's involvement in this decision making
process, a whole and most important area in the field of medicines was overlooked - drugs
that do not save lives or cure people but do vastly improve the quality of their lives. This is
especially true in the fields of psychiatry and neurology for a host of illnesses such as
Bipolar Disorder and Parkinson's Disease. It is generally accepted that there are two areas of
particular concern within Europe. Firstly, the ever increasing incidence of mental illness,
particularly stress and depression. Secondly, the ageing population and the financial
implication this will have on health budgets, particularly as the number of traditional unpaid
carers within the family is dwindling rapidly. These are problems that will affect us all, either
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directly or indirectly. Again, it is only right that citizens should be involved in seeking
solutions and assisting in determining which proposals will be implemented. In this way they
will more readily assume ownership and, perhaps more importantly, responsibility for seeing
that those decisions are carried through to completion.
The educated patient can add an extra dimension to the political heath arena as may be
viewed in the UK through such bodies as the National Institute for Clinical Excellence, the
Commission for Health Improvement, the National Clinical Assessment Authority and the
Clinical Standards Advisory Group. On the European scene, it is hoped that the creation of
the Commission's proposed EU Health Forum coupled with the introduction of a European
Patients Platform will see the concept of "patient partnership" at a political level reach new
heights that could only have been dreamed of less than two decades ago. The manner in
which medical care is delivered through the primary care system will change radically in the
next twenty to thirty years. Patients will be required to accept a greater degree of
responsibility for the management of their illness in partnership with the healthcare
professional. Involving citizens in the health decision making process at this time is simply
the start of that process. We are living in rapidly changing and challenging times. The health
care challenge will be met, to a significant extent, by doing more with less. This involves,
inter alia, reducing the currently high wastage levels. Reduced wastage can be achieved
through improved compliance rates, through more knowledgeable patients who can assist
the doctor in reaching an accurate diagnosis and through educated citizens appreciating the
value of not smoking, exercise and a healthy diet. But this win/win situation will only come
about if citizens feel engaged in the decision making processes and a genuine and equal
partner with the EU Institutions. To adopt a policy of exclusion would be foolish in the
extreme and unsustainable in the long run. The current initiatives of DG SANCO are
welcomed and to be applauded.
The US-Experience
David Lansky
American health system researchers have examined quality of care issues since the mid1970s and found a widespread and persistent pattern of overuse, underuse and misuse of
health care services. More recently, high rates of medical error have raised additional
concerns about the allocation and effectiveness of the nation’s very substantial health care
expenditures.
Numerous efforts to improve quality have been attempted, but none have had significant
impact. Analysts have concluded that the dependence of most major stakeholder groups –
physicians, hospitals, insurance carriers, politicians, patient advocates – on existing financial
arrangements continues to limit the possibility of meaningful reforms that might improve
quality of care or more significantly engage the public in the health system. The U.S. health
system seems to function to maximize economic benefits to health care organizations and
professionals, rather than to best meet the health needs of American citizens.
As a result, reformers have given growing attention to increasing the role of consumers in
the health system. Consumers provide financing for virtually all care – through taxes and
withheld wages – and of course are the ultimate recipients of health services, yet have very
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few mechanisms to influence health policy, allocation of resources, or the behavior of health
professionals. Since the U.S. lacks any centralized health policy mechanism, the sheer
diffusion of economic and political control has prevented consumers from exerting influence
over the system. Several factors compound this problem:
•
•
•
•
Consumers typically have more limited access to information and expertise than
professionals.
Consumers lack an organizational mechanism to educate and advocate with
policymakers on quality issues.
Health care organizations are businesses, with substantial research, communication,
and lobbying resources devoted to protecting their interests, while interested
consumers do not have time and do not get paid for engaging in health policy
advocacy.
Sympathetic policy leaders do not know how to get more extensive and
representative consumer involvement.
Yet these barriers are being eroded by more powerful social forces. Rising educational levels
and new information technologies are giving patients and consumers equal access to health
information. The “new consumer” is more insistent on being treated with respect and
courtesy, and having her voice heard by both policymakers and service providers. Longer
life and the increasing prevalence of chronic illness in the U.S. population have motivated
more Americans to learn about how best to manage their own health, day-to-day. And major
institutions such as employers and governments find it more palatable to work on
empowering consumers to be responsible for their own care rather than trying to exercise
paternalistic, protective authority over a large, restive and diverse population.
The emerging policy strategy in the U.S. is to focus, first, on raising the awareness and
capacity of the general public to demand more from the health system. Consumers need to
understand what quality care is, be able to identify and select the most appropriate doctors,
hospitals, or insurers to meet their needs, be able to interact more effectively with their own
doctors, and participate in policy debate to support continued changes in the structure of the
system.
The strategy in place attempts to leverage the current roles of many credible organizations in
communicating with some part of the population, by creating a set of uniform messages and
terms and encouraging many organizations to adopt these common ideas and materials.
Employers, labor unions, government agencies, patient advocates, insurance funds,
journalists, professional societies – all engage in direct communication about health care
with some part of the public and could, by sending a common message, begin to change
consumer thinking about the health system and their role in it. By collaborating on such a
communications effort, consumers may become better able to (1) participate in policy
discussions, (2) interact effectively with their providers, and (3) manage their own health and
health behaviors to reduce their health risks.
This campaign will, ultimately, need to address four components:
•
•
•
Science: The public needs to have access to evaluative information about the
performance of the health system that is based on the best clinical and
measurement science;
Awareness: Broad public attitudes need to shift towards greater recognition that
quality is uncertain and that personal engagement with health care is essential.
Disclosure: The public needs to have access to comprehensive, understandable
information on all available health care providers, both in comparative terms and
also to illustrate the absolute level of performance of the care they receive.
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•
Decision support: Patients and consumers should have access to performance
information in a form that helps them make important personal decisions: which
doctor or hospital to see, which procedure to undergo.
Significant research has been done in each of these areas, which can make the entire
campaign more effective. We know, for example, how to construct sound measures of
quality that speak to the concerns of most patients. These typically blend clinical indicators
with measures of communication, patient education, and health outcomes. To raise
awareness, we have tested various types of messages, and understand that performance
information must be communicated within a structure that makes sense to people and within
a context that helps them interpret its meaning. And we know that American society
encompasses many types of people, with varying levels of interest or need or competence
and a communications strategy must be nuanced enough to touch people where they are. In
the U.S., we have learned that disclosure of meaningful performance data will not come
voluntarily from hospitals or doctors or insurance funds. Government action – or massive
public pressure - will be required to force information into the public arena. And we know
that decision-making involves difficult trade-offs for many people, so that quality information
must be provided to consumers within a decision tool that helps them evaluate several
factors and their own values and needs. Simply publishing data in tables and charts does
not affect how people make real-life decisions.
This strategy – to encourage and empower American consumers to become more informed
and engaged in their health care – faces many challenges. It runs the risk of compounding
the very American inclination towards individualism at the expense of the social good. It is
difficult for multiple, independent organizations to agree on the vocabulary and messages of
a common campaign. And it will take many years to bear fruit. Ultimately, the citizens’
agent – its national government – must provide the necessary visibility and leadership to this
process. Paradoxically, that leadership is only likely to emerge when a sufficient groundswell
of public discontent is articulated as the result of this grassroots empowerment strategy.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
How to involve citizens in health policy development
implementation? Current activities of the European Community
and
Walter Baer
1. Introduction and Background
On 16 May 2000, the European Commission published a Communication on the health
strategy of the European Community, together with a proposal for a Decision of the
European Parliament and of the Council for a new programme of Community action in the
field of public health39.
39
COM (2000) 285 final of 16.5.2000
207
As set out in this Communication, a central theme of the new Community approach to health
is openness and transparency. The Commission therefore announced that it intended to set
up a European Health Forum as an important element of the new health strategy. This would
be an information and consultation mechanism to ensure that the aims of the Community’s
health strategy and how they are being pursued are made clear to the public and respond to
their needs. It would also allow representative organisations of patients, health professionals
and other stakeholders, such as health care providers, to have an opportunity to make
contributions to health policy development and implementation and the setting of priorities
for action.
In order to prepare the establishment of the Forum, the Commission prepared a
comprehensive Consultation document on 20 December 2000. This was distributed to
interested parties and placed on the Commission’s website to achieve maximum coverage.
The document raised key issues related to the composition, scope, structure and functioning
of the Forum.
While the deadline for putting forward views and responses was initially set at 15 February
2001, all responses received up till now have been taken into account. The Commission
wishes to thank all respondents for their contributions which address a wide range of issues
and questions related to the creation of this body.
The Commission has received 130 responses from various institutions and organisations to
date. Respondents can be divided into four main groups:
•
•
•
•
non-governmental organisations (NGOs) in the health field, representing patients
and citizens views;
organisations representing health professionals and trade unions active in the
health field;
organisations representing health care providers and different health and social
services;
organisations representing industry in areas of key relevance to health (e.g.
pharmaceuticals, medical devices or food).
A number of individuals also presented their points of view. These were largely either health
professionals or academics working in the health field.
Finally, the Commission received a number of reactions from national and regional
governments in Member States and some candidate countries and organisations representing
local and regional governments and entities. A contribution was also received from EFTA.
2. Purpose and scope of the European Health Forum
The consultation on this point revealed a general consensus among the respondents,
welcoming the Commission’s initiative to set up a Health Forum. Not surprisingly, most
organisations also indicated their willingness to participate in it.
There is also a general view in the replies that a structured approach is needed. This would
be the only way to guarantee the openness and transparency in the Community’s approach
to the Forum. However, there have to be different solutions adapted to the needs of different
actors. Some organisations, for example, may be more interested in exchanging information,
others would like to make an input into policy development. Some bodies may want to
influence only a single issue, while others have a broad agenda. Some may be active at
European level, while yet others are national or regional organisations.
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The Health Forum should cover issues which are relevant to the Community’s broad health
agenda, with work in public health at its core (see topics for discussion below).
A number of respondents raised the issue of whether the European Health Forum
members will be involved in the implementation and follow-up of initiatives. There is
plea to give the European Health Forum a possibility to make an input early in the
cycle, to avoid the possibility that proposals would be submitted to the Forum as
accompli‘, allowing only minor fine-tuning.
or its
also a
policy
‘a fait
The Commission welcomes the broad support it has received on its proposal to create a
European Health Forum. It regards the Forum as an important instrument which can increase
transparency and openness, help inform partners about health policy at Community level and
give them a key input into the development of new initiatives. In doing so, the Commission
is committed to maximising the impact and effectiveness of the Forum. It will therefore aim
to ensure that the Forum is fully involved at an early stage of the policy process. It also
intends to report back to the Forum about the follow-up given to its positions and will seek
to give it an opportunity to revisit issues as appropriate.
3. Organisation of the European Health Forum
In its consultation document, the Commission proposed that there should be a three-tier
structure for the Health Forum, i.e.
•
•
•
First, a Health Policy Forum which would have a defined membership by invitation.
It would discuss key policy areas in a structured way and would, together with the
Commission services, be in charge of the preparation of the Open Forum;
Second, the Open Forum which would focus on one or two main topics for
discussion and would be all interested parties could attend;
Third, a Virtual Forum which would use information technology to enable the
exchange of information and to foster discussions among the public health
community in the widest sense.
The proposal of a three-tiered structure was generally accepted by respondents. Some
doubts were raised, however, concerning the bureaucracy which could potentially be involved
and the resulting strain on participating organisations. Respondents agreed that a secretariat
was needed to act as a permanent contact point.
On the basis of the consultation, the Commission intends to pursue the three-tiered structure
set out in the discussion document. It will make every effort to ensure that the process is
transparent and that bureaucracy is reduced to a minimum. It recognises the need to define
clearly the role of the different ‘tiers’ and intends to put this in writing for information and
discussion at the initial meetings of the Forum. The Forum should discuss ways to ensure
continuity, appropriate follow-up between meetings and effective preparation of meetings.
This may involve the creation of a small ‘steering group’. The Commission will set up a
secretariat within its services to act as a focal point and ensure the necessary organisational
work.
Health Policy Forum
Some of the respondents addressed the different ‘tiers’ separately in their contributions.
There was considerable support among the organisations which responded on this subject
for the creation of a Health Policy Forum. The general view was that it should have a limited
attendance to ensure the continuity of the process and provide structured input into health
policy development. In contrast, the Open Forum (see below) would enable a wider audience
209
to take part in the discussions concerning an individual issue, but would not be able to
provide the same degree of continuity and structured dialogue. The Policy Forum would
therefore need to play a role in preparing the Open Forum, e.g. in selecting topics for
discussions, and in securing adequate follow-up.
In the opinion of respondents, the Policy Forum would need a prepared agenda and should
hold well-structured discussions. It would formulate and adopt opinions. Contributors agreed
that a small steering committee should be formed which would support the secretariat in
preparing the meetings and organising the follow-up.
Many respondents support using working groups and other substructures to pursue
individual issues in more detail or to prepare discussions for the whole Forum. The Health
Policy Forum would decide on the creation of such groups and their mandate, and would
monitor their work.
On the basis of the consultation, the Commission intends to organise an initial meeting of
the Health Policy Forum in November this year. In light of the results of this consultation and
further discussions in the coming months, it will publish the list of organisations invited to
send representatives to the initial meeting. This will be done on the basis of the criteria set
out below (cf. part C – composition).
A draft agenda will be prepared before the meeting. At this stage, the Commission envisages
that the initial meeting will focus on certain priorities for the new public health action
programme.
Proceedings and results of the Forum will be made publicly available.
Open Health Forum
Respondents welcome the Open Health Forum as providing the possibility for a wide
audience, including organisations and bodies which would normally not take part in the
Policy Forum, to make an input into health policy development. The Open Forum is seen as a
platform for general information exchange and discussion. It should have a close link to the
Policy Forum, but would need a clear and defined role of its own. It could serve to test
proposals and positions developed in the Health Policy Forum amongst the members of the
wider public health community. Moreover, it could identify issues which warrant in-depth
consideration by the Health Policy Forum. People felt that speakers should be selected to
represent different stakeholder groups. Discussions amongst delegates were seen as the core
element of this event.
The Commission intends to discuss the exact structure and functioning of the Open Forum in
the Health Policy Forum once it is established. The intention is, however, that meetings of
the Open Forum would take place once a year. They would be organised around a specific
topic (or possibly two related topics) which would be selected in close co-operation with the
Health Policy Forum.
Virtual Forum
Respondents welcomed the Commission’s intention to make full use of information
technologies and to create a Virtual Forum as a key tool for information and communication
with the public health community and the general public at large. It could serve as a
technical support platform through which important documents of the Health Policy Forum as
well as the Open Health Forum would be made available. In addition, discussion groups on
specific topics could be created. Furthermore, the Virtual Forum could help to distribute an
on-line newsletter and the ordering of documents. Finally, restricted access areas could be
set up in order to circulate preparatory documents to members of the Health Forum and its
sub-structures.
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The Virtual Forum would be developed in connection with the Commission’s initiative on
“Interactive Policy Making” and should include links to relevant Internet sites, such as the
websites of the European Commission, national governments, members and participants of
the Health Forum, and other relevant bodies and organisations. It could thus become an
Internet portal for health issues at European level.
It should be accessible to blind and partially sighted people.
There was also a plea, however, that certain key documents and materials should also be
circulated in printed form.
As an integral part of its commitment to openness and transparency, the Commission intends
to develop the Virtual Forum as a focal point for health-related information at Community
level and as the main source of documentation and information about the activities of the
Health Forum. It should be an interactive mechanism which will enable members of the
public to make an input into the work of the Health Forum and into the policy-making
process more generally. The Commission is currently seeking the necessary expertise and
resources to launch the Virtual Forum during the course of this year and to sustain its
operation in the long term.
The Virtual Forum will not be the only communication tool used by the Commission in this
area. Key information will also be made available through other routes, and as printed
documents.
4. Composition of and Participation in the European Health Forum
Many respondents commented on the profile of participating organisations for the Open
Forum and the Health Policy Forum. Since all stakeholders and organisations interested in
European public health issues should have the possibility of attending the Open Forum there
was consensus that participation by invitation only should not be considered. Efforts should
be made, however, to ensure that it remains a credible and workable structure in spite of its
size. There was also some concern that even in the Open Forum, efforts should be made to
ensure that representation among key groups of stakeholders is balanced.
On the other hand, according to a large number of respondents, the Health Policy Forum
should be organised by invitation only. A number of contributors supported an approach
which foresees a ‘core’ of general organisations, while a number of ‘expert organisations’
would be invited to take part for the discussion of specific topics in which they hold
particular expertise or interest.
Respondents generally support limiting participation in the Health Policy Forum to
representatives of European (umbrella) organisations. While the political and practical need
to work with true EU-wide bodies is widely understood, there is, however, a feeling that this
approach should not be applied too rigidly when it prevents the involvement of leading
experts not affiliated to a particular body.
Moreover, respondents pointed to the lack of recognised European-level umbrella
organisations in some areas. There are, for example, few non-disease specific European
patients’ organisations. One should also beware of overlap in membership (e.g. the members
of an organisation representing medical specialists would also be represented by the body
bringing together the medical associations within the EU.
There was also a wish to involve local and regional authorities, since they have important
responsibilities in the health sector in a number of Member States.
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The Commission regards the composition of the European Health Forum as a key issue for
the success and the acceptance of the process.
It agrees that in principle any interested body or organisation should be able to participate
in the Open Forum. However there is a need to ensure that the Open Forum is not so large
as to be completely unworkable. Prior registration will be required to limit numbers, and it
may be necessary to introduce some restrictions for reasons of organisation and to ensure
the workability of the Forum. The Commission will reflect on this issue and on the question
of how a balanced representation between the key groups of stakeholders can be achieved.
It will also seek the views of the Health Policy Forum.
The Health Policy Forum will be by invitation only. The Commission considers that there
should be a total of about 60 participants. It intends to ask some 40 organisations and
bodies to nominate a representative to take part in the Policy Forum. These permanent
members will be reviewed by the Commission every two years. Some 20 places will be
available for organisations which are invited to take part in an individual meeting where a
specific issue is being discussed in which they have relevant expertise.
Participation will be restricted to European (umbrella) organisations and to bodies which
have members in at least half of the EU Member States. Only in exceptional cases, would the
Commission invite an organisation with a specific expertise in a given area if it were not
considered a European organisation as set out above.
The Commission intends to involve the following key groups of organisations in the Policy
Forum: (1) Non-governmental organisations in the public health field, and patients’
organisations, (2) Organisations representing health professionals and trade unions; (3)
health service providers and health insurance; (4) Industry with a particular health interest.
Representation between the groups will be properly balanced.
A number of representatives from Member States, candidate countries, the other Community
Institutions, associations representing local and regional governments and international
organisations will also be invited to attend the meetings as appropriate.
5. Issues to be discussed
Many suggestions have been received for the issues to be discussed in the meetings of the
European Health Forum. Of course many of these reflect the particular interests of the
organisations that responded.
Some examples of possible issues are:
•
•
•
•
•
•
•
the new EU health strategy, public health activities and the new public health action
programme;
the integration of health aspects into other policy areas;
health implications of enlargement
specific policy areas, such as pharmaceutical policy, technology and IT, drugs, or
research, and health;
cross-border co-operation in health and health services;
specific public health concerns, such as inequalities in health, mental health, equity
of access to treatment and to medicines, tobacco, training of health professionals,
blood safety, etc.
concerns of specific population groups (youth, the elderly, immigrants, women,
etc.).
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The Commission intends to decide on the issues to be discussed at the meetings related to
the European Health Forum in full collaboration with the organisations involved. It intends to
organise the first Health Policy Forum around issues of relevance to the new public health
programme, and the preparation of the first Open Forum.
6. Resources
Many responses underlined that the European Health Forum can operate successfully only if
adequate resources are made available for its operation.
A number of respondents emphasised the need for a secretariat within the Commission
services which should be adequately staffed. One respondent raised the issue of whether
new approaches, such as public-private co-funding, should be explored.
Many respondents, especially NGOs, emphasised the need to ensure that resource
constraints do not prevent relevant partners from taking part in the meetings. They regard
this as a key issue in creating a balanced and comprehensive structure.
Some organisations emphasised that systematic consultation requires more than organised
yearly meetings of the Health Policy and the Open Forums. They argue that the Health Policy
Forum should meet at least twice a year. If this was not feasible, at least working groups
should come together more often to prepare documents and papers for this Forum. There
was general support, however, for holding the Open Health Forum as a yearly event.
It was also suggested that meetings should be translated into a maximum of Community
languages.
The Commission fully shares the view that there must be a balanced representation between
the key groups of stakeholders. It is committed to setting up a meaningful health forum
process and will explore possibilities of making appropriate resources available. This covers
inter alia the following areas:
First, as mentioned above, a secretariat will be established within the Commission in order to
prepare the Forum meetings and working group sessions, to organise the necessary followup activities and to take charge of information work. It will also be in charge of operating the
virtual forum. If the Forum considers this to be a viable option, a steering group could
support the secretariat in these efforts.
Second, the Commission has taken note of the various points made regarding travel costs. It
will be reflecting further on this issue with a view to finding ways to assist organisations
which would otherwise have difficulty in sending representatives to meetings.
It will also consider whether interpretation in the meetings is needed.
Third, the Commission will consider whether the frequency of meetings of the Health Policy
Forum should be increased to two meetings a year. It will also study possibilities to establish
working groups as a means of securing more continuity in the Forum’s work. The Health
Policy Forum will be consulted on these points.
A number of respondents point to the existence of other international fora and congresses in
the field of health and suggest that the Health Forum meetings could be combined with
them. There have also been a number of suggestions from individual organisations that they
might organise meetings of the European Health Forum.
The Commission takes the view that the Forum must remain separate from any other
conference or meeting organised by other bodies. The Forum is being established by the
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Commission to play a role in the framework of the development and consideration of
Community policy and the exchange of information and ideas in relation to this. It should not
therefore be linked to events which are organised for other purposes. The Commission will
therefore organise the Forum meetings on its own behalf to ensure the continuity of the
process, enhance the relevance of discussions and avoid any inference that preference is
being given to any particular stakeholder in the field. As a general rule, meetings should be
held in Brussels or Luxembourg. One possibility that will be studied over time is whether
specific meetings could be held in a Presidency country, or in a candidate country.
Notwithstanding the need to preserve the independence of the Forum, it may also be
possible on occasion, to link particular meetings, for example of working groups, to
conferences or seminars which are being organised by other bodies on a relevant theme, if
this is considered appropriate.
7. General conclusions
There was general support among respondents for the Commission’s initiative to create a
European Health Forum. The exchange of information and experiences, networking amongst
the relevant actors in this field and the recognition of the role of civil society in health are
regarded as key factors for the development and implementation of the European
Community’s health policy agenda. The three-tiered structure proposed in the consultation
document has also been endorsed.
Respondents made considerable input into issues to be discussed, practical arrangements
and organisational questions.
The Commission wishes to thank respondents again for their valuable input. If the Forum is
to succeed it must reflect in its work and organisation the views and wishes of all
stakeholders. This document shows that most of the key points raised by respondents have
been taken up by the Commission. The Commission intends to develop further its plans in as
transparent a way as possible.
It intends to organise an initial meeting of the Health Policy Forum in November of this year.
This will have an important say for example in the way the first Open Forum will be set up.
This is foreseen for the first half of 2002.
In the meantime, the Commission would emphasise that the process to establish the
European Health Forum is now underway, and it is as open by a process as possible. Any
organisation or body which wishes to make further observations on the basis of this
document is therefore invited to do so.
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Summary Report of Forum V
Stipe Oreskovic
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Forum VI: Health in the Information Age
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Forum VI: Health in the Information
Age – Health Technology and Policy
Development
Ricky Richardson
The Healthcare sector has firmly embarked on an eHealth journey from which there is no
turning back. Even the most recalcitrant of supporters of medicine being delivered in the
“old hands-on way” and also those staunch defenders of the term “telemedicine”, are
changing their positions and coming behind the term “eHealth”, which embraces so many of
the healthcare reforms made possible by an IT enabled healthcare environment.
It is relevant to set out what we mean by eHealth.
The term eHealth captures four principal pillars of activity, which stand in an ocean of
opportunity, which in itself perhaps makes up the most interesting component of all.
The four pillars being:
Tele-Consultations - being one of the clinical applications including the transfer of
electronic medical records for the seeking of more specialist opinions sourced from
a distant location and also includes clinical decision making support software –
surely the medical encyclopaedia of the modern age.
eDissemination of Healthcare Professional Education – to all members of the
healthcare professional body (doctors, nurses, technicians and administrators) thus
improving skill levels and raising standards of medical practice worldwide.
Public Health Information - focused on raising the knowledge of the general public
in healthcare matters such that they take on more responsibility for keeping well.
LifeTime Health Records – involving a comprehensive recording and innovative
usage of prospectively gathered healthcare event information, which enables a sea
of invaluable information to become available for data mining. This data can be
supplemented by genomic (Human Genome Project), environmental and socio
economic information. Such data can be used for national, regional and even
global, healthcare strategy planning leading to global ePrevention, which is surely
the essential tool for human development in the future generations.
The Ocean of eHealth Opportunity – is where the multiplicity of eHealth services,
which now become possible through the creation of en eHealth enabled
environment, reside. National ePrescribing Services linking hospitals, clinics and
pharmacies, Homecare Monitoring for the more vulnerable (especially the elderly)
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members of our communities, eNursing services and linkage into the Social Services
are all powerful steps towards an improved health environment for all.
eHealth for Developing Countries
We must not forget our responsibilities to those developing nations whose access to
healthcare services – taken for granted in over developed countries - have long been denied.
It is to those fellow citizens that we can deliver the greatest prize in eHealth and we should
not forget our responsibilities because we are all members of the global community and the
future of our children and our grandchildren lies in our hands now
Providing eHealth Services in Europe : A case study
Carl Brandt
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Online information system for rare diseases in Europe
Michael Schubert
The Engelhorn Foundation Database for Rare Diseases (EFFORD)
The Engelhorn Foundation for Rare Diseases has developed an interactive database and
information system for rare disorders.
•
This database allows you to search and receive, in selected European languages
information about treatments, patient support groups, centres of excellence,
symptoms and clinical trials. Most of this information we receive from medical
centres and databases around the world or our collaborating medical teams in
Europe and the United States.
•
In a separate section, health professionals can consult a symptom based database
which will help to confirm a proposed diagnose and offer contact details for further
information and possible referral of the patient.
•
A research database will allow researchers to enter and receive patient-specific
(anonymous) information across diseases and disease groups.
•
This research database is a joined effort between our Foundation and many
universities and researchers, which contribute with their information and data about
specific topics or diseases. Our Foundation supplies the entire IT-structure with the
datasheets, input- and query models. Although the information as such which we
get from the various collaborators remains entirely under their control (with
firewalls, security features and back-ups), it is mirrored into our database which
then combines the increasing number of these separate databases from the
collaborating universities and researchers.
Special programming allows to run extensive queries across the database,
regardless the disease or disease group and regardless the platform from where the
information originates.
The queries are totally flexible and can be presented in many different ways, such
as graphs or pies: for example, you want to receive information about those
diseases which present with a specific combination of symptoms, you want to get
patients in a specific age group, receiving a certain medication, or you want to
know which disease gets treated with a specific drug, etc.
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Main features of this database:
•
•
•
•
•
highly flexible input model allowing researchers and universities to design their own
questions and answers in a very easy way;
multi-lingual;
enhanced security features with encrypted data which allows researchers and
universities to control their databases and authorize queries;
highly flexible query across all connected databases;
fast updating through innovative technology.
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NHS Direct
Bob Gann
Abstract
The presentation will describe social factors leading to the development of online health
services, and the UK policy context. There will be an update on progress on NHS Direct
Online to date including levels of use and public reaction. NHS Direct is increasingly
developing as a multi-channel service using call centres, the Internet, digital TV, touch screen
kiosks and print channels to reach as wide a user base as possible. New features will be
introduced at 20 November 2001 relaunch.
Petra Wilson
An Update report on the targets of the Health Online Chapter of the eEurope Initiative - An
Information Society for All prepared
The European Council meeting Lisbon on 23/24 March 2000 set the ambitious objective for
Europe to become the most competitive and dynamic economy in the world. In order to
attain this, the Heads of State and Government invited the Council and the Commission to
draw up an Action Plan for eEurope which would bring Europe on-line and exploit its strong
position in the new global digital economy. Coming together again in Feira on 19/20 June
2000 the European Council endorsed the eEurope – An information Society for All Action
Plan40, and charged the Commission to report on its progress in November of the same year.
The Action Plan adopted set out a series of targets which are clustered into three main
objectives: a cheaper, faster, secure internet; investment in people and skills; and
stimulation of the use of the internet. Within the three broad objectives a total of eleven
target areas are described as follows:
1. A cheaper, faster, secure Internet
a) Cheaper and faster Internet access
b) Faster Internet for researchers and students
c) Secure networks and smart cards
2. Investing in people and skills
a) European youth into the digital age
40
http://europa.eu.int/comm/information_society/eeurope/documentation
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b) Working in the knowledge-based economy
c) Participation for all in the knowledge-based economy
3. Stimulate the use of the Internet
a) Accelerating e-commerce
b) Government online: electronic access to public services
c) Health online
d) European digital content for global networks
e) Intelligent transport systems
Health Online
The Health Online action underlines the strategic importance of full exploitation of new
information technologies in the public administration of health, for the benefit of the citizen
as consumer of both health care services and health information. The Member State
administration is of course the key actor in achieving the objectives set out in the Health
Online action, for it is at this level that the key decisions on implementation of the
information technology infrastructure in health car provision must be made. However, a
European dimension to the challenge exists in the identification and dissemination of best
practices and the joint development of relevant benchmarking criteria for eHealth.
The Health Online action recognises that the first step towards exploitation of the power of
information technologies in the health sector is the implementation of an infrastructure which
will provide user friendly, validated and interoperable systems for medical care, disease
prevention, and health education through networks which connect citizens, practitioners and
authorities on-line.
In order to assist Member States in reaching the stated target of ensuring that primary and
secondary care providers have the necessary health informatics infrastructure in place,
Health Online action sets out four action areas:
Best practices in eHealth will be identified and disseminated, in order to assist
purchasing departments in decision–making.
A set of quality criteria for health web sites will be developed to boost consumer
confidence in use of such sites and foster best practice in the development of sites.
A series of data networks will be established which will facile the sharing of
technology,
application and product assessment in order to help informed
purchasing and European level quality assurance.
A publication on legal aspects of ehealth will be drafted which will clarify the
existing legislation impacting on eHealth in order to remove some of the
uncertainties and fears expressed by the health telematics related industry about
responsibility and data protection, the legality of providing on-line medical
opinions, as well as on-line pharmaceutical information and product supply.
It is clear that the targets of the Health Online action, as well as the targets set out in the
other ten action areas of the Action Plan, herald a great deal of work at both Member State
and European level. However, in endorsing the Action Plan the Heads of State have shown
that the political will to undertake that work exists, and thus we will now begin addressing
the challenge of eEurope, so that by the end of 2002 eHealth is a reality for every
European citizen.
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The Current Update report focuses on Quality Criteria for Health Related Websites.
A set of quality criteria for health web sites
The objective of this action was not to develop a code to be enforced by law or even selfaccreditation, but rather to develop a basic set of principles according to which Member
States could guide national or regional initiatives – the objective is therefore to set only the
essential outline of good practice, not a strict code of good conduct.
The objectives of the action may be summarised as follows:
•
To develop guidelines on quality criteria for health related websites which may be
used to guide Member States in possible implementation of quality assurance
measures for the health related Internet.
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The guidelines should address issues of both supplier and user education: one
document that simultaneously tells suppliers how to comply with key quality criteria
and educates users as to what they ought to expect from a good health website.
•
The guidelines should be made applicable to both passive information giving sites
as well as sites that allow for transactions between service or information providers
and users (i.e. information, products and services).
•
The guidelines should encourage compliance with other current guidelines, EU
directives and technical standards relevant to this area.
In order to achieve these objectives a workshop was held on 6-7 June 2001 in Bruxelles of
experts and Member State representatives to begin working on developing basic guidelines
for Quality Criteria. As a result the following basic criteria have been elaborated and are
open for further discussion until October 2001. The basic principles are set out below, full
details including a report of the workshop, and notes and definition of terms are available on
the eHealth Website at:
http://europa.eu.int/information_society/eeurope/ehealth/index_en.htm
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DRAFT GUIDELINES ON QUALITY CRITERIA FOR HEALTH WEBSITES
Transparency and Honesty
Transparency of provider of site - name, physical address and electronic address of
the person or organisation responsible for the site.
Transparency of purpose and objective of the site (including any commercial
purposes).
Target audience clearly defined (further detail on purpose, multiple audience could
be defined at different levels).
Transparency of sources of funding for site (grants, sponsors, advertisers, nonprofit, voluntary assistance).
Authority
Clear statement of sources for all information provided and date of publication of
source.
Name and credentials of all human/institutional providers of information put up on
the site, including dates at which credentials were received.
Privacy
Privacy, security and confidentiality policy and systems to be clearly defined,
including required opt-in for the storage of any personal data.
Currency
Clear and regular updating of the site, with up-date date clearly displayed for each
page and/or item as relevant
Accountability
Accountability - user feedback, and appropriate oversight responsibility (such as a
key quality compliance officer for each site).
Responsible partnering - all efforts should be made to ensure that partnering or
linking to other websites is undertaken only with trustworthy individuals and
organisations who themselves comply with relevant codes of good practice.
Editorial policy - clear statement describing what procedure was used for selection
of content
Accessibility
Accessibility - attention to guidelines on physical accessibility as well as general
findability, searchability, readability, usability, etc.
Presentation
slides
are
available
for
download
at
the
EHFG
web-site
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Quality of health information on the Internet - Moderated Panel
Discussion: Statements of professional interest
Albert van der Zeijden
Statement not available.
Charlotte de Roo
Health is no longer just the concern of professionals. The patient has developed a far more
active role in his or her treatment than ever before. Most patients now want to completely
understand the proposed treatment before accepting it. Freedom of choice is only effective
if we possess all the information we need in order to choose between the range of
treatments on offer. And this is where the added value of the internet comes in for a lot of
people.
The internet has already given many people an opportunity to find information on their
specific illness, where they before only had the doctor and maybe the family from whom to
learn about its characteristics. There is therefore no doubt that the internet can be an
important tool for health information.
Clearly there is also a great interest among consumers about health issues and consumers
are willing to spend time and effort to find information on the internet to acquire knowledge.
However do they find what they are looking for? Is the information they find correct or
whether is it pure nonsense. These questions highlight the debate on the internet as an
information tool.
There are many questions and concerns over this new market place for health advise and
medicine. But many of our organisations have found that for the time being consumers who
are buying drugs or ask for health advice over the internet - in most cases they will be given
poor advice, biased advice or limited advice, and occasionally they will even be given
dangerous advice. Therefore a main part of consumer demand on health information on the
internet must be delivery of basic good quality care, safe advice and safe products.
However the internet has potential and we must not forget that the development of this new
market place dynamic has already begun. The real world is far ahead of this policy
discussion here today. This is due also to the fact that consumers want to find their own
information and that they want to make their own choices.
Michèle Thonnet
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Petra Wilson
Michèle Thonnet
Abstract and Speech not available.
Otmar Kloiber
Abstract and Speech not available.
Summary Report of Forum VI
Rolf Engelbrecht
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Plenary Session III
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Plenary Session III
Marc Danzon
Reinhart Waneck
As it concerns a very complex matter, this question can be answered either very briefly and
quite simply, or in a rather convoluted way. In my following comment I am attempting to find
a compromise between the two aforementioned possibilities.
First a brief answer:
Europe needs a lot of health! So far it has done very little and is, most of all, rather
unprepared for future challenges.
Now let me enter into the more complex part:
What is health? The WHO defines health as a condition of physical, psychological and
sociological well being. At the same time we say “Life’s most precious gift is good health!”
Therefore our first goal is to preserve health, and the second to restore it. All serious
opinion- polls conducted within the EU suggest that its citizens see health, internal safety
and education by far as the most important precondition for a safeguarded life and hence
range top of the list.
In the health-sector, Austria has in the last years, well, in the past decades really, moved far
too much, meaning that all of us involved in the health-sector have been unable to really
align- within existing performance structures- the medical progress which has been achieved
in the meantime to the greater good of man.
It is therefore our main task to restore the balance between financial backing and the
required medical performance. Besides, there is the other fact that we cannot really predict,
where medical progress is going to lead us.
It is an unwritten law that a society with a high degree of performance and development, as
is the case in Austria, cannot only be asking for access-guarantees to further medical
progress, but also has to be prepared to invest into it. This could be achieved either through
joint contributions, or cost – sharing.
For we all have to be fully aware that the practiced smoke-screen strategy which conveyed
the impression that medical care can be available for nothing, is no longer viable
economically.
These rather broadly spoken words are, with a few alterations and considerations applicable
to most countries, as well as to EU-countries.
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The basic ethical question – just how valuable health is to a society has to be put into
perspective, when faced with data from Western states: Within EU – countries the amount of
health expenditure in relation to the GDP varies below 7% in GB and Ireland, to 10% in
Germany and France. Relatively low health expenditure in GB, hardly more for example than
in Hungary, and even lower than in the Czech Republic, have already led in GB to the
political objective of increasing expenditure to Western European average, which according to
the year moves between 8% and 9%, and henceforth put an end to recurring overlong
waiting lists.
On the other hand there is also an upper limit beyond which no further benefit in health-care
can be gained for the population, especially concerning the amount of public health
expenditure. With 8,3% – split into 6% public funding and 2,3% out of private means (the
latter figure showing a steady increase) – Austria is ranking mid-field in Europe. We might
occasionally have the odd bottlenecks in terms of waiting – times, but certainly not in cases
of emergency. But on the other hand, due to stagnation over the years, our present system
has become inflexible, so that necessary adjustments, usually with suggestions regarding
cost – calculation, are not feasible in practical terms.
The ethical question in connection with financing the health care system is also not primarily
how much is being invested, but rather, if all groups of the population have access to each
and individual care, which of course should also be highly comprehensive, as well as of
utmost quality.
In principle we are therefore determining reforms in the health care system on the structural
level. To my knowledge no initiatives are being taken in any countries where social welfare
has a high standard, which are aiming from the start to restrict care, introduce rationing or
plan expenditure-cuts. On the contrary, structural changes and adjustments, as well as
efficiency and better performance of efficiency will have to stem the increase in expenditure.
In highly developed health care systems there will always be a potential for that.
What I want to state is that regardless in which area of the health care system they are
implemented, they must never have any detrimental effects on the patients.
Now lets move to Central-and Eastern Europe, where new challenges are waiting. With the
accession of the applicant countries the present member states of the EU will almost double,
which will have far-reaching consequences not only for medical systems from candidate
states, but also for medical doctors in the present member states. European health
organisations will have to face the fact that the economic situation as well as the health
status of the population in the candidate countries is considerably worse than in the EU.
The share of health care expenditure in the GDP will have to be increased in most of the
candidate countries in order to provide the population with health care systems which
comply with present EU-standards. Medical studies and postgraduate training have to
guarantee quality which meets the requirements of EU standards.
The unfavourable economic situation of medical doctors, together with a low social status in
many candidate countries might cause a migration problem to the prejudice of the EU
member states as well as of the applicant countries.
General and particular solutions on a broad consent have to be found with regard to the
economic and structural conditions to be established in order to provide high quality of
medical care in all of Europe.
I would like to stress the point that Austria will immediately be confronted with the applicant
countries, and not as other EU-countries, after their entry. These countries are already our
neighbours and, regardless of Eastern expansion they have to be accepted as full partners.
Plenary Session III
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It is common knowledge that diseases do not know of national borders. We have had to
accept this to an ever higher degree in the past years. I want to specifically address
contagious diseases, such as the advance of tuberculosis and the spreading of AIDS and HIVinfections respectively. All this is being paired with an overwhelming drug problem. Many
states have just started to set-up a comprehensive, up-to-date, basic health care system. We
will be well advised to massively intensify cooperation, which will eventually lead to crossborder solutions.
For each Million of Euro, which the EU will invest in improving the medical structures in
these countries it can eventually save Billions in its own domain. Should this not be
possible, the costs for these untackled cross-border problems will hit us a hundredfold.
Therefore I, as well as the person responsible for the Health Department cannot quite
comprehend that so far EU-policy has had no room for it’s own domain to maintain and
expand health in Europe within the public welfare system. On the contrary, health is nearly
completely left in the hands of the WHO and some idealistic governing bodies. Within the
E.U- community-law these aforementioned organizations try to level-out questions concerning
competence or non-competence.
Fainthearted attempts can be perceived. However, it took until 1993 (Maastricht) until in
article 129 a skeletal agreement was implemented concerning Community’s activities within
the public health area. Up till then there was hardly any more than recommendations for
coordination efforts and no attempts whatsoever for a coordinated, joint health-policy. This
last mentioned article has also to be seen as having no binding coordination efforts in the
health care system. Promotional programmes were set-up with the aim to develop addenda
to autonomous prevention strategies and best practice medicine – models for certain serious
diseases, such as AIDS, cancer and drug addiction.
Due to non-existing specifications legally binding measures such as guidelines for quality and
safety of blood and blood products were not possible for a long time.
Quite often therefore the Council had to restrict itself to the instrument of recommendation
only.
The Amsterdam treaty has appended to in the European charter of 1986 and the Maastricht
treaty established ameliorations of the EU – Founding Treaty.
But then again this is not a general concept. It is rather a confirmation that the population’s
health protection within the Community should not be a side-effect of all the other
Community’s activities , but that health policy measures have to be positioned equally if not
pre-eminently within the power play of other policies. Only in some areas does the treaty
carry a certain extension of Community competence. That is the authority of issuing legally
binding measures regarding the
veterinary sector and plant protection, as well as
determining high quality and safety standards for organs, substances of human origin, blood
and blood-derivatives. It has explicitly been established in the so called integration clauses
of article 152 of the European Founding Treaty.
This article does not hold any initiatives for coordinating law-and administration regulations,
but only contains promotional measures for the next six years.
Fortunately, considerable progress was made at the European Council meeting in
Gothenburg, where effective development strategies which also included the health sector
were being addressed. This made it possible that after quite some time a substantial amount
of money that is 300 million Euro, was set aside in the budget for the purpose of
establishing a coordinated health-report-system. Based on this data, acquired under
comparable and methodically coordinated conditions, it will be possible to show EU – wide
deficiencies in the health sector, and thus enable counter measures.
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Before I come to the end, let me stress one point which in all our deliberations has not yet
led to appropriate reflections. For me however, it poses a grave, unsolved and neglected
problem which, eventually will present itself as a sociological problem. I am talking about
our children’s situation and their future.
We live in a society where in an ever increasing way children are being suppressed from our
minds , a society giving too much thought to its own problems, meaning problems of the
adult population. This society disregards children and even neglects them to an increasing
extent.
It is well known that today more than 3/4 of diseases and fatalities predominantly concern
the group of chronic, degenerative ”life-style” diseases. For example, cardiovascular diseases
count for 54% of fatalities, or carcinoma which are responsible for 24%, of fatalities. In
addition we have diseases relating to the locomotor system and the supporting apparatus,
as well as metabolic diseases, diseases of the respiratory system and with increasing
significance psycho-manifested afflictions, including drug-related diseases. In this context we
can also speak of stress – related diseases.
These diseases affect adults and children - the latter being actually more affected than
previously thought. More and more children show early signs of mental and physical health
defects. Usually children are quite able-bodied to react or even counter-react when faced
with adverse or taxing situations, as they do for example when they experience starvation
and at least to some extent when they have to cope with physical suffering. But to an always
lesser extent can children cope with the psychosocial starvation they are being exposed to
in our times.
This vague and not really discernable flaw in our overall feeling of mental and physical wellbeing has increased over the years and affects adults and children alike. Alas, in this context
children represent a forgotten group. According to a Scandinavian survey nearly a half of all
15-year old girls suffer from recurring headaches, which means the number has doubled
within 10 years. One fifth of children meet the criteria of a so called anxiety-stress-syndrome,
each 10th child is suffering due to neglect, lack of contact and physical guidance, or simply
due to ignorance. 1% is being sexually exploited and abused.
After school, a half of the children are deprived of suitable leisure time activities which
consider their requirements and also offer educational value. A quarter of children live in
families who find it difficult to pay their bills and a fifth live in single-parent families. Each
3rd child in the first years of Secondary School attends classes with more than 25 pupils.
This listing could be continued and could be applied to a high degree to many EU-countries.
After all, big parts of the population in our society are being coined by restrictions and
disinterest towards our children. Less and less adults want to have children. The share of
children und juveniles below the age of 17 related to the total population is down to 20% in
many EU-countries, which means a significant drop compared to the situation 10 years ago.
One gets the impression that children are being voted out.
Increasingly today’s children have to grow up in a conflicting environment, where the parents
are either absent or disinterested - thus resulting in a lack of guidance and support.
Therefore more and more children show distinct signs of mental, physical and health related
weaknesses.
A society unable to look after its children in an appropriate way is sick and decrepit and
does not merit to be called civilized. Great, discerning and prudent minds always stress the
fact that weaker vessels have to be supported. Therefore we have to dare to ask this rather
unpleasant question: How high a price do our children have to pay for our self-fulfilment and
the liberties we are taking for granted just because we are adults.
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Concluding and so to speak as a postulate for a medicine of the 3rd Millennium I want to
stress: ”Future does not just happen, it is being prepared in the present”. Therefore longterm structural changes in health care either develop coincidentally or, and this procedure is
my aim, are envisaged, innovative answers to challenges of the future and thereby for the
health of the European population.
Inserat DaMe
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Health across other policies
David BYRNE
Dr. Leiner, Ministers, Ladies and Gentlemen,
I am delighted to have been invited back to Bad Gastein, to address this notable forum on
health issues, in this unusually healthy conference setting. As in previous years, I understand
that your deliberations have again provided decision-makers and advocates alike, with a
breath of fresh mountain air on these complex public policy issues. And I would like to thank
Dr. Leiner, and his team for facilitating this impressive meeting of minds. I am pleased and
indeed reassured to note that all this has been achieved in close cooperation with the
Austrian State Secretary for Health Mr. Waneck, and with our close friends at the WHO under
Dr. Marc Danzon's ever watchful eye.
I don’t know whether Dr. Leiner possesses a crystal-ball, or whether you have a unique
insight into the mind of the European Court of Justice. Because your choice of Health Across
other Policies as our theme is extremely timely. By the way, if either case is true, I would
welcome any future tips! Because within a matter of months, the theme of "Integrating
Health across Policies" has moved centre-stage for European policymakers. The sequence of
events is familiar to you all. Whether one looks back on the Göteborg Summit, the Global
Access to Drugs debate, or the more recent European Court of Justice Rulings - a year has
been a very long time in the politics of health. And without even venturing to include the
Charter of Fundamental Rights - I think it is fair to say that we are entering uncharted
territory. At this point, we find ourselves on the threshold of a new approach to health
issues in the life of our Community. And it is now up to our collective political imaginations
to map out the future.
In addressing the theme of Health in other policies, I would like to look at this issue in three
key respects. First, the importance of Health issues as part of the debate about Governance.
Secondly, how health can become a driver of community policies - rather than a sideshow.
And finally, some preliminary reflections about the future role of Health issues in the
unfolding evolution of European integration.
1. Health and Governance
To understand the importance of health in other policies, we need to see the broader
political horizon which it evokes. Indeed, we need to reflect on the important link between
effective health policy and good governance in the minds of our citizens. Placing health at
the centre of other policies is a significant political challenge. And how we respond to this
challenge in the years to come, will affect not only the machinery of health policy, but the
health of our political machinery. This will affect decision-makers at European, national,
regional and local levels. And it will directly impact upon our traditions of social cohesion
and effective government in the coming years.
In looking at the issue of health in other policies, we need to accept right from the outset,
that the political stakes are high. We must recognise, that our success or failure in
responding to the health policy concerns of our citizens in whichever sector they may arise,
will have a wider impact on the health of our systems of governance.
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Increasingly, they will judge us and the value of our systems of governance, by our ability to
place their health and wellbeing at the centre of other policies. And not as some secondary
afterthought. It is a challenge we cannot afford to fail. But we will only manage to meet this
challenge by working closely together with renewed imagination and without preconceptions.
And we need to work together quickly. Because events are driving the process. And as you
all know, events are what politicians were invented to manage - not the other way round!
At the European level, by events, I would go beyond the familiar toll of health-scares and
emerging threats to health to include a wider picture of dynamic activism. By this I mean not
only the political and economic activism of summits, campaigns and protests, but the
increasingly important judicial activism of the Courts. I will come back to the recent ECJ
judgements regarding the impact of the Single Market acquis on crossborder healthcare later
in my speech. But I would like to make a general point about who makes and who should be
making health policy.
As a former Attorney General, I have a healthy respect for the ability of the Courts to make
progressive judgements. Without a doubt the Courts have played a definitive role in
European integration. But I believe that any future discussion of health policy in a European
context must address the reasons why the Courts are required to be so active in so sensitive
an area of policy? Because it is becoming increasingly clear that if the Community and the
Member States do not clarify, coordinate and - where necessary - complete the acquis
together, then the Courts are in danger of doing so on their behalf. In this light I believe that
we urgently need to reflect upon how such policy change should be managed in future. And
who will set the rules of the game? The Member States in partnership with the Community,
or the Courts?
2. Health in Community policies
In turning to address the specific issue of Health in other Community policies, I am aware
that as the first designated European Commissioner for Public Health I carry a particular
responsibility. First and foremost the responsibility to reassure our citizens that their health
comes first when decisions are made at European level. This means ensuring that the
opportunity offered by the Amsterdam Treaty to raise the level of our citizens health - is
seized and its potential fulfilled quickly. This also means working within the European
Institutions and with our stakeholders to turn the innovations of article 152 into concrete
proposals. And in doing so to build mutual confidence in our capacity to work together for
the common good in full respect for one another's specific roles.
When you look at the gathering flow of Community proposals from tobacco, and blood
safety, to emerging antimicrobial resistance policies, I believe that we are beginning to
answer the call. This is due in large part to the efforts of Fernand Sauer and his small but
dedicated team in Luxembourg. Good work on the first generation of health programmes has
laid a sound foundation for the future. For example, I believe that the early work done on
cancer, will prove to have been decisive in the longer term.
And I have no doubt that the organic development of the communicable disease network,
will prove to be extremely important in the future, particularly with an imminent Enlargement.
Because the completion of an effective early warning system with adequate coverage and
quality data for surveillance and monitoring, will prove vital to ensuring co-ordinated
responses. And history teaches us that such responses may one day arise. Finding the right
response to pandemics is a public policy priority - which is why I am promoting a conference
to look at these needs in Brussels in November. Our success in raising our collective game
on Communicable Diseases, will have an important impact on other policies in the long term.
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Of course, within our public health competence our ability to meet today's challenge would
be significantly enhanced by the availability of our proposed Euro 300m Health Action
Programme. Because given adequate resources and sufficient scope, our Health Action
Programme will provide the kind and quality of information which is needed to make
informed future policy choices.
It will facilitate effective health policy by providing "joined-up" analysis at the hub, for
decision-makers and citizens alike across Europe. By providing intelligent links between
widely scattered sources, it will facilitate an accelerated learning process for all concerned.
So the sooner we all manage to get it up and running - the better for all concerned.
In our Community Health Strategy, the new Health Action Programme stands alongside
"Health in other Policies" as the cornerstones of a new framework. This framework is being
put in place to ensure that fulfilling our health potential can become a driver of European
policies. And not as it sometimes appears – an accidental passenger! But to develop this
mainstreaming reflex within our institutions, we need to start with some practical first steps.
Steps such as improving co-ordination, focussing extremely limited resources on priorities,
providing evidence-based scientific policy input, and developing badly needed new
institutional arrangements and expertise. I am pleased that progress has already been made
in developing interservice coordination on health issues within the Commission backed by a
network of correspondents, and in elaborating the necessary health impact tools for new
policy proposals.
In your hectic programme for Gastein I am happy to be able to state that progress is evident
in each of the areas under discussion in your parallel sessions. You have looked at how to
influence sectors. With our limited resources we have decided to focus on key proposals in
areas such as pharmaceuticals, food, the environment, research and social policy. Let me use
our role in reviewing pharmaceuticals policy as a case in point.
Many of you will be aware that I have been actively involved in working with Erkki Likanen
to achieve a balanced approach to the Community's review of pharmaceutical policy. We
presented our ideas in July. Additionally in the high-level G10 Medicine group which we are
chairing, we are looking with stakeholders at the future of Innovation and the Provision of
Medicines. We want an informed debate on the choices ahead, with the widest possible
consultation along the way. The Consultation Paper should be on the G10 website next week.
My main concern is to put the patient first. Given safety issues I want to make sure that we
retain a system that offers maximum health protection, while at the same time ensuring that
patients have access to new drugs without undue delay. In addition, we need to keep a clear
eye fixed on the concerns of healthcare purchasers and providers regarding the rising drugs
bill. We have got to find cost-effective solutions that will also stimulate competition, improve
patient care and motivate innovation.
It is in all our interests that we empower patients through appropriate information and
compassionate access. And that we protect them through effective pharmacovigilance
systems. Systemic changes affecting patients are taking place in health-related policy areas
like pharmaceuticals and the Single Market. Therefore, it may well be the moment to look at
how an independent European advocacy platform for Patient's can be developed.
You have also extensively discussed information technology and health. Given technology's
increasing role, it is important to ensure that decisions to introduce particular IT application
in health systems are driven by health reasons rather than technophilia. Clearly, the quality
and reliability of information on the internet for our patients is also vital for an integrated
approach to technology in health. I look forward to seeing the e-Health findings on the
quality assurance of websites in the coming months.
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Elsewhere on issues relating to Food and Agriculture, I need not elaborate on what is the
widest-ranging raft of legislative and institutional measures on Food Safety in the history of
the Community. But alongside the big ticket items like the new Food Authority, my new
proposals on Zoonoses will make a significant impact on the control of salmonellosis and
campylobacter. In other aspects of agriculture and food policy, I have no doubt that our
emerging initiatives on Nutrition will provide an essential point of reference. Particularly as
we begin to examine how best to tackle the current links between diet and health outcomes,
ranging from cardiovascular disease and cancer, to diabetes and obesity.
At the international level health issues have played a major role in setting the Community
agenda over the last year. A fact no doubt confirmed in your discussions on the globalisation
of health. Having formalised our strategic partnership with the World Health Organisation, we
are busily working together to set out a map for future co-operation on a range of shared
priorities from Global Tobacco Control, to tackling Communicable Diseases and raising the
profile of Mental Health. And I think Marc Danzon will agree that we will have much to do
together in the European region, particularly as Enlargement beckons. We have worked
closely with the WHO and our DG Development colleagues on "access to drugs" and the
Global Health Fund. We are now working to ensure that our Development policy and partners
benefit from a more consistent approach to tobacco policy. And just to prove that our
approach is yielding benefits, we are currently working with our colleagues in DG Agriculture
to begin the difficult process of phasing out tobacco subsidies!
So on balance, I would suggest that whilst there is a long way to go, a promising start has
been made to mainstreaming health in other policies. Which is all but miraculous - given the
available resources.
3. Future orientations
Turning to the future, in my mind, there is no doubt that health-related issues are moving to
the very centre of the European policy agenda. This process which was originally provoked
by the BSE crisis and which has steadily evolved, is entering a period of significant
transition. Questions continue to arise as to how health is to be understood in the light of
existing Community competences in other policy areas - from the Internal Market to
Competition and Enterprise policy. And the pressure to clarify where European health-related
policies are heading, emanates from a formidable coalition of policymakers, patients,
providers and indeed judges. But in some cases, the European Union is finding novel ways
to respond.
One clear indication of how the European institutions intend to manage this process has
been signalled by the Göteborg European Council. Because Göteborg endorsed an ambitious
new policy agenda launched by the Commission called the Sustainable Development
Strategy, an agenda which deals with the interlinking themes of quality of life and good
governance.
The Sustainable Development concept identifies a shortlist of priorities affecting the future
well-being of our society. It sets in motion a process which will systematically assess the
impact of Community policies against sustainability criteria. The Strategy sets five priority
areas for action. These are - combating climate change, ensuring sustainable transport,
addressing threats to public health, managing natural resources and integrating environment
into Community policies.
On public health Sustainable Development has prioritised a number of areas for action
namely: wrapping up the Food Authority and Food Law preparations; putting in place an
appropriate chemicals policy; and setting out a clear plan to tackle antimicrobial resistance.
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In fact, I have pre-empted this by presenting a Communication setting out areas for action on
antimicrobial resistance.
But it also prioritises the creation of European capacity to monitor and control outbreaks of
infectious diseases by 2005. In doing so, the European Council has given its blessing to an
important part of the institutional jigsaw, which we all agree, needs to develop rapidly in the
coming years.
And each year as the Community makes its annual Spring stocktaking of economic and social
progress, we will assess our sustainable development too. Or in other words, how well we
are serving the needs and well-being of future generations of our citizens. In banking terms
we will not only be keeping an eye on our current account, but maintaining a watchful eye
on how our investments are shaping up to leave a decent inheritance for the future.
This managed European response to Sustainable Development, contrasts with the impact of
recent European Case law on cross-border health services on policy management. This is
ironic when one considers that against the background of an ageing society, Göteborg called
on the Commission to report by Spring 2002 on the possible extension of the "open method
of coordination" to the field of healthcare and care for the elderly!
The welcome evolution of new thinking in our capitals witnessed at Göteborg, needs to come
to terms with the unfolding revolution in case law. And this is increasingly urgent. As the
debate on "Health in Other Policies" is currently at its keenest among those who are
responsible for the management and delivery of health services at all levels in our Member
States.
Because in its formative judgements, the Court has placed health issues firmly under the
sway of a range of existing Community policies. We were warned about the likelihood of
breaches of the Internal market acquis for certain health services within the limits of the
Kohll-Dekker judgement. Now, after the Judgements on Smits/Peerbooms and VanBraeckel, it
is clear that such medical activities fall within the Internal Market's meaning of services
provision. It is also clear, that patient's freedom to normal and necessary treatments in other
Member States cannot be arbitrarily refused. And it remains to be seen how, what the Court
refers to as "undue delay", will link in to the extent of patients rights to seek treatment
elsewhere. This too is likely to be clarified by the Courts in the future. But the likely impact
of the Internal Market's four freedoms, poses the most significant challenge to date to health
policymaking in Europe.
I think it is fair to say that the sustainability of universally accessible healthcare and health
services is of primary importance to our citizens and to our Member States. In many
respects, when our citizens try to grasp what is referred to as the European Social Model it is
the availability of healthcare for all members of society which provides a practical example.
And the difficulty of meeting citizen expectations by providing a decent quality of care given
the challenge of cost containment, the role of technology and the impact of demography is
probably the most difficult problem which our Member States face today.
The Courts have recognised this by emphasising the primacy of maintaining the financial
balance of social security systems and the maintenance of hospital services. But the Courts
have responded to the growing wave of what has been called patient-power in raising the
spectre of patients needs such as access, speed of treatment and reimbursement. The
eventual impact on our social security services remains to be determined.
But in preparing a policy response, attention needs to be paid to the impact on our overall
health policy at all levels of administration and across the Community acquis. We need to
see our social security and health experts working together to identify an integrated
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approach to this complex challenge. And we need to see all actors involved whether as
providers, purchasers, policymakers or patients.
But at the Community level, finding an appropriate response will not be easy. And as part of
this reflection some thought will need to be given to whether the existing Community legal
environment across the policy range, provides sufficient checks and balances to respond to
patients, purchasers and providers alike? In all of this I believe that the Commission, and in
particular the services of Commissioner Diamantopoulou, can play a useful role in facilitating
a structured discussion on the future. And for this debate to provide durable solutions I
believe that some kind of inclusive process will be needed in which the principal actors such
as our Member States, Regions, policymakers, purchasers, patients and providers, can come
together to seek sustainable solutions.
In concluding, we should not forget that the Laeken Council will launch a far-reaching debate
about the future shape and destiny of an enlarged Europe. And whatever the ambition of the
end product, there can be no doubt that a wide and indeed exotic variety of health policy
issues, will arise at various stages of the public debate. As such, all the actors in this
process should be ready to work together to find a politically compelling and economically
sustainable conclusion. This is doubly true given the nutritionally rich diet of health-related
policies contained in the Charter of Fundamental Rights!
Despite all the legal difficulty, economic anxiety and institutional concerns, this is a moment
to turn what currently looks like a problem, into a real opportunity. An opportunity to set out
a positive political concept of health as fundamental to the fulfilment of our personal and
economic well-being - as individuals and collectively. The concept of Health as a driver of
policies. A concept of Health as both the driver of our economic prosperity, and as a source
of renewal for citizenship and governance alike.
I look forward to hearing your views on this fascinating opportunity.
Special Interest Sessions
263
Public Health Research and the Proposal for a new Framework
Programme on Research
Kevin McCarthy
ON 21 FEBRUARY, the Commission adopted proposals to be submitted to the European
Parliament and Council for the next framework programme for research and innovation. In
contrast to that of its predecessors, the context in which the European Union must today
implement its traditional research activities is fundamentally new and innovative - that of the
European Research Area (ERA), of which the framework programme is becoming the financing
arm.
This initiative, instigated by Philippe Busquin, Commissioner responsible for research, aims
to provide the Union with a genuinely common strategy – comparable to that of the single
market and currency - designed to strengthen Europe’s scientific and technological dynamism
on an increasingly global stage. The concept of the ERA was extremely well received by
Europe’s politicians who have given the Commission a very clear mandate to implement it.
The projected global budget (including Euratom activities) is Euro 17.5 billion, a 17%
increase on the previous framework programme. The framework programme consists of three
main areas of action which reflect the main thrusts of the ERA.
1. Integrating research
The framework programmes to date have been instruments for stimulating and supporting
collaboration between European researchers. Without actually disappearing, this mission
must now be adapted to deliver the new strategy of the ERA by incorporating actions that
will catalyse the integration of European research. In specific terms, this means two key
changes in the programme concept:
•
•
concentration on a limited number of priority fields of research to which activities at
the Union level can add real value (see table);
strengthening of links between the Community research effort and national and
regional research policies.
In the priority areas, the new framework programme will work mainly by supporting the
development of cooperation within networks of centres of excellence. These networks will
bring together the best research capabilities in Europe’s regions to conduct common research
programmes, enabling the emergence of ‘virtual platforms of excellence’ on a European scale.
Substantial resources might also be allocated to support integrated projects involving public
and private partners, with clearly stated scientific and technological objectives and with a
view to generating new knowledge and/or applications in the priority fields.
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In this respect - and as authorised by the European Treaties - the new framework programme
will innovate by using its powers of intervention to encourage active participation in research
programmes jointly implemented by a limited number of Member States.
2. Structuring the European Research Area
The ERA aims to correct structural weaknesses or deficiencies which could be described as
‘transverse’. The most notable of these, already widely covered by previous programmes,
concern:
•
•
the strengthening of bridges between research and innovation;
the renewal of the human potential for research and mobility of researchers. There
must be an active policy to make the ERA a more attractive area for scientific and
technological research, not just to stop the traditional deficit caused by the ‘brain
drain’, but also so that it attracts the best foreign researchers.
However, there are two specifically innovative aspects of the programme which are destined
to play a particularly important role.
•
•
Support for the development of research infrastructures. Until now the Union has
mainly tried to attract European researchers to the existing infrastructures of the
Member States. In addition to this support for the mobility of researchers, the new
framework programme initiates a policy for the coherent development of
infrastructures, in the form of integrated actions facilitating their networking and
ability to deliver scientific services at a European level.
The attention given to questions of ‘science and society’. To achieve the necessary
deepening of the Union’s democratic foundations, better relations between ‘science’
and ‘governance’ and an improvement in the scientific and technological culture of
the average European are seen as priorities by policy-makers, researchers and the
general public.
3. Strengthening the foundations of the European Research Area
The new framework programme will also aim to strengthen one of its fundamental missions,
which is to meet scientific and technological needs which arise in the implementation of
Union policies in all fields where Community responsibilities are constantly growing - such as
agriculture, fisheries, health and consumer protection, the environment, transport and the
information society. The tasks assigned to the Joint Research Centre will come under this key
programme activity.
Another important aspect is support in improving the coordination and coherence of research
activities, at national and European level. This search for better coordination, which
embodies the very spirit of the ERA, will aim to create opportunities for the mutual opening
up of national programmes and cooperation between existing European scientific and
technological frameworks.
A third element of this action plan, the flexibility of which will be guaranteed by annual
budget management, is increased anticipation of the scientific and technological needs of
European policies and the often rapid responses these require. .
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Summary Report of Workshop II: EUEnlargement: Implications for
Health Systems
Laura MacLehose
1. ‘Progress in the Health and Enlargement Process.
Mr Bernard Merkel, Principal
Administrator, Health and Consumer Protection Directorate General, European Commission
The European Commission’s staff working paper on health and enlargement, the European
Parliament’s Report on public health and consumer protection aspects of enlargement and
the Council of Ministers’ conclusions identified different health related issues with regard to
enlargement. These included issues such as health status in the candidate countries (CCs),
different public health traditions, lack of resources on health, communicable diseases and
weaknesses in quality assurance and surveillance systems.
These issues have been addressed in several ways. Regular information exchange,
international, European Community and bilateral projects and activities targeting particular
problems, as well as participation in Community networks and programmes are some of the
measures taken. Co-operation with other European/international organisations is being
developed further so as to pool resources and avoid duplication of effort in supporting the
CCs in the enlargement process.
2. ‘Health and Enlargement: Challenges and Opportunities for Health’. Professor Martin
McKee, Professor of European Health, London School of Hygiene & Tropical Medicine
In March 1998 accession negotiations were formally opened with six countries: the Czech
Republic, Estonia, Hungary, Poland, Slovenia and Cyprus. The process was widened in
February 2000 to include six additional candidates: Bulgaria, Latvia, Lithuania, Malta,
Romania and the Slovak Republic. Turkey is also a candidate country for accession to the EU
although not yet in accession negotiations. Accession of these countries to the EU will bring
benefits but also challenges for both the EU and those acceding to it.
Among the challenges for the pre-accession countries is the need to implement the
accumulated body of existing EU law, the Acquis Communautaire. Although, formally, the EU
does not have competence in health care, this being a matter reserved for governments of
member states under the principle of subsidiarity, there is a large number of provisions in
relation to free movement of goods, services, and people that do affect health care
arrangements and have implications for health. Other policies, such as parts of the Common
Agricultural Policy (CAP), can also be considered to have impacts for health status and care
in member states. These impacts will become clearer as health impact assessment of ‘nonhealth’ EU policies is carried out. Among the issues of enlargement to be addressed are: the
extent to which regulatory systems of acceding countries meet EU standards, how
comparable EU health priorities are with those of the accession countries, and the extent to
which existing national legislation of accession countries may conflict with EU law, which will
have primacy.
This new round of accession to the EU is simply one further step in a process of enlargement
that began as long ago as 1973 when Denmark, Ireland and the United Kingdom joined the
original six members. As recently as 1995, Austria, Sweden and Finland joined. Consequently
there is now a considerable body of experience that can be drawn upon by those countries
that are currently negotiating accession. It is, however, essential to recognise that the EU has
evolved in many ways since it was established in the 1950s, of which some have a direct or
indirect effect on health. In addition, the relatively wide gap between the wealth and health
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of the EU and pre-accession countries compared to the countries most recently joining the EU
in 1995 also has implications for health systems in both the EU and the pre-accession
countries.
While the candidate countries each differ with respect to health and health care systems,
taken overall the health status of the candidate countries’ population differs negatively on
most key indicators in comparison with that of the EU average. Today, a man living in central
and eastern Europe (CEE) is twice as likely to die before reaching 65 than is a man in the
European Union. Similarly, a woman living in C&E Europe is 70% more likely to die before
reaching 65 than is a woman in the EU.
What are the components of such differences in health? Three leading factors form the basis
for this pattern: heart disease, cancer and injuries. For both heart disease and injuries, the
age-specific death rate in CEE is about double that of the EU. Cancer mortality is about a
quarter higher than the EU rate. Differences between the east and west of Europe were
apparent in the 1980s. However, progress between east and west has been markedly
different since 1990 and provides important clues as to why such a large health gap should
exist. In 1980 the EU average, age-standardised, death rate for ischaemic heart disease was
around 80 per 100,000 males under 65 years. In Romania it was around 55. However, while
the countries of the EU showed steady progress dropping this to below 50 by 1997, in
Romania a reverse of this trend was found and in 1997 there were over 80 deaths per
100,000. A similar trend is found in some other CEE. Causes of death that are more common
in eastern Europe, such as heart disease, stomach cancer and childhood injuries, are also
more common among the poor in the west.
The ‘usual suspects’, diet and smoking, are two of the key causes explaining the differences
between east and west. Alcohol, an ‘unusual suspect’, is also, however, a major factor. High
levels of cirrhosis are found in southern countries (Hungary, Slovenia and Romania) and the
health effects of binge drinking have been shown to be especially serious. Although
governments have undertaken a range of measures to respond to the challenges, the efforts
of implementing health care reform in many countries have preoccupied many
administrations and some countries have failed to develop broad health policies to address
these and other underlying health causes. Some health improvements can be attributed to
government actions, while others are the by-products of improvements such as diet (due to
improvements in retailing) and the emergence of civil society organisations and self-help
groups. In terms of healthcare, some countries have made substantial improvements in
outcomes for cancer survival, low birth-weight baby care and control of hypertension.
However, at the same time, there are growing inequalities in health in the region.
Some of the concerns in terms of health related to enlargement include: the increased
movement of people and related implications for communicable disease control, health care
provision, drug trafficking and increased tobacco smuggling. Other issues that need further
review include the movement of health professionals and enlargement (are there risks of
‘brain-drain’?, is there a need to strengthen regulation of health professionals?), patient
movement and the regulation and manufacture of pharmaceuticals.
The European
Observatory has begun a study to look at some of these issues. The study, ‘Health and
Accession: Managing the Transition’, will aim to develop generalisable policy lessons using
surveys, case-studies and literature reviews. Anybody wishing to know more about the study
or with suggestions for contributions should contact Laura MacLehose at the European
Observatory on Health Care Systems at the London School of Hygiene and Tropical Medicine
on: [email protected]
3. Quality policy in the health care systems of the EU accession countries. Dr Ursula
Fronaschutz, Head of Department VII/B/8, Health Economics and Quality Management,
267
Austrian Federal Ministry of Social Security and Generations. Dr Ursula Pueringer, Consultant
on Health Reform and System Comparison to the Austrian Federal Ministry of Social Security
and Generations
This presentation intends to give a short overview about the status quo of health care
quality issues in the now 12 EU candidate countries. All quality efforts in the 12 EU
candidate countries have to be seen in the light of the recent political and economic
developments in the region. Except in Cyprus and Malta, where the health care system is
financed by general taxation, the health care systems have undergone considerable
organisational changes over the last decade. The previously dominant Russian Semashko
Model of health service revision (state centralised planning, controlling, financing and
provision of health care) with high bed-capacities and predominantly specialist physicians
has proved to be inefficient, expensive and little patient-oriented. Comprehensive health
care reforms have taken place, competencies have been shifted, new financing systems
implemented and health care provision has been completely restructured. Following
international trends, the state is now responsible for legislation, planning and controlling of
health care provision, registration of drugs and new medical technologies, licensing
physicians and setting medical standards. Health care insurance has been introduced in all
countries. The emphasis lies on primary health care with the introduction of general
practitioners as gatekeepers. The most prominent problems remaining in the candidate
countries in CEE are an oversupply of physicians, mainly specialists, large hospital capacities,
too little long-term and nursing care structures and the ongoing struggle with costcontainment in health care.
The development of quality policy and the introduction of quality assurance measures have
only recently become a topic on the health care agenda and are not surprisingly very much
oriented towards structural quality issues.
The main reasons for implementing quality assurance strategies are usually unacceptable
variations in performance, practice and outcome; ineffective or inefficient health care
technologies and/or delivery; customer dissatisfaction; unequal access to health care
services; waiting lists; high costs to society and the commitment to cost containment.
In all the countries the importance of a national health care quality policy is well recognised,
various laws and regulations are in place and often defined responsibilities exist at the
national level such as quality task forces, expert committees or even a national co-ordinator
for quality in certain medical fields. However, these functions are not always vested with the
power and resources to sufficiently co-ordinate ongoing quality activities.
The main quality approaches used are: registration and licensing of physicians and health
care institutions, certification, accreditation, registration of drugs, medical devices and blood
products followed by the development of practice standards / guideline and audit / peer
reviews. Some countries conduct regular patients satisfaction studies. Latvia has already
formulated a quality policy including a systematic approach along the quality of structure,
process and outcome with regard to all health care service delivery. Poland and Hungary
have installed mechanisms to start Health Technology Assessment.
Professional organisations in all countries surveyed showed great interest in developing
diagnostic and treatment guidelines to improve day-to-day practice and basing their work on
scientific (evidence-based) decision-making. Quality assurance is of particular importance in
the disciplines that have yet to prove themselves in the health care system (family medicine,
nursing etc). By providing good quality services their role can be legitimated within the
health care system. Thus, diagnostic and treatment guidelines exist nearly everywhere for
diseases of public health importance and / or the most cost-intensive treatments.
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Continuous medical education (CME) has high priority to enhance the qualifications of
doctors in all medical specialisation.
The health insurance companies / institutions play a crucial role in improving external quality
control of the services they purchase. Via contracting they can influence the quality of
services delivered by their contract-partners (doctors, health care institutions) to a much
greater extent than they actually do at present.
At the hospital level several quality activities take place in all the countries investigated.
These are mainly: medical audit, quality circle work, participating in quality awards and
carrying out patient satisfaction surveys. Interestingly, different financing models have been
worked out, for instance, in Hungary where some 0.1 per cent of total budget of a hospital is
dedicated to the establishment and operation of a quality system. The main hurdles and
barriers for broad implementation of quality assurance in the respective health care systems
are seen at the national level: missing national quality policies, strategies and financing as
well as a lack of co-ordination of the various activities. In addition, relevant institutions to
ensure quality implementation may be missing altogether at the national level (quality
centres, committees or national co-ordinators) and there may be a lack of unified quality
assessment criteria or clinical indicators. At the institutional level, challenges reported
included: the resistance of doctors, the lack of adequate information systems and the
additional (mainly administrative) workload. In addition, quality specialists are not available
everywhere and have to be trained abroad. On the other hand, having undergone a
specialisation as a quality manager does not necessary guarantee an adequate position
within the health care system.
Possibilities of a cross-border co-operation in the field of quality assurance in the public
health sector are seen positively and in the following areas closer co-operation with the EU
would be appreciated:
•
•
•
•
•
•
•
•
•
•
•
•
Quality in hospitals, in particular, accreditation and evaluation
Establishment of evidence-based guidelines
Establishment of central medical databases
Establishment of a Health Information System
Tele-medicine
Management of upcoming challenges concerning electronic health care, e.g. chip
cards
Establishment of standard data sets for electronic patient records (generic and / or
disease specific)
Participation in joint EU projects in the field of quality assurance
Participation on workshops, seminars, conferences
Training and education for quality
Collaboration with the EU institutions running similar activities
Co-operation and advice with regard to health care reform
It is especially emphasised that health care quality issues should have a higher priority on
the political agenda of the EU. EU-directives should force governments to develop national
quality strategies and provide the legal framework for organisational change, eg. install
quality boards and quality managers within organisations.
Support in research, mutual projects, and the exchange of experiences and quality indicators
for international comparisons could also be of great help to meet the challenges of the
future.
4. ‘Health Systems and EU enlargement – An accession country's view’ Dr Tit Albreht,
Institute of Public Health of the Republic of Slovenia
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The last decade was marked by intense changes in health care systems around the globe,
the changes being the most remarkable in the transition (accession) countries. These
changes will be further supplemented by the intense process of accession to the European
Union. Even if there is much more stress on economic and administrative reforms, health
care remains an important issue. Economic constraints, coupled with redefinition of national
priorities and introduction of market forces into health care pose a threat to the further
development of health care as a universal, publicly financed service.
Introduction
Reforms of health systems are a universal process, dealt with in almost all European
countries and in many countries around the world. These processes have reached various
stages – from the early phases when the general ideas are only about to be implemented to
the actual positive or negative experiences with reforms that had been initiated several years
ago. As much as the various countries differ, there is also significant variation in how they
had approached health system reforms. That depended on their historical background or
economic needs or simply the need to change the delivery of health care.
Countries of the Central and Eastern European area share the experience of living in the
same countries (most of them) as well as several aspects of the former political systems.
They have seen the eve of transition at various points of economic and social development,
some have had a more favourable starting point and some much less so.
Current situation from the system's point of view
Bismarckian-type systems have become the most frequent solution for almost all Central and
Eastern European (CEE) countries. They have resorted to them for two important reasons:
1.
2.
such systems being part of their historical tradition (for most of these countries)
offering more stability in the period of unstable fiscal policies and especially,
unsecure national budgets
Since the role of the State has already become significantly reduced, there is a question
about how to preserve some of the essential functions that the Ministries of Health usually
have. Among those are especially: working towards better and more equitable health
(reducing the differences in both health and disease), maintaining the system and the
adequate infrastructure of the public health system and ensuring a comprehensive package
of rights and other health care entitlements under public funding. Many of these principles
have become challenged over the course of the last few years. On the one hand that was a
direct result of the deregulation processes in many of the CEE countries and on the other
hand, the new system approaches, e.g. privatisation of health care provision and facilities,
insurance system, private and voluntary insurances, fiscal pressures at the level of the State.
For some of the countries, the independence from the former common state also represented
a particular challenge.
Challenges for the accession countries
1. Changing epidemiologic situation
Accession countries face two processes in their epidemiological situation: on the one hand
there is an ongoing process of epidemiological transition coherent with the ageing
population. On the other hand, there are 'regression' processes that contradict the usual
trends in epidemiological transition. Some communicable diseases are becoming more
important again and that poses special challenges on the health care system. There will be a
need for an overall redefinition of priorities in health care that will require a system support,
too. Increased movement of people across borders will definitely need to be supported by a
common and well co-ordinated surveillance system.
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2. Patient mobility and mutual influences on each other's systems
According to the established policies of the European Union with respect to the area of
health care, there is no direct interference of the Union in the definition of a national health
care system. However, since there are differences both in financing and delivery of health
care in different existing member states, there is a question whether such an approach is
viable in the future. The famous Kohl and Dekker cases have triggered many questions that
arise from the conflict between an open and free market approach pursued by some and the
integrity of own national health care systems with their specifics. There is a danger that there
might be too much 'outflow' of patients to more developed member countries and a net
'deficit' of patients in the domestic health care.
3. Internal health care markets
Markets have become a much more important issue and a revival of the old business
principles for all the accession countries following the political and social processes leading
to transition. In health care that line of thinking has led to a shift from a more public health
oriented system (even if often poor on resources) to a more service and production oriented
one. That in itself should not be that bad if it were not followed by a shift towards more
purely curative services.
4. Opening of health care markets and international competition
That dilemma leads to another important and closely related issue and that is the health
markets. The accession countries might find themselves at the challenge of not being able to
compete with the health care facilities of the neighbouring member states. Assistance in
accreditation procedures and their standardisation seem to be rather important in that sense,
otherwise, the accession countries might find another obstacle to their more active presence
on the European health care market.
5. Defining the common minimum package
It is becoming increasingly difficult to define a common minimum package.
Comprehensiveness of health care needs to be preserved in spite of the efforts to make it
competitive and more market oriented. A regulation that would somehow standardise the
minimum of care provided by a certain country therefore, seems warranted. If such a
provision is not made, there might be gradually a wider variation in the type, extent and
quality of services provided across different countries. That would effectively potentially
worsen the existing inequities and inequalities within Europe. Both quantity and quality of
publicly financed services would be at stake then.
Slovenia's own views
Slovenia sees both challenges and opportunities in view of the accession to the European
Union.
Challenges are related to:
opening of borders and free movement of workforce and patients
broader and more demanding health care market
Opportunities are in:
more professional development and research
offering own facilities on the health care market (especially certain medical
specialities)
Slovenia has a quickly ageing population (both bottom-up as well as top-down). That will
certainly increase the demand for certain types of health care (e.g. long-term care, increases
in chronic diseases prevalence and incidence rates). Communicable diseases are well
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controlled, both through a well-developed surveillance mechanism as well as through
interventions (vaccinations). Slovenia's obvious lagging behind EU is in the areas of alcoholrelated conditions and injuries (both accidental as well as suicides). In any case, Slovenia
looks forward to a harmonised effort in defining priorities in health care at the European
level.
Slovenia has a longstanding tradition of good quality health services. These will, however,
become scrutinised with standardised tools when the accession gets closer to completion.
Full harmonisation of postgraduate training of physicians and dentists has been reached with
programmes co-ordinated by UEMS. As there have been high increases in salaries of these
two groups of professionals over the past 5 years, the financial incentives for physician
movement might not be as strong as in some other accession countries. There should be,
however, a rather important interest in patient movement to the neighbouring countries. That
is possible even today but with several restrictions and left to the ultimate decision of the
national health insurance company.
Hospitals are still all publicly owned but that does not exclude their need to become
prepared for an organised presentation on the common European market. They will have to
work actively and intensely to get adequately accredited to be able to take part in that
competition.
Public health needs a serious redefinition and reorganisation. That is true for its coming
closer to the current European trends and for its internal organisation. The first steps have
been taken – there is a joint, harmonised programme of Public health medical specialty
training that will be adopted shortly and preparations for a national School of Public Health
have also started.
As much as the development of certain European structures seems reasonable and,
potentially, even necessary, Slovenia would not be comfortable about seeing supranational
bureaucratic structures which would try to dominate the member states. That was the main
negative experience of living in the former State. Still, there are certain system solutions
where Slovenia's experience can be successfully shared with other countries:
-
an effective and comprehensive information system to support the vaccination
programmes
-
an extensive reporting system for the national health and health services statistics.
It would be important, though, to discuss and reassess the issues related to a common
minimum package of services publicly financed and available since that harmonisation seems
to be warranted, too, in spite of some earlier reserves about that.
Conclusions
1.
2.
3.
4.
5.
6.
The accession to the European Union is an exciting and demanding process that
has both its challenges and advantages as well as uncertainties.
Health care delivery should be standardised in quality of services and in the
minimum package available to the European citizen.
A European surveillance system should be developed supported by standardised
indicators.
Potential brain drain needs to be assessed and forecasted where and if possible.
Providers should be enabled to compete at the common health care market.
Public Health's role needs to be reaffirmed by modernising it, standardising its
guidelines and ensuring effective responsibility of the State.
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5. Public Health and EU Enlargement: The Stewardship Role of the State. Ms Magdalene
Rosenmöller, IESE, Barcelona and World Bank and Dr Armin Fidler, World Bank
When Central and East European countries started far-reaching health care reforms at the
beginning of the nineties, they did not realise what a challenging endeavour they had
embarked upon and how significantly it would change the different roles in the sector,
especially the role of the state. The context of the reforms has been very challenging, marked
by the serious fiscal crisis at the beginning of the nineties: a context of overall economic
reform with issues more pressing than that of health, and a fierce struggle for democracy
combined with permanent political instability, to just name a few of the adverse context
factors.
Accession to the European Union, or rather the prospect of accession, has been an important
driver of health care reform in these countries, as accession has created high expectations
and a strong reform motivation at all levels of the population. The acquis has played an
important role as a model in the law making process, and compliance with EU regulations
has helped to push unpopular bills through parliament. At the same time, EU accession has
had a reform-inhibiting effect: since health has not been a priority on the accession agenda,
the health sector has not received the attention it deserves.
The countries have not been left alone in their efforts. Support for the reform and accession
process has come mainly from the EC Phare programme. Unfortunately, with the shift in
Phare from a demand-driven to an accession-driven focus, health has lost importance as it is
not considered to be an explicit accession priority. Member States have very actively
supported the reform process with many different bilateral programmes, and more recently
they have increasingly taken part in twinning projects. The World Bank has been providing
lending and advisory support to health care reforms in most accession countries. Often the
Bank’s initial analysis represented the important baseline for reform undertakings. Accession
has come to be the primary objective of the Bank’s support in the respective countries, for
instance by backing institutional reform of the ministries of health or the development of
epidemiological surveillance systems. The Bank’s support for health insurance reform has
proved to be important in attenuating possible adverse impacts on macroeconomic
performance.
Despite all these efforts, now, ten years into the reforms, they seem to have stalled halfway,
and an overall “reform fatigue” is apparent. Even though there have been advances, most
countries are still far from having a fully functioning system, especially as regards the new
‘role of the state’. So what is the role of the state? Why is there a particular role for the state
in the health sector? Health is an important part of the economy, usually representing
between 5% and 15% of GDP and 10-40% of public expenditures. The state has the mandate
to assure the good health of the population, as health is a public good with high
externalities, as in the control of communicable diseases, which has become particularly
important in view of the alarming increase in tuberculosis, HIV/AIDS and other communicable
diseases in Central and Eastern Europe.
With respect to health systems, the state has to assure the provision of and access to high
quality health care. In reforming their health systems most of the accession countries have
moved from highly integrated to more open, decentralised systems with a series of marketoriented elements, albeit in different forms and to different degrees. The more decentralised
systems require a clear definition of the roles of the different players, and comprehensive
regulations and structures to ensure compliance. This concerns the accreditation of facilities,
the licensing of professionals or the regulation of the pharmaceutical and medical technical
industry. Here there is still a lot to be done, and often health ministries in these countries
have had difficulties in assuming the new role.
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It is also the role of the state to guarantee those health system functions which are not
explicitly demanded, such as health promotion, which is of particular importance in the
accession countries in view of the high prevalence of life-style risk factors such as smoking,
alcoholism and unhealthy diets. This role is far from sufficiently developed and often is
completely ignored. The accession countries have found it difficult to embrace a modern
concept of public health, which is so different from the former communist idea of hygienic
control, which in the SANEP system was limited to the collection of data. At the same time,
formerly effective vaccination systems are being neglected in favour of other, apparently
more pressing, system reform issues.
Another important role of the state is to guard against system failures: protecting the poor
and assuring access for ethnic minorities. And the state has to respond to citizen’s
perception of priorities as the social safety net, and catastrophes events (a very real concern
today). Last but not least, the state has to manage the ever-higher expectations of citizens
by giving better access to information. In the accession countries, the state’s communication
role has been particularly neglected, partly due to the heritage of the way information was
handled in communist times. All this suggests that the countries are not really assuming the
new role at state level, and so are ill prepared to correctly assume their roles as future EU
Member States.
What has been done about these issues? In June 1999 the European Commission published
the Staff Working Paper on Health and Enlargement, and the 2000 EP Bowis report stresses
the importance of health in the enlargement process. Actions followed. Health Commissioner
Byrne initiated a round of visits to accession countries, and officials of those countries are
increasingly participating in Member State consultation meetings such as the high level
committee. The Swedish presidency followed up actions taken under previous presidencies
by organising a specific conference on health and enlargement. Likewise, enlargement has
been on the agenda of various conferences held under the Belgian presidency.
We can see that health and enlargement seems to be an unfinished business. Countries are
lagging behind on compliance with specific acquis, such as the implementation of the
tobacco directive. Other potential problems are the mutual recognition of health care
professionals or functioning epidemiological surveillance systems, to just name a few. There
is still a lot to be done, and support is far from sufficient. Will Phare put health back on the
priority list for funding? And once countries become full members, will the resource-limited
public health programme be able to address these needs if they still persist? Or will there be
a transitory prolongation of the Phare programme, and if so, will health be on the agenda for
funding? – DG Sanco will surely have an important role here to assure that health protection
is put high on the agenda of enlargement policies. Despite the efforts made to date, there
seems to be room for improvement in the coordination between different commission
services.
Enlargement means a whole new set of challenges for European health, increasing the EU
health agenda, in addition to all the challenges related to ‘a high level of health protection’,
as defined in the treaty of Amsterdam. Health has recently gained momentum at EU level. In
the last year we have witnessed new challenges for European health: the BSE and Dioxin
crises, the Lipobay affair putting a question mark on the assurance of quality of drugs. And
all of this has shown an increasing concern for health on the part of EU citizens. On the
health system side, the Kohl and Dekker cases and others like it point to a potential
supranational role in assuring good quality and access to health systems for EU citizens.
Enlargement will accentuate these problems and bring others, such as the rise in tuberculosis
and other communicable diseases. As regards communicable diseases, the candidate
countries’ fire fighting power is not sufficiently developed and coordination structures need
to be put in place.
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In this sense, enlargement may trigger the long overdue formulation of a new or extended
role for health at EU level. The newly proposed and already quite progressive EU public
health strategy looks only half-hearted in the light of the possible problems related to
enlargement. There will be important roles for a future European Public Health Coordinating
Centre, a new institution recently mooted by the Commission. Here some US federal
institutions might serve as examples. The US Centre for Disease Control and Prevention
(CDC) and other federal institutes use legal and financial levers to achieve compliance with
federal regulations and support state and local networks with scientific advice and
coordinating capacity.
In conclusion, health accounts for an important share of a country’s economy and is a
substantial public concern. The state must take responsibility for health as a public good and
related externalities such as infectious disease control. It has a pivotal role in health care
systems: regulating financing and provider markets and avoiding market failures, fostering
good health and preventing health threats. In the specific area of EU enlargement a
substantial agenda remains to be tackled. For health and accession issues and the reform
agenda, is there an increased EU “federal” mandate?
6. Workshop Summary: Ms Laura MacLehose, Research Officer, European Observatory on
Health Care Systems, London School of Hygiene and Tropical Medicine
The five papers presented a broad range of issues related to the enlargement of the EU and
provoked a lively discussion. Issues from patient movement to the stewardship role for the
European Commission were touched upon. Views from the current EU member states and
from the accession countries were shared. The wide and varying topics broached throughout
the session reflected the complex process of enlargement, highlighted the far-reaching effects
of the move and pointed to many health issues for which the evidence is still unclear.
The new developments in the enlargement process in relation to health were highlighted by
Bernie Merkel. The Commission has been active in areas including funding, training,
information exchange and coordination. Martin McKee provided a broad overview of the
health situation across the EU and candidate countries. Epidemiological evidence for some of
the main health issues and their underlying causes were presented. In both presentations,
some of the challenges and opportunities for health through the enlargement process were
described. The future movement patterns of patients and health professionals are unknown
but this is a concern in terms of future planning, quality regulation and funding. The issue of
whether a minimum package for health was necessary for patients to move between
countries was raised. Pharmaceutical production, supply, quality and pricing are also issues
that need ongoing review in light of enlargement. Communicable disease control across
borders was also touched upon. The challenge of actually putting in place the Acquis
Communautaire (the complete body of EU law), which is estimated to total around 80,000
pages of text, and implementing and enforcing this new legislation was also considered. The
role of informal payments for health, common in many accession countries, was also
discussed.
The study carried out by the Austrian Federal Ministry of Social Security and Generations in
collaboration with candidate countries provided an interesting insight into quality policy in
the health care systems of the accession countries. The study, which built upon a previous
exercise of current EU countries, looked at the potential and need for cross-national
cooperation for quality issues. The study found that while quality policy issues have been
recently introduced in some of the accession countries, there is much interest in this area
and some laws and regulations in support of improving quality have been put in place.
However, although the importance of a having national health care quality policy was
275
recognised in many countries, those trying to carry out work in support of this are not
always vested with the power and resources to do the job.
The view from an accession country of what the enlargement process means for health was
presented by Tit Albreht from Slovenia. He gave an overview of health reform measures
being undertaken in accession countries and presented challenges and opportunities in
relation to health and accession. Five challenges were presented: the changing
epidemiological situation, patient mobility, internal health care markets, opening of health
care markets to international competition and defining a common minimum health service
package. Opportunities for accession countries lie in professional development and research
and the potential for offering their health care facilities on the international health care
market.
In the presentation on stewardship, Magdalene Rosenmuller reviewed the enlargement
process in relation to health reform in the accession countries and looked at the profile of
health in relation to other enlargement priorities. Whether the time has now come for an
increased role for the European Commission in health was considered. Examples from the US
were presented as possible models for an alternative model for EU regulation of some public
health issues.
Discussion about some of these health issues also raised issues relating to the Commission’s
role in health itself both for the current EU member states and candidate countries. The
Commission’s mandate to act directly on health issues is fairly limited. However, the
question of whether countries should work more closely together through linking national
centres of expertise or EU level centres of excellence should provide advice across the EU
was considered. Concerns about too much supra-national bureaucracy were voiced. To what
extent enlargement will address (or even detract from) solving the health gap between the
current EU member states and the candidate countries is not yet clear.
The presentations and discussions highlighted a number of key issues. Firstly, much activity
and progress has been made by the candidate countries in both preparing for accession and
in health reform efforts and this should be recognised by EU member states. Secondly, the
broad public health approach is not yet fully developed across all accession countries and
further support is needed both from the EU member states and from within the candidate
countries themselves to achieve this. However, and thirdly, health is not receiving a high
profile in the accession negotiations process. At the same time, there are a number of health
issues including quality regulation, patient and professional movement, communicable
disease control and supporting the development of a broad public health approach that need
high level political attention and financial support. There are also opportunities for health
gains through influencing non-health sectors such as the tobacco and agriculture industries
that have not yet been grasped. Fourthly, further discussion is needed to see whether a
stronger public health function at the European Commission level would bring benefits to
member states. However, arguments for strengthening this function have to be balanced
against concerns about excessive central bureaucracy.
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Final Programme 2001
Programme Overview
Wednesday, September 26th , 2001
10:30 – 11:45
Official Welcome Addresses
12:00 – 13:00
Plenary Session I
14:30 – 18:00
Plenary Session II
19:30 – 21:15
Special Interest Sessions: Dinner Sessions
21:30 – 22:30
Official Welcome Reception
Thursday, September 27th , 2001
8:30 – 12:00
Parallel Forum Sessions
14:30 – 18:00
Parallel Forum I
Health in other Policies and Sectors
Parallel Forum II
Parallel Forum III
Parallel Forum IV
Building a healthy Common Agricultural Policy (CAP)
Parallel Forum V
Health in the Information Age – The informed patient / citizen
Parallel Forum VI
Health in the Information Age – Health Technology and Policy
Implementation
12:30 – 14:00
Special Interest Sessions: Lunch Sessions
14:30 – 18:00
Parallel Forum Sessions continued
18:15 – 19:00
20:00
Reception at the Casino Bad Gastein hosted by the mayor of Bad Gastein
President’s Evening
Friday, September 28th , 2001
10:00 – 12:30
Plenary Session III
12:30 – 12:45
Closing Ceremony
12:45 – 13:45
Reception
14:00 – 17:00
Special Interest Sessions: Workshops
18:30
Informal Conclusion Evening
Saturday, September 29th , 2001
9:30 – 12:30
Elaboration of Gastein Health Declaration
9:00 – 18:00
Social Programme
18:30
Modern Folk Evening Bellevue Alm upon invitation of the President
277
Plenary Sessions
Wednesday, September 26th , 2001
10:30 – 11:45
Official Welcome Addresses
Chair: Günther Leiner, Paul Lincoln, Klaus Zapotoczky
-
Herbert Haupt, Minister for Health, Austria
-
Gyula Pulay, Administrative Secretary of State, Hungary
-
James Walsh, EU Committee of the Regions
-
Günther Leiner, President, European Health Forum Gastein
12:00 – 13:00
Plenary Session I
The work of WHO in championing health in development
-
David B. Evans, Director, WHO
-
Jane Hutt, Minister for Health, Wales
14:30 – 18:00
Plenary Session II
Chair: Paul Lincoln
•
Part A: The art and science of integrating health across policies and programmes
The potential and limitations of health impact assessment
-
Roscam Abbing, Netherlands School of Public Health
Progress and prospects for promoting and protecting health across EU policies and actions
Bernard Merkel, European Commission, DG Health and Consumer Protection
•
Part B: Investment for Health
Establishing health as a key component of economic policy
-
Sarah Burns, New Economics Foundation
The WHO Investment for Health project and the Verona Initiative
-
Erio Ziglio, WHO
Debate: Why do we tolerate high disease burdens, health inequalities and the social and
economic costs of health crisis and how do we ensure sustainable development?
Facilitator: Maurice Mittelmark, International Union of Health Promotion and Education
Discussants:
Genon Jensen, European Public Health Alliance
Ilona Kickbusch, Yale University
Mihaly Kokeny, Member of Parliament, Hungary
Rolf Krebs, International Federation of Pharmaceutical Manufacturers Associations
Wilhelm Molterer, Minister for Agriculture and Environment, Austria
Erio Ziglio, WHO
Summary of Session
Introduction to the Parallel Forum Sessions
278
Friday, September 28th , 2001
09:30 – 12:30
Plenary Session III
Chair: Günther Leiner, Paul Lincoln, Günther Bernatzky
Feedback from Rapporteurs from Parallel Forum Sessions and discussion of results
-
Forum I:
Cecily Kelleher, National University of Ireland
-
Forum II:
Julius Weinberg, University College London
-
Forum III:
Philip Berman, European Health Management Association
-
Forum IV:
Mike Rayner, British Heart Foundation
-
Forum V:
Stipe Oreskovic, University of Zagreb
-
Forum VI:
Rolf Engelbrecht, European Federation of Medical Informatics
Key notes:
-
Marc Danzon, WHO Regional Director for Europe
-
Reinhart Waneck, State Secretary for Health, Austria
-
David Byrne, Member of the European Commission, Health and Consumer
Protection
12:30 – 13:45
Closing Ceremony followed by Reception
Programme co-ordinator: Paul Lincoln, National Heart Forum, UK
279
Parallel Forum Sessions - Thursday, September 27th , 8:30 – 12:00 and
14:30 – 18:00
Parallel Forum I: Health in other Policies and Sectors
The purpose of Forum I is to reflect on the challenges which are posed in developing and
implementing integrated public policy in support of health, and to provide examples of how
these challenges are being addressed by some of those who are committed to improving
health status through multisectoral effort. In developing some of the themes of the opening
plenary sessions, the Forum will:
Reflect on the conditions which must be created and the challenges to be overcome in
moving from the policy objective to implementation, including the difficulty of creating
widespread public awareness of the significance and potential benefits of the policy;
Provide accounts of how Sweden and Wales are addressing the multisectoral policy approach
and the lessons which can be drawn from their experience to date; and
Describe the outcome in the Italian region and in Slovenia of seeking to apply a
benchmarking system, developed as part of the Verona initiative, to measure progress and
impact in developing and applying a multisectoral approach to improvement of health status
Chairman:
Veneto Region.
Dr. Luigi Bertinato, Director Office for International Public Health Projects,
Rapporteur:
Professor Cecily Kelleher, National University of Ireland, (Galway).
Speakers:
John Bowis, European Parliament.
Shirin Wheeler, BBC (Europe) Brussels
Carlos Ribeiro, EU Economic and Social Committee
Speaker:
Bosse Pettersson, National Institute of Public Health Sweden
Speaker:
Mike Ponton, Welsh Assembly.
Speakers:
Dr. Mojca Grunter Cinc, State Under Secretary Slovenia.
Dr. Luigi Bertinato, Director Office for International Public Health Projects, Veneto Region.
Discussion
The presentations will be structured to encourage and allow time for discussion between
speakers and participants. At the closing of the Forum the Chairman, Speakers and
Rapporteur will form a panel for a general discussion and identification of preliminary
conclusions.
Programme organiser: Jerry O’Dwyer, Haughton Institute, Ireland
280
Forum II:
International trade policies and their potential to impact upon the health of people in Europe;
Globalisation, a force for good health, or ill?
Chair and Mediator - Laurie McMahon, Office of Public Management, London
Rapporteur: Julius Weinberg, City University London
This will take the form of an informal enquiry into the impact of international trade policies
on the health of the people of Europe. Particular attention will be given to:
Trade in health services – GATS
Access to medicines vs. intellectual property rights - TRIPS
Citizens across Europe are demonstrating a growing unease at the way in which policy
decisions which are taken at a transnational level can impact upon their health. In addition,
while there are undoubted benefits to be gained from the developing global market place,
there is also a debate as to whether the poorest countries will have the opportunity to
participate and reap any rewards. However, there are two sides to every story and this
enquiry is an attempt to reveal the facts without bias and to allow participants to come to
their own informed decisions as to whether globalisation is a force for good health or ill.
The enquiry
Expert witnesses will be called to make a statement of the facts from their particular view
point to a representative panel of stakeholders. Delegates will have an opportunity to feed
questions into the enquiry process and are called upon to actively participate in the open
floor debate.
The stakeholders – a panel of judges
Nina Hvid, European Federation of Pharmaceutical Industries and Associations – EFPIA
Mehtab Currey, Department for International Development Health, UK
Mihaly Kokeny, Member of Parliament, Hungary
Ron Labonte, European Public Health Alliance - EPHA
Maurice Mittelmark, International Union of Health Promotion and Education - IUHPE
The expert witnesses
Paul Strickland, European Commission – European trade policies and their impact upon
health
Robert Beaglehole, World Health Organization – The role of international agencies in health
protection and in developing health positive trade policies
Rolf Adlung, World Trade Organization – The role of health issues in multilateral trade
agreements
Petra Laux, GlaxoSmithKline, – The role of commercial enterprises in health
Programme organiser: Maggie Davies, NHS Health Development Agency, England
Forum III:
281
(hosted by the European Commission, DG Health and Consumer Protection)
The purpose of Forum III will be to explore the impact that the Single European Market
(SEM) is likely to have on the ways that health services function. This Forum will explore
three principal aspects of the SEM as it may affect health services:
•
The development of the labour market for doctors and nurses
•
Public procurement of medical goods and services
•
The Forum will also consider the recommendations of a major EU-funded study on the impact
of SEM regulations on health services which was published recently.
Chairs: Michael Hübel (morning), European Commission, DG Health and Consumer
Protection; Nick Boyd (afternoon), UK Department of Health
Rapporteur:
Philip C. Berman, European Health Management Association
Introduction: The European Union and Healthcare
Speaker: Philip Berman, European Health Management Association
The Labour Market for Doctors and Nurses
Paper:
Prof. Bie Nio Ong, Keele University, United Kingdom
Response: Annette Kennedy, Standing Committee of Nurses of the EU (PCN) and discussion
Public procurement of goods and services
Paper:
Dr. Fernando Silio, Andalusian School of Public Health and discussion
Purchasing hospital services – the Swedish experience
Paper: Soren Berg Director of Information and Communication, both Stockholm County
Council and discussion
Speaker: Dr. Matthias Wismar, Hannover Medical School and discussion
Response:
Alain Coheur, Projects Director, Association Internationale de la Mutualité,
and General Coordinator of the Euroregional project for Meuse-Rhine and discussion
The SEM and healthcare - policy conclusions from the EHMA project
Speaker: Dr. Reinhard Busse, European Observatory on Health Care Systems
Roundtable discussion
Participants:
Hans Stein, EU High Level Health Committee and Federal Ministry of
Health, Germany
Catherine Stihler, MEP, President of the European Parliament Intergroup on Health
Alain Coheur, Projects Director, Association Internationale de la Mutualité, and General
Coordinator of the Euroregional project for Meuse-Rhine
Josie Irwin, Royal College of Nursing
Bram van der Ende, Dutch Council of the Chronicle Ill and Disabled
Comments
Rapporteur:
Philip Berman, European Health Management Association
282
Concluding comments
Speaker:
Michael Hübel, European Commission, DG Health and Consumer Protection
Programme organiser:
Philip Berman and Paul Belcher, European Health Management Association; Michael Hübel,
European Commission DG Health and Consumer Protection
Forum IV:
Building a healthy Common Agricultural Policy (CAP)
Amidst the ongoing food crisises across Europe, decline in consumer confidence and
increasing globalisation, European agricultural policy is under intense scrutiny by society and
policy makers alike. A substantial reform of the EU's Common Agricultural Policy (CAP) in the
near future is inevitable before the Union can expand. For the first time ever, the calls to
ensure that future agricultural policy supports public health objectives have a reasonable
chance of being taken on board, particularly as Article 152 of the Amsterdam Treaty requires
the Community to ensure a high level of health protection in all policies and activities.
This purpose of Forum IV will be:
•
to highlight how food safety concerns and crises can contribute to change within a
multi-sectoral approach;
•
aim to increase participants’ knowledge of and participation in CAP reform by
showcasing the work already being done by the health community and other major
stakeholders in integrating health, environmental and social concerns in agricultural
policy;
•
provide recommendations on how CAP can be reformed to provide health benefits
to Europe's people and create sustainable food and agricultural production
systems.
Chair: Dr Tim Lang, Food Institute, University of Thames
Rapporteur, Dr Mike Rayner, British Heart Foundation
Common Agricultural Policy reforms and opportunities for transformation
Shifting CAP's objectives to the provision of healthy, sustainable food production and
safeguarding the health and vitality of rural communities and landscapes
Speaker: Dr Aileen Robertson, Acting Director on Nutrition Policy, WHO European Region
Case studies at local, national and European level which illustrate ways in which social,
environmental and health concerns can be used for change
Local level: Using urban agriculture and local sustainable food production to safeguard food
security, reduce health inequalities and preserve cohesion in rural communities
Speaker: Jeannette Longfield, Sustain, and coordinator of the European Network of Alliances
for Sustainable Agriculture (REPAS)
National level: Austrian farmers call for a radical change in CAP to provide healthy food (BSE,
small producers, elimination of export subsidies)
Speaker: Elisabeth Baumhoefer
283
EU level: Interpreting the multifunctional role of agriculture and rural development across
Europe
Speaker: Elisabeth Guttenstein, WWF, European agricultural advisor
EU level: The EU farmers’ views on the development of the CAP
Speaker: Anton Reinl, Austrian Chamber of Agriculture
European level: European supermarkets set standards for their suppliers in response to
growing consumer demand for environmentally sustainable and pesticide free products
Speaker: Nigel Garbutt, EUREPGAP
Re-assessing CAP: Recommendations for reform
Roundtable discussion on prospects for CAP reform with panel comprised of speakers and
consumer representatives.
Programme organiser: Genon Jensen, European Public Health Alliance
Forum V: The informed Patient / Citizen: a new partner in the political health arena
Chair: Stipe Oreskovic, University of Zagreb
1. What are the information needs of citizens? Results from research & academia
Speaker:
Angela Coulter, Picker Institute Europe
The Right to Health and Patients’Rights: Population-based assessment
Speaker:
Anne Brunner, University Eichstätt
Manfred Wildner, Bavarian Health Research Centre
Speaker:
Albert Jovell, Josep Laporte Foundation
2. How to involve citizens in the decision making process? Experience from NGO- and
business & industry- partnerships in different countries
Speaker: Theresa Petrangolini, Tribunale per i Diritti del Malato
Speaker: Rodney Elgie, GAMIAN-Europe
The US-Experience
Speaker: David Lansky, Foundation for Accountability
3. How to involve citizens in Health Policy Development and Implementation? Current
activities of the European Community
Speaker: Walter Baer, European Commission, DG Health and Consumer Protection
Closing Remarks and Summary by Chair
Programme organiser: Monika Kaiser, Gesellschaft für Versicherungswissenschaft und –
gestaltung
284
Forum VI:
Health in the Information Age -Health Technology and Policy Development
(organised with financial support from the European Commission, DG Information Society)
Chair: Jürgen Dolle, Aktionsforum Telematik im Gesundheitswesen
Rapporteur: Rolf Engelbrecht, European Federation of Medical Informatics
Speaker: Ricky Richardson, UK Telemedicine Association and International eHealth
Association
Providing eHealth Services in Europe
Case study 1:
Speaker: Carl Brandt, Netdoktor
Case study 2: Online information system for rare diseases in Europe
Speaker: Michael Schubert, Engelhorn Foundation for Rare Diseases
Case study 3: NHS Direct
Speaker: Bob Gann, Director NHS Direct
Speaker: Petra Wilson, European Commission, DG Information Society
Patients and Health Information on the Internet
Quality of health information on the Internet
Moderated Panel Discussion
Moderator: Bob Gann, NHS Direct
Members of the panel:
Albert van der Zeijden, International Alliance of Patients Organisations - IAPO
Charlotte de Roo, European Consumers Organisation – BEUC
Michèle Thonnet, Ministry of Health, France
Petra Wilson, European Commission, DG INFSO
Conclusions: Implementing eHealth solutions
Speaker: Michèle Thonnet, Ministry of Health, France
Speaker: Otmar Kloiber, professional organisation of German doctors (BÄK)
Closing Remarks and Summary by Chair
285
Wednesday, September 26th 2001
19:30 – 21:15
Social Health Insurance Countries in Western Europe, organised by: European Observatory on
Health Care Systems; Speaker: Reinhard Busse
Developments in EU public health policy - informal dinner session, hosted by: European
Commission, DG Health and Consumer Protection, Directorate G; Speaker: TBA
Health Impact Assessment: An opportunity for considering policy options in Europe; Speaker:
Anna Ritsatakis
National Health Promotion: The benefits of an international network; Speaker: Bosse
Pettersson
Tackling health inequalities in England, hosted by Department of Health, England, Speaker:
TBA
Thursday, September 27th 2001
12:30 – 14:00
Patient access to innovative medicines in Europe, hosted by: GlaxoSmithKline;
Speakers:
Prof. Angela Coulter Chief Executive, Picker Institute
Mr. Rodney Elgie President, GAMIAN Europe (Global Alliance of Mental Illness Advocacy)
Rare Diseases in Europe; hosted by: Engelhorn Foundation for Rare Diseases – EFFORD;
Speaker: Dr. Michael Schubert
Public health research and the Proposal for a new Framework Programme on Research,
organised by European Commission DG Research; Speaker: Mr. Kevin McCarthy, European
Commission
Developing Health Targets in Germany - the Federal Initiative; Speaker: Dr. Matthias Wismar,
Medical School Hannover
Title: TBA,, organised by: WHO Regional Office; Speaker, Aileen Robertson, Acting Regional
Adviser for Nutrition, WHO - Europe
Friday, September 28th 2001
14:00 – 17:00
Workshop I: „Health Advocacy: Integrating Health into the EU political process“
Organised by: BSMG Worldwide
Introduction: The EU’s new approach to public health action: towards better consultation
mechanisms for non-governmental health stakeholders?
Chair and introduction: Dr. Hans Stein, Federal Ministry of Health, Germany
Help or hindrance? Involving outside groups in EU policy development
Speakers: Michael Hübel, European Commission, Directorate General for Health and
Consumer Protection
Paul Belcher, European Health Management Association
Influencing Europe’s health agenda from the perspective of a national NGO: the tobacco case
Speaker: Dr. Martina Poetschke-Langer, Head of Cancer Prevention Unit, Deutsches
Krebsforschungszentrum, Heidelberg
Case study: Mental Health and the EU
Speaker: Rodney Elgie - Gamian
286
Advocating for better health action: Is the European Parliament becoming a driving force?
Speaker: John Bowis, Member of the European Parliament
The role of the Council: health advocacy at the interface between Member States and the EU
Speaker: Nick Boyd, Department of Health, United Kingdom
Open discussion: Obstacles and opportunities to influencing the EU agenda
Facilitator: Andrew Hayes, European Public Health Alliance
Workshop II: „EU Enlargement: Implications for Health Systems“
organised in co-operation with: European Observatory on Health Care Systems
Chair: Armin Fidler, IBRD / World Bank
Rapporteur: Laura MacLehose, European Observatory in Health Care Systems
Progress in the EU enlargement process
Speaker: Bernard Merkel, European Commission
Quality policy in the health care systems of the EU accession countries
Speakers:
Ursula Fronaschuetz, Federal Ministry for social Security and Generations
Ursula Püringer, health care consultant
Health and Accession to the European Union – Managing the Transition
Speakers:
Martin McKee, London School of Hygiene and Tropical Medicine
Health Systems and EU Enlargement: An Accession Country’s View
Speaker: Tit Albreht, Institute of Public Health, Slovenia
Public Health and EU Enlargement: The stewardship role of the state
Speaker: Magdalene Rosenmöller, IESE – Business School and IBRD / World Bank
Open Panel Discussion: Implications of enlargement for health systems
List of Authors, Who is who
287
List of Authors, Who is Who
Biographic Information
Ernst Roscam Abbing (1945), Dutch, medicine and laws, Senior Professor of social medicine
at the University of Nijmegen in the Netherlands and Chief Inspector of public health at the
Ministry of Health , Chair of the HIA-project of the Ministry of Health., former Deputy DirectorGeneral at the Ministry of Health and Director-General of the Rotterdam public health service.
Tit Albreht, Head of the centre for health care organisations, economics & information,
Institute of Public Health of the Republic of Slovenia
Walter Baer is the Assistant of the Director for Public Health of the European Commission in
Luxembourg and in particular responsible for the staff management and administrative
dossiers at directorate level as well as information activities in the field of public health
including the co-ordination of dossiers on enlargement, international co-operation and policy
development. Mr. Baer is working in the public health area within the Commission services
since 1994, he joined at that time the unit for policy development, analysis and health in
other policies, where he was responsible for the secretariat of the High Level Committee on
Health, enlargement issues as well as information activities in the field of public health. After
finishing his studies in public administration and legal affairs in Germany, he worked for 2
years at the German Ministry of Economics before he joined the European Commission
services in 1984.
Elisabeth Baumhoefer, (1957) Austria, agricultural studies at the University of Agricultural
Studies, Vienna; since 1990 general secretary of the Austrian Mountain Farmers Association
(OEBV); representing the OEBV in the European Farmers Coordination CPE.
Dr Robert Beaglehole (1945), New Zealander, Public Health Physician, trained in medicine in
New Zealand and then in epidemiology and public health at the London School of Hygiene
and Tropical Medicine and the University of North Carolina at Chapel Hill. He is on leave
from his position as Professor of Community Health at the University of Auckland, New
Zealand. He is currently working as a public health adviser in the Department of Health and
Development at WHO, Geneva on several emerging public health issues including the public
health implications of the WTO Multilateral Trade Agreements. He has published several
books on epidemiology and public health.
Soren Berg, Director of Information and Communication in Stockholm County Council,
Medical Services Committee. Board member; Information for Medical Purpose (Infomedica).
Former positions in The Swedish Federation of County Councils; project manager on
structural changes in health care and project director on projects concerning long term
challenges for health care. Earlier: senior management consultant and partner, Sinova
Management Consultants.
Philip C. Berman (1947), British, Director European Health Management Association. Recently
completed study for the European Commission on the impact of EU directives on health
services in the European Union, focusing in particular on Germany, Spain, the UK and
Sweden. A major new 3 year project began in March on managing services for older people“.
Has been World Bank and WHO consultant, advising on healthcare management strategies in
Poland, Hungary, Romania and Turkey. Member of the Editorial Board of International Journal
of Health Planning and Management; Fellow Royal Society of Medicine.
288
Luigi Bertinato, M.D., (1955), Italian, Medical Doctor, Director of the Office for International
Public Health Projects at the Department of Health of the Veneto Region (Venice, Italy), PhD
in Internal Medicine, member of Italian Society for Tropical Diseases and member of IUHPE,
focal point for the Veneto Region for the WHO project on health promotion and investment
for health called “The Verona Initiative”, lecturer in public health at the University of Verona
(Italy).
John Bowis (1945), British Conservative (EPP/ED) Member of the European Parliament for
London; Spokesman Environment, Health & Consumer Committee, Rapporteur on Food
Safety White Paper and on the Health Impact of Enlargement, Member of the Development
Committee. Member of the British Parliament (1987 – 1997), Health Minister (1993 – 1996),
Transport Minister (1996 – 1997), Policy Adviser to the Institute of Psychiatry and the WHO
Collaborating Centre. WHO Global Campaigns on Mental Health and Epilepsy.
Nick Boyd (1952), British, Government Official; Head of International Affairs at the
Department of Health in London (since 1997). Leads a team of 25 people with responsibility
for the UK for international health policy both in Europe and globally. From 1991-3 worked
on EU public health policy within the Federal Ministry of Health in Bonn.
Prof. Dr. Anne Brunner, MPH (1961), German, Medicine, Public Health, Continuing Education;
Professorship for Social Medicine and Public Health (Catholic University of Eichstaett) in
Eichstaett; Dean of Studies; Consultant of the Academy of Medicine and Health in the Media,
Munich; Member of the German Society for Social and Preventive Medicine.
Dr. Gabi Burgstaller, Deputy Governor of Salzburg, member of the Government responsible
for health affairs.
Sarah Burns (1972), British, New Economics Foundation, London. Leads work on alternative
approaches to health care provision - including mutual health care models. Set up Rushey
Green Time Bank - time bank based in health centre. Speaker at People's Health Assembly
(2000) Savar, Bangladesh. Co-ordinator of London Time Bank.
Dr. Reinhard Busse MPH (1963), German, Medicine and Public Health; head of the Madrid
hub of the European Observatory on Health Care Systems (www.observatory.dk); "Profesor
Visitante" at Escuela Nacional de Sanidad in Madrid and "Privatdozent" (adjunct associate
professor) for epidemiology, social medicine and health system research at Medizinische
Hochschule Hannover (www.epi.mh-hannover.de); working in comparative European health
system research and health technology assessment (HTA).
David Byrne (1947), Ireland, Law, Barrister, Member of the European Commission, Health &
Consumer Protection, Member of Cabinet Subcommittees on Social Inclusion, on European
Affairs, and on Child Abuse, Member of the Council of State, 1997-1999 Attorney General,
1990-1997 Member, ICC International Court of Arbitration, Paris, 1995-1996 Member
Constitution Review Group, 1988-1997 Member, National Committee, International Chamber of
Commerce, 1974-1992 Member Executive Committee, Irish Maritime Law Association.
Dr. Mojca Gruntar Cinc (1960), Slovenian, MD, State Under-secretary, Ministry of Health,
Ljubljana, Slovenija; responsible for Public Health, Health Promotion and Prevention Policies
and Programmes.
Alain Coheur (1964), Belgian, Degree on Public Health (specialization on hospital
management) and economics. Projects director at the International Association of Mutual
Health Funds (AIM), leader of the Task Force International Cooperation of AIM. General
Coordinator of the Euroregional project Meuse-Rhin for health care during 1997 - 2001. Expert
specialised for ILO on health.
289
Prof. Angela Coulter (1948); British; research and policy analysis; Chief Executive, Picker
Institute Europe, based in Oxford, England responsible also for branch offices in Hamburg,
Zug and Gothenburg; Visiting Professor in Health Services Research at University of Oxford.
Dr Mehtab Currey; British; Public Health and Population; Deputy Chief Adviser, Health and
Population, DFID. Formal training in India and the US in Public Health and Population; over
25 years experience in developed and developing countries, working in the public sector, in
Academic and Research Institutions as well as in multilateral and bilateral institutions;
particular interest in management and in the health of the poor.
Dr. Marc Danzon, (1947), France, medical doctor, specialisation in public health, psychiatry,
health administration and economics, WHO Regional Director for Europe, 1992 – 1999
Director of the Department for Country Health Development, subsequently Director of the
Department of Health Promotion and Disease Prevention, WHO Regional Office for Europe,
1989 – 1992 Director of the French Health Education Committee, 1985 – 1989 responsible for
communication and public information at WHO Regional Office for Europe.
Jürgen Dolle, M.Phil., Senior Project Manager. After his graduation in political Philosophy in
Aberystwyth, Wales, in 1991, Mr Dolle worked as a research and personal assistant for
members of the German parliament. Beside this he was lecturer and training teacher for the
Friedrich-Ebert-Foundation. He joined the GVG in January 2000. Since then he is coordinating
the Health Telematics Action Forum for Germany (Aktionsforum Telematik im
Gesundheitswesen, ATG). Mr. Dolle is fluent in English.
Rodney Elgie (1944), British, formerly a commercial lawyer; President of Gamian-Europe
(Global Alliance of Mental Illness Advocacy Networks) and responsible for European-wide
political activities and training programmes of the organisation; Life Vice- President of the
Imperial Cancer Research Fund, Board member of the European Brain Council, the European
Federation of Neurological Associations and The Men's Health Forum.
Dr. Rolf Engelbrecht (1944), German, Senior researcher in medical informatics, Head of
department “Telemedicine and electronic health care records” at GSF National Research
Centre for Environment and Health in Munich-Neuherberg, President of EFMI (European
Federation for Medical Informatics), co-ordinator and partner in several European and German
research projects in telemedicine and knowledge management, e.g. TOSCA, DIABCARD,
DIADOQ. Member of the board of GMDS (Deutsche Gesellschaft für Medizinische Informatik,
Biometrie und Epidemiologie), AIME (European Association for Artificial Intelligence in
Medicine), Advisor to WHO, Honorary member of the Romanian Academy of Medical Sciences.
Dr. David B. Evans, Director Evidence for Health Policy, WHO, Geneva.
Dr. Armin Fidler, Economics, Health Sector Manager, International Bank for Reconstruction
and Development, World Bank.
Dr. Mag. Ursula Fronaschütz (1966); Austrian; Studies of Economics and Business
Administration; Federal Ministry of social Security and Generations: 1993-1996: Health
Attaché at the Austrian Permanent Representation to the E.U. (Brussels); since 1998: Head of
Department VII/B/8-Health Economics and Quality Management (Vienna).
Bob Gann is Director of NHS Direct Online, the NHS website for patients and the public. He
was until March 2001 Chief Executive of The Help for Health Trust, a registered charity
involved in the provision of a range of consumer health information services. Bob has served
on a number of national committees and advisory groups and was a signatory to the NHS
Plan. He has published and lectured extensively on health information topics and has visiting
academic appointments at the Universities of Southampton and Brighton in the UK.
290
Nigel Garbutt (1960) United Kingdom. Graduate in Agricultural Botany.12 years in Food
Technology Management in UK retailer Safeway. Now independent Chairman of EUREPGAP a
partnership of Food Retailers and suppliers implementing independently verifiable Good
Agricultural Practices on a global basis.
Costa Golfidis, Committee of Agricultural Organisation in the European Union.
Elisabeth Guttenstein, European agricultural advisor, World Wildlife Fund (WWF).
Mag Herbert Haupt (1947) Austria, Federal Minister for Health, veterinary medicine, third
President of the Austrian Parliament (1994 – 1996), member of the Austrian Parliament (1986
– 2000), member of the party executive of the province of Carinthia, executive director of the
Austrian Freedom Party in Carinthia (1995 – 1997). member of the national party executive of
the Austrian Freedom Party, member of the executive committee of the Austrian Freedom
Party.
Andrew Hayes, European, EU Liaison Officer for the International Union against Cancer and
the Association of European Cancer Leagues (advocacy for tobacco control), member of the
WHO Committee for a Tobacco Free Europe, President of the European Public Health Alliance.
Michael Hübel, M.A. (1962), German, living and working in Luxembourg; Political Science;
European Commission, Health and Consumer Protection Directorate General, Public Health
Directorate, Luxembourg. He joined the European Commission in 1995, and started in the DG
on Employment and Social Affairs. He is now working on Public health policy development,
and on its links to other Community policies related to health. Previously, he was European
representative of the German Red Cross and worked for different organisations in the social
and youth field.
Josie Irwin (1961), British, Trade Union Officer, Senior Employment Relations Adviser for the
Royal College of Nursing. National Staff Side Secretary of the Nursing and Midwifery Staffs
Negotiating Council. Educated at Oxford University (BA Hons PPE) and currently Warwick
(MPA).
Génon K. Jensen (1965), American, Journalist/Political Affairs Specialist; General Secretary,
European Public Health Alliance; Master’s Degree in European Administrative Studies with
distinction, College of Europe; BA degree with honours in international affairs, George
Washington University; Member of the WHO European and Health Environment Committee
(www.eehc.dk), Pesticide Action Network Europe Executive Board; Frequent contributor to
European and international journals on health issues.
Dr Albert J. Jovell holds an MD and a PhD in Sociology from the Universitiy of Barcelona
(Spain); a Master of Public Health (MPH) in Epidemiology, a Master of Science (MS) in Health
Policy and Management, and a Doctor of Public Health (DPH) degrees from Harvard
University (USA), and a MA degree in Political and Social Sciences from the University
Autonoma of Barcelona (Spain).
He is the Chief Executive Officer of the Josep Laporte’s Library Foundation and Associate
Professor of the Department of Preventive Medicine and Public Health of the School of
Medicine of the University Autonoma of Barcelona.
Dr Cecily Kelleher is the holder of the foundation chair of health promotion at the National
University of Ireland, Galway and also a Director of both the national Centre for Health
Promotion Studies and the National Nutrition Surveillance Centre in the Republic of Ireland.
Projects include the first ever National Health and Lifestyle surveys for the country's
Department of Health and Children, a variety of health promotion settings projects in school,
workplace, community and primary care and a national Health Research Board research unit
291
for Health Status and Health Gain. She has a longstanding research interest in cardiovascular
disease particularly.
She is a member of various national and international committees including the Cross Border
Food Safety Promotions Board, National Task Force on Cardiovascular Disease, National
Advisory Group on Fluoridation, European Science Foundation Programme on Social
Variations, and European Health Risk Monitoring Project.
Annette Kennedy, Irish, Nurse, Director of Professional Development, Irish Nurses
Organisation (INO). MSc, BNS. Bachelor in Nursing Education, Masters in Science in Public
Sector Analysis. Responsible for setting up and development of an education and library and
information centre for the INO for registered nurse/midwives. Member of PCN (Standing
Committee for Nurses in Europe). Steering Group Member of WENR (Workgroup of European
Nurse Researchers). Member of ICN/ANCC Credentialing Forum. Member of several Irish
Committees developing strategies on such issues as manpower development, education,
recruitment and retention practices, skill mix, research and partnership, transition of nurse
education to third level colleges.
Dr. Otmar Kloiber, professional organisation of German doctors (BÄK)
Prof. Dr. Ilona Kickbusch, Professor and Head Division of Global Health, School of Public
Health, Yale University.
Dr. Mihály Kökény, (1950), M.D.,M.P. Medicine (Cardiology), Health care management;
Member of the Hungarian Parliament, Chairman of the Health and Social Affairs Committee;
Visiting Professor in the Department of Health Studies at the University of York (UK); former
Minister of the Welfare; adviser to the World Health Organization; regular participant in
international health policy events; has nearly 100 publications on health promotion, health
policy.
Prof. Rolf Krebs M.D., Ph.D. (1940), German, Professor of Pharmacology, Chairman Boehringer
Ingelheim; President, International Federation of Pharmaceuticals Manufacturers Associations
(IFPMA), Geneva; President (1996 – 1998), European Federation of Pharmaceutical Industries
and Associations (EFPIA), Brussels; Honorary Doctor award from the Pharmaceutical Faculty
of the University of Athens/Greece; Honorary member of the Bulgarian Pharmacological
Society - Section Clinical Pharmacology -; Grand Decoration of Honour in silver for services to
the Republic of Austria.
Dr. Ronald Labonte (1953), Canadian, Sociologist, Health Promotion and Population Health;
Director, Saskatchewan Population Health and Evaluation Research Unit (SPHERU); Professor,
Community Health and Epidemiology, University of Saskatchewan and Professor, Physical
Activity Studies, University of Regina; Board member, Canadian Society for International
Health, Advocacy Committee member International Union for Health Promotion and
Education; Leader, SPHERU research program on health impacts of globalization.
Tim Lang (1948), British, Professor of Food Policy at Thames Valley University’s Centre for
Food Policy since 1994. Over the last 25 years, he has worked as an academic, a farmer, in
NGOs and as a consultant to local, national and international bodies. Director of the London
Food Commission, 1984 - 1990 and Director of Parents for Safe Food, 1990-1994. Chair of
Sustain, UK’s 105 Food NGO Alliance, member of the International Forum on Globalisation.
He works on food policy and the public interest, linking public and environmental health with
consumers and social justice.
David Lansky, PhD (1953), United States, health services and policy research; Director of
Outcomes Research and Clinical Information Services for large regional hospital and health
system; analyst for Jackson Hole Group; Founding President of FACCT--The Foundation for
292
Accountability, non-governmental organization developing quality measures and
communications systems to help consumers make better health care decisions. FACCT was
created and has been governed by major consumer organizations, corporate health care
purchasers and government purchasers representing 80 million Americans.
Dr. Petra Laux (1962), German, Pharmacist, PhD in Neurochemistry, Master of Public Health
(Hannover Medical School, Germany), currently Director Pan European Government Affairs at
GlaxoSmithKline (GSK) in Brussels, responsible for liaising with Member States and GSK
country organisations with regard to health policies; previously various positions in
pharmaceutical industry, including country management team.
Dr. Günther Leiner (1939), Austria, M.D., an internal specialist, medical superintendent at the
Institute of Rheumatology, Rehabilitation and Psychosomatic Medicine at Bad Gastein,
Member of the Austrian Parliament, speaker of the conservative party in the Health
Committee. President of the International Forum Gastein.
Paul Lincoln (1956), English, Public Health, Health Promotion; Chief Executive of the UK
National Heart Forum based in London and Public Health Policy consultant; Has been
involved with developing public health policy, strategy and actions in a wide range of areas
at international, national and local levels.
Jeanette Longfield (1957), English, Co-ordinator of Sustain: The alliance for better food and
farming, a network of over 100 British public interest organisations; International Relations
and Development Studies; publications and appearances in food, health and consumer
media. Recently appointed to Royal Society Inquiry into Infectious Diseases in Livestock.
Laurie Mac Mahon, British, Office of Public Management, UK
Kevin Mc Carthy, European Commission, Directorate-General for Research
Prof. Dr. Martin McKee, British, Medicine, Professor of European Public Health, London
School of Hygiene and Tropical Medicine, Research Director, European Observatory on Health
Care Systems
Miguel Ridriguez Mendoza, Venezuela, Law, Economics, Political Sociology, Deputy DirectorGeneral, World Trade Organization; 1994 – 1998 Chief Trade Advisor at the Organization of
Am,erican States (OAS); 1991 – 1994, Minister of State responsible for Trade Affairs; 1989 –
1991 Special Advisor to the President of Venezuela on International Economic Affairs.
Dr. Bernard Merkel (1949), British, Political Theory, Social Science; Head of Unit in the Public
Health Directorate of the European Commission in Luxembourg. Responsible for the
development and analysis of policy, in particular in relation to assessment of health
interventions and technologies, priority setting, pharmaceuticals and quality assurance and
best practice; Visiting Fellow at LSE Health in the London School of Economics and Honorary
Senior Lecturer at the London School of Hygiene; member of the Editorial Board of
Eurohealth and author of a number of articles on European health policy.
Maurice B. Mittelmark (1946), Norwegian, Professor, Ph.D in psychology, Fellow, American
College of Epidemiology; Director, Graduate Programme in Health Promotion, University of
Bergen (UB); Director, UB World Health Organisation Collaborating Centre for Health
Promotion; President, International Union for Health Promotion and Education.
Mag. Wilhelm Molterer (1955), Austria, Federal Minister for Agriculture, Forestry, Environment
and Water Supply, Economic and Social Sciences, since 1994 Federal Minister for Agriculture
and Forestry, 1993 – 1994 Secretary General of the Austrian Conservative Party (ÖVP), 1990 –
1994 Member of Parliament, 1989 – 1993 Director of the Austrian Farmers Association, 1989
head of cabinet of Minister Franz Fischler.
293
Professor Bie Nio (Pauline) Ong (1951), Dutch, Social Scientist. Professor of Health Services
Research, Faculty of Health, Keele University, UK. Responsible for research development
between the university and the health service. Board member of South Cheshire Health
Authority and Crewe and district Primary Care Group.
Prof. Stipe Oreskovic (1960), Croat, Behavioural Sciences, Health Economics, Director of the
Andrija Stampar School of Public Health in Zagreb; Responsible for Health System Project in
Croatia. Member of Executive Boards of ESHMS and IAHP. Consultant to WHO and EU
Commission. More than 70 publications in referenced journals.
Teresa Petrangolini, Tribunale per i Diritti del Malato
Bosse Pettersson (1946), Swede, Director of strategic policy development and deputy
Director-general at the National Institute of Public Health (NIPH) in Sweden. He has academic
graduation in social and political sciences and public administration and post-graduate
training in public health. He is contracted by the Karolinska institute as a senior lecturer in
public health sciences. In 1991 he was Secretary-General of the 3rd International Conference
in Sundsvall, Sweden. In the Secretariat of the National Public Health Committee worked as
an adviser 1997-2001. He represents Sweden in EU and WHO bodies and has published a
number of articles, book-chapters, reports etc since 1976.
Dr. Martina Poetschke-Langer, Head
Krebsforschungszentrum, Heidelberg
of
Cancer
Prevention
Unit,
Deutsches
Mike Ponton, Project Director for NHS Plan, National Assemble for Wales
Dr. Ursula Püringer, M.D., MSc. (1962) is a General Practitioner and Public Health Expert
working as a free lance health care consultant in Austria and Europe mostly concerned with
health reform and health system comparison in middle and east European countries. She is
currently involved in organising the first Public Health curriculum in Austria.
Dr. Gyula Pulay, Administrative Secretary of State, Hungary
Dr Mike Rayner (1955)
Group, University of
Treasurer: Joint Health
alliance for better food
British, Director, British Heart Foundation Health Promotion Research
Oxford; Chair: Nutrition Expert Group, European Heart Network;
Claims Initiative, UK; Trustee: National Heart Forum and Sustain: the
and farming (UK). (For more details see www.dphpc.ox.ac.uk/bhfhprg)
Dato Dr Ricky J Richardson (1947), British, Consultant Paediatrician with an honours degree
in Cell Biology and Immunology. Chairman of the UK Telemedicine Association, Chairman of
T2 eHealth (Working Group of European Health Telematics Association), co-founder and
Board Member of International eHealth Association, Founder of Richardson Consulting UK Ltd
and co-founder of Whizz-Kidz (National Children’s Charity), Consultant Physician at Great
Ormond Street Hospital for Children and Consultant Physician at the Portland Hospital for
Women and Children, Personal Medical Adviser to His Majesty The Sultan of Brunei; Fellow
of the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the
Royal Society of Medicine and the Royal Society of Tropical Medicine.
Dr. Carlos Ribeiro, Member of the European Economic and Social Comittee
Dr. Aileen Robertson, (1952), British; Nutrition; Acting Regional Adviser for Nutrition and
Food Security, World Health Organisation Regional Office for Europe, Copenhagen, Denmark.
Charlotte de Roo (1965) is Policy Adviser at BEUC, the European Consumer’s Organisation, on
EU Environment, Health and Safety issues. She is responsible for co-ordinating policy
positions with consumer organisations around Europe and for developing and implementing
political strategy to force change to EU policy in the consumer interest. Charlotte joined BEUC
294
in November 1999 straight from the European Parliament where she was political adviser for
a national delegation on the Environment, Public Health and Consumer Policy Committee.
Her six-year experience within the EP began after her traineeship in the European
Commission followed by her graduation in Environmental Planning and International Law
from a leading Danish University.
Dr. Magda Rosenmöller, IESE Business School and World Bank.
Fernand Sauer is the Director for Public Health of the European Commission (DirectorateGeneral Health and Consumer Protection) since December 2000. He qualified in pharmacy at
the University of Strasbourg. He subsequently received a Masters in European and
International Law from the University of Paris II and various post-graduate diplomas in public
health, pharmaceutical legislation and European Community Studies. From 1972 to 1979 Mr
Sauer held various positions in France as a hospital pharmacist and pharmaceutical inspector
at the Ministry of Health. In 1979 he joined the European Commission in Brussels and in
1986 became Head of Pharmaceuticals. He has been involved in the completion of the
European Internal Market, trilateral harmonisation of regulatory requirements (ICH) between
Europe, the US and Japan, the accession of the Community to the European Pharmacopoeia
Convention and the development of pricing transparency and industrial policy in the
pharmaceutical sector. He became the first Executive Director of the Agency for the
Evaluation of Medicinal Products (EMEA) based in London, from September 1994 to
November 2000.
Dr. Michael Schubert, Managing Director, Engelhorn Foundation for Rare Diseases.
Dr. Fernando Silió (1959), Spanish, Master of Public Health (University of Glasgow). Director
of Consultancy and lecturer in Health Services Management, Andalusian School of Public
Health, Granada, Spain.
Dr. Hans Stein (1937), German, Lawyer, Government Official, European Liaison Officer at the
Federal Ministry for Health (Bonn), Member of the EU High Level Health Committee of the EU
Commission, Chairman of the Working Group „EU Internal Market and Health“.
Catherine Stihler (1973) United Kingdom, Member of the European Parliament, Member
Committee on the Environment, Public Health and Consumer Policy and Committee on
Fisheries, MA Hons. (Geography and International Relations), St Andrews University (1996);
M.Litt. (International Security Studies), St Andrews University (1998). Researcher and
facilitator to Anne Begg, MP (1997-1999). President, St Andrews University Students'
Association (1994-1995). Young Labour representative on the Labour Party Scottish Executive
Committee (1993-1995) and the National Executive Committee (1995-1997). Represented local
organisations and women's sections on the Scottish Executive Comm ittee (1997-1999).
Parliamentary candidate (1997). Auditor to the European Parliamentary Labour Party (since
1999). President of Public Health Intergroup, 2000. Honorary life member of the University of
St Andrews Students' Association.
Michèle Thonnet, Ministry of Health, France
Drs. Bram van der Ende (1943), Netherlands, disability pension because of a rheumatic
disease, social scientist, in former days management consultant and head of a post-academic
management school in Amsterdam (until 1993), at the moment member of the board of the
Dutch Council of the Chronicle Ill and Disabled (portfolio health care and medical devices)
and of different boards within or outside the Dutch patient movement and of advisory
boards of the Dutch government.
Albert van der Zeijden (1942), Netherlands, didactic, teaching management, Chrohns'and
Bechterew patient, Vice - Chair Council of the Chronically Ill and the Handicapped in the
295
Netherlands (CG - Council) and International Alliance of Patients Organisations (IAPO) in
London, Member of the Dutch Advisory Council for Health Research.
Paul Vandoren is Head of Unit of "New technologies, intellectual property and public
procurement" in the Directorate General for Trade of the European Commission. He was
previously the Head of Unit of "Copyright and neighbouring rights, including international
aspects" in the Directorate General for Internal Market and Financial Services of the
European Commission. Before that, he was Deputy Head of Unit for Relations with the United
States. He graduated in law at the Katholieke Universiteit Leuven and at the College of
Europe (Bruges). He also holds a Master's Degree in Comparative Law from the University of
Michigan (Ann Arbor). He has published several articles in the following areas: competition
law; anti-dumping policy; interface between competition and anti-dumping; EU-US economic
relations; copyright and related rights.
Ms Katarina Veres, Project manager in Stockholm County Council, Medical Services
Committee, the project for procurement of hospital care. Background as political advisor in
the liberal party. Former positions in the Swedish International Development and Aid
organisation and the Swedish Red Cross. Masters degree in Political Science and Economics
(Sweden) and Bachelor's Degree in Eastern European Politics (including studies in Russia and
Hungary).
Mikael Vissing, Chief Strategy Officer, Netdoktor
Dr. James Walsh, English, Medicine Member of the Committee of the Regions
Prof. Dr. Reinhart Waneck (1945) Austria, medical doctor, specialist for radiology, professor
for radiology, Secretary of State for Health, since 1985 Head of the Department for Radiology
at the Hospital of the „Barmherzigen Schwestern des Hl. Vinzenz von Paul“, Vienna, 19951999 medical Director, member of the Austrian Association for Radiology, American Institut
of Ultrasound in Medicine, European Society of Cardiovascular and Interventional Radiology,
International College of Angiology (FICA), Committee of Austrian Doctors.
Julius Weinberg is Director of the Institute of Health Sciences and ProVice Chancellor for
Research at City University, London. He qualified in Medicine from the University of Oxford.
After completion of specialist training in Infectious Disease and General Medicine he worked
in Zimbabwe. This was followed by training in Public Health. He then worked for WHO in
Bosnia and the UK Communicable Disease Surveillance Centre as an Epidemiologist. He was
responsible for developing international infectious disease surveillance activities, in particular
the developing collaborations between the EU Member States. His current research interest
is in Policy pertaining to the development of international disease surveillance.
Shirin Wheeler (1963), British, Europe Correspondent BBC Brussels since 1995; Currently
presenting political discussion programme Eurofocus for BBC Parliament and regular features
for BBC World TV and World Service radio on mainly health , social and environment issues.
Previously health Correspondent for BBC South East .
Dr. Manfred Wildner, MPH (1959), German, Medicine, Public Health; Scientific Director of the
Bavarian Public Health Research Center (Ludwig-Maximilians-University) in Munich; Deputy
Head of the PR-Committee of the German Society for Public Health; Member of the German
Society for Social and Preventive Medicine, the Society for Epidemiological Research, the
International Epidemiological Association, the American Public Health Association.
Dr. Petra Wilson, European Commission, Directorate-General Information Society
Dr. Matthias Wismar, (1965), German, research fellow, head of the Research Focus on Health
Policy, Department of Epidemiology, Social Medicine and Health System Research (Director:
296
Prof. Schwartz), Medical School Hannover, Political Scientist (Frankfurt FRG, Southampton UK,
Nuffield College Oxford UK), Member of the Scientific Advisory Committee of the European
Health Management Association, Hannover.
Dr. Erio Ziglio (1952), Italian, Regional Adviser for Social and Economic Development at the
World Health Organization Regional Office for Europe in Copenhagen; Honorary Professor,
University of York; Honorary research fellow, University of Edinburgh, Lecturer at Yale
University, USA. Field of expertise: decision-making applied to the area of health and social
economic developments, social and economic determinants of health, futures‘ research and
organizational development; degree in medical sociology, post-graduate studies in evaluation
research and a Ph.D. in social policy.
297
List of Participants
Title
First Name
Last Name
Position
Organisation
Country
Dr.
Brigitte
Abbühl
Health Care Consultant
A
Mr.
Rolf
Adlung
Counsellor
Mr.
Tit
Albreht
Head of the centre for health Institute of Public Health of the SI
care
organisations, Republic of Slovenia
economics & informations
World Trade Organisation
Mr.
Padraig
Allen
Ms.
Simona
Alunni
Ms.
Annita
Anastassiadou EU coordinator
Prof.
Daina
Andersone
Ms.
Efi
Angelidis
Mr.
Philippe
Arhets
Ms.
Edith
Bachkönig
Dr.
Peter
Baeckström
Dr.
Walter
Ms.
Rita
Dr.
Ekkehard
Bahlo
Mr.
Angelo
Dr.
Alicia
Dr.
Manfred
Bauer
World Health Network
Bauer
Bundesministerium für Landund Forstwirtschaft
Dr.
Associate Manager
CH
Parliament of Ireland
IRL
Merck Sharp & Dohme
I
Ministry of Health
CYP
Head
of
Latvian Latvian University Hospital
Rheumatologists Association
LV
Ethniki Hellenic Gen. Ins. Co. GR
S.A.
Scientific Officer
Assistance Publique - Hopitaux F
de Paris
Österreichischer Rundfunk
A
Director Medical Services
Örebro County Council
S
Baer
European Commission
L
Baeten
Observatoire Social Europeen B
President
Deutsche Gesellschaft für D
Versicherte und Patienten e.V.
Bargiggia
Consulente sanità
Regione Lombardia
Barwicka
Director
Polish Institution
Insurance
Expertin für Qualität
I
of
Social PL
UK
Mrs.
Eva-Maria
Baumer
Bundesministerium für Soziale A
Sicherheit & Generationen
Ms.
Elisabeth
Baumhöfer
Österreichische
Bergbauernvereinigung
A
Prof.
Robert
Beaglehole
World Health Organisation
CH
EHMA
UK
Mr.
Paul
Belcher
Ms.
Kerstin
Belfrage
Adviser R.N.M.B.SC
Mr.
John
Bell
Member of the Cabinet of European Commission
Commissioner David Byrne
Mr.
Igor
Belov
"Rossijskij
Kurier",
"Voice of Russia"
Dr.
Alastair
Benbow
GlaxoSmithKline
Ms.
Karin
Berensson
Federation of Swedish County SE
Councils
Mr.
Sören
Berg
Director
Swedish Association of Health SE
Professionals
B
Radio A
Stockholm County Council
UK
SE
298
Dr.
Ken
Berger
Lecturer, Physician
University of Toronto, Canada; CAN
Bathurst-Richmond
Medical
Centre
Mr.
Philip
Berman
Director
European Health Management IRL
Association
Prof.Dr. Günther
Bernatzky
Mr.
Luigi
Bertinato
Ms.
Maria Luisa Bianchi
Segretario Generale
LIOS
I
Mr.
Finn Z.
Bielefeld
Public Policy Director
GlaxoSmithKline
UK
Ms.
Claire
Birckel
Administrative Officer
Assistance Publique - Hopitaux F
de Paris
Direttore Rapporti OMS
Universität Salzburg
A
Regione Veneto
I
Dr.
Ulrich
Bode
President
Pharmig Austria
A
Ms.
Christa
Bogath
Obmannstellvertreterin
Niederösterr.
Gebietskrankenkasse
A
Mr.
Lluis
Bohigas
General Director for Health Department of Health
Planning
E
Mr.
Jozsef
Borsi
Ms.
Sunita
BosnicPilipovic
Korrespondentin
Mr.
John
Bowis
Member of the European European Parliament
Parliament
Mr.
Nick
Boyd
Ministry of Health
Radio
Posta
H
Bosanska A
Sarajevo,
B
Department of Health
UK
Mr.
Carl
Brandt
Ms.
Sissel
Brinchmann
Director
Affairs
Netdoctors
Dr.
Peter
Brosch
Abteilungsleiter
Sicherheit und Generationen
Age Concern
European
Public Merck Sharp and Dohme Inc.
B
Ms.
Vanda
Brown
Head Of Active Age Unit
Prof.
Anne
Brunner
Professor of Social Medicine Katholische
and Public Health
Eichstätt
Ms.
Ralica
Budu
Office Assistant
Universitatea
Constanta
Mag.
Gabi
Burgstaller
Deputy Governor
Land Salzburg
Ms.
Catriona
Burness
Ms.
Tjasa
Burnik
Ms.
Sarah
Burns
Dr.
Reinhard
Busse
Visiting Professor
of
Public E
Mr.
David
Byrne
Commissioner for Health and European Commission
Consumer Protection
B
Dr.
Alessandro Campana
Partner
SGC - Sviluppo
Controllo S.r.l.
Mr.
Joaquin
Camprubi
External Affairs Manager
Merck Sharp & Dohme
Ms.
Francesca
Caprari
Dirigente
Ag. San. Servizi Regionali
I
Mr.
Gilberto
Carraro
Group Manager
Merck Sharp & Dohme
I
Mr.
Jim
Casey
Member of Health Board
Mid-Western Health Board
IRL
Universität D
ovidius RO
European Parliament
External Affairs Manager
B
Merck Sharp & Dohme IDEA, SL
Inc.
New Economics Foundation
National
Health
School
UK
Gestione I
E
299
Ms.
Marina
Cerbo
Dirigente Ser. o Progr.ne Regione Lazio
Assessorato Sanità
I
Dr.
Renè
Chahrour
Gesundheitsreferent
A
Mr.
Graham
Chambers
Dr.
Yves
Charpack
Mr.
Joseph
Church
Ms.
Vicky
Claeys
Advocacy Manager
Ms.
Renia
Coghlan
Health
Policy
&
Relations Manager
Mr.
Alain
Coheur
Project Director
Dr.
Joan
Colom Farran Director
General
of Departement of Health and E
Substance Abuse and AIDS Social Security, Government of
Catalonia
Prof.
Angela
Coulter
Ms.
Andrea
CrevatoSzabady
Dr.
Jorge
Cunha
President
Ms.
Mehtab
Currey
Deputy Chief Health and Department for
Population Adviser
Development
Mr.
Marc
Danzon
Regional Director
Ms
Maggie
Davies
European &
Policy Adviser
Ms
Margareth
Davies
Ms.
Kirsty
Davis
Assistant Editor
Mr
Charlotte
de Roo
Environment, Safety
Health Policy Adviser
Ms.
Francoise
Debart
Freelance Journalist
B
Dr.
Johann
Dengler
Ambassador ret.
Vjesnik Zagreb
A
Mr.
Hervé
Doaré
Executive Director
EHTEL
F
Mr.
Günther
Drda
Dr.
Hubert
Dreszler
General Manager
Aventis Pharma GmbH
A
Ms.
Annette
Dumas
European Community Affairs Merck Sharp & Dohme
Associate
B
Fonds Gesundes Österreich
European Parliament
Senior Adivser
Regional Director
to
L
the World Health Organization
DK
Ministry of Health
MT
IPPF European Network
B
Gov. Serono International
CH
Association International de la B
Mutualité
Chief Executive
Picker Institute Europe
UK
Managemed
A
Associacao Antigos
Faculdade Ciencias
Alunos P
International UK
WHO Regional
Europe
Office
for DK
International Health Development Agency
The National
Wales
UK
Assembly for
Healthcare
Equipment UK
Supplies International
and BEUC,
the
European B
Consumers' Organisation
Med.ökonm.
Planungsbüro, A
Projektmanagement f. PraxisWirtschaftsbetriebe
Mr.
Benjamin
Duncan
BMA News
Ms.
Sophie
Edwards
Merck Sharp & Dohme
Mr.
Angelos
Eftychidis
Executive Manager & Claims Allianz Life (Greece)
Manager
Ms.
Isabella
Egidi
Journalista
Repubblica Salute
Mr.
Rodney J.
Elgie
President
Gamian Europe Alliance of Mental
Advocacy Networks
UK
UK
GR
Global UK
Illness
300
Health UK
Mr.
Melvyn
Ellis
Chief executive
South Staffordshire
Authority
Dr.
Rolf
Engelbrecht
President
European
Federation
Medical Informatics
Dr.
Carolin
Engelhorn
Mitglied
Verwaltungsrates
Mr.
Eddy
Engelsman
Dr.
David B.
Evans
Dr.
Albrecht
Falkenbach
DI Dr.
Klaus
Fankhauser
Ms.
Giuliana
Farinelli
Associazione
Reumatici
Prof.Dr. Lothar
Feige
Fachhochschule
Braunschweig/Wolfenbüttel
Dr.
Armin
Fidler
Health Sector Manager for World Bank
Europe and Central Asia
Ms.
Elisabeth
Fiedler
Präsidentin
Dr.
Josep
Figueras
Head of Secretariat
Research Director
Senior Associate
of D
des Engelhorn Foundation for Rare D
Diseases
Ministry of Health, Welfare and NL
Sport
Director
Vorstandsdirektor
CH
Gasteiner A
Krankenanstalt
Heilstollen
Steirische
Krankenanstaltengesm.b.H.
Laziale
Fulvia
Filippini
Maria
Fladl
Dr.
Ingo
Flenker
Präsident
Mr.
Padraig
Flynn
Former Commissioner for
Employment,
Industrial
Relations and Social Affaires
Prof.
Antonia
Fraioli
Professore
associato
Medicina Interna
Mr.
Thomas A. Friedrich
Dr.
Ursula
Ms.
Mr.
D
Morbus A
Ulcerosa
and WHO Regional
Europe
Ms.
Malati I
USA
Österreichische
Crohn/Colitis
Vereinigung
Ms.
A
for DK
Office
Merck Sharp & Dohme
I
Austrian A
Permanent
Representation
Ärztekammer Westfalen-Lippe D
IRL
di Redazione Libertà
Ärztezeitung,
Wissenschaft
Die
I
Welt B
Fronaschütz
Abteilungsleitung Qualität & Bundesministerium für Soziale A
Gesundheitsökonomie
Sicherheit & Generationen
Poli
Gaki
Health Care Consultant
Bob
Gann
Director
NHS Direct
Mr.
Nigel
Garbutt
Chairman
EUREPGAP
Dr.
Karoly
Garda
Österreichreferent der UÄK, Ärztekammer Ungarn / CEPCO H
Geschäftsführer Cepco H
Ges.m.b.H
Mr.
Pascal
Garel
Mr.
Glenn
Gathercole
Brussels Co-ordinatior
Mr.
Antonio
Gaudioso
Responsabile
Esterne
Mr.
Harald
Gaugg
Sektionschef
Dr.
Pál
Géher
Deputy State Secretary
Ministry of Health
GR
French Hospital Federation
UK
F
Standing Committee of Nurses B
of The EU (PCN)
Relazioni Cittadinanzattiva
I
H
301
Ms.
Elmire Af
Geijerstam
Director International Affairs Swedish Federation of County B
Councils
Dr.
Antoni
Gelonch
General
Manager
Ms.
Elita
Georgana
External
Affairs Merck Sharp & Dohme Spain
Committee of the Regions
E
B
Ms.
Michaela
Giner
Client Executive
Cerner Deutschland GmbH
A
Ms.
Sonja
Glahn
Europabeauftragte
DEGE MED e.V.
D
Dr.
Walter
Glueck
Verein für Homöopathie
A
Mr.
Camillus
Glynn
Member of Parliament
IRL
Ms.
Barbara
Gobbi
Giornalista
Il Sole 24 ore
I
Dr.
Jens
Gobrecht
World
WHO
Health
Organization CH
Ms.
Fiona
Godfrey
Consultant
European Respiratory Society D
Ms.
Raquel
Goicoechea
Executive Secretary
Fundacio Salut,
Economia
Dr.
Gouvras
Empresa
iE
Ministry of Health and Welfare GR
Dr.
Anneliese
Grafinger
Obfrau & Geschäftsführerin Selbsthilfe Salzburg
Mr.
Martin
Green
Chief Executive
Counsel and Care for the UK
Elderly
A
Ms.
Julie
Griffith
Head of Health Practice
Interel European Public Affairs B
Assembly Member
Mr.
John
Griffiths
Dr.
Katharina
Grimm
National Assembly for Wales
Mr.
Xavier
Grosclaude
Mag.
Isabella
Grubenthal
Dr.
Alois
Grüner
Hofrat
Dr.
Mojca
Grunter Cinc
State Under Secretary for Institute of Public Health
Health
Ms.
Elisabeth
Guttenstein
World Wide Fund for Nature - B
European Policy Office
Ms.
Aziza G.
Haas
Bundesministerium für soziale B
Mr.
Helmuth
Hahn-Klimroth Geschäftsführer
Kliniken des
Kreises GmbH
Dr.
Günther
Hammer
Ms.
Melinda
Hanisch
Manager
Merck & Co. Inc., USA
Ms.
Mette
Harder
Consultant
DKK
The
Confederation of
Employees
Dr.
Hubert
Hart
Dr.
Herbert
Haupt
Bundesminister
Mr.
Petr
Hava
Director
Institute of Health Policy and CZ
Economics
Mr.
Andrew
Hayes
President
European
Alliance
Gesundheitssprechstunge
MSD Chibret AG
Official Representative
UK
- CH
Mutualité Francaise
P
mymed.cc AG
A
Salzburger Landesregierung
A
SLO
Main-Taunus- D
USA
Danish DK
Municipal
Bundesminsiterium für Soziale A
Public
Health B
302
Mr.
Claude A.
Hemmer
Chef de Cabinet - Staatsrat Ministerium für Gesundheit und L
Soziale Sicherheit
Ms.
Henriette
Hentschel
Director Health Politics
MSD Sharp & Dohme GmbH
Ms.
Dawn
Hill
Chairperson
Blackliners Organisation
D
Dr.
Flora
Hobdari
Head of Programming and Health
Developing Dept.
Albania
Mr.
Tony
Hockley
Director
Dr.
Susanne
Hof
Leiterin
der
Vertretung
Ms.
Judith
Hoffmann
Ms.
Anna
Holécyová
Mr.
Joachim
Hombach
Ms.
Gisela
Hopfmüller
Ms.
Veronika
Horvath
Referentin
Mr.
Tom
Hourigan
Assistant
Officer
Dr.
Hubert
Hrabcik
Kabinettchef
Mr.
Michael
Hübel
Dr.
Josée
Hulshof
Director Health Care Policy Eli Lilly & Co
Europe
Ms.
Maria
Husarova
Director General
Ministry of Health of the Slovak SK
Republic
Ms.
Jane
Hutt
Minister of Health
The National
Wales
Ms.
Nina
Hvid
Trade and IP Advisor
European
Federation
of B
Pharmaceutical Industries and
Association (EFPIA)
Ms.
Sabine
Hybasek
Projektassistentin
Wirtschaftsuniversität Wien
Mr.
Stefano
Inglese
Segretario Nazionale
CNAMC
Ms.
Josie
Irwin
Senior
Employment Royal College of Nursing
Relations Adviser
UK
Prof.
Mary
Jackman
IRL
Ms.
Helga
Jäniche
Board Member
Deutsche
Rheuma-Liga D
Bundesverband e.V.
Ms.
Sladjana
Jelisavcic
Assistent to Director General Health Insurance Institute of SL
Slovenia
Ms.
Genon
Jensen
Secretary General
European
Alliance
Mr.
Maris
Jesse
Director
Estonian
Fund
Mr.
Franzisc
Jeszenszki
Zentrul de sanatate publica
RO
Dr.
Albert
Jovell
General Director
Josep Laporte Foundation
E
Ms.
Monika
Kaiser
Projektkoordinatorin
Gesellschaft
für D
Versicherungswissenschaft u. gestaltung (GVG)
HIV/AIDS UK
Institute Albania
Insurance
Policy Analysis Centre
UK
B
Europa- ABDA-Bundesvereinigung
Deutscher Apothekerverbände
NTV Berlin
Director
D
Ministry of Health
SK
GlaxoSmithKline Biologicals
B
ORF Salzburg
Chief
Executive Mid-Western Health Board
IRL
European Commission
L
NL
Assembly for
A
I
Public
Health
Health B
Insurance EE
303
Ms.
Jana
Kárniková
Head of Department
General Insurance Fund of CZ
Czech Republic
Prof.
Cecily
Kelleher
Lecturer
National University of Ireland
Ms.
Annette
Kennedy
Irish representative to PCN
Standing Committee of Nurses IRL
to the EU
Mr.
Janko
Kersnik
National Coordinator
Quality in Health
Prof.
Mykola
Khobzey
Head
of
Health
Departement
Dr.
Andreas
Kiefer
for Kranjska Gora Health Centre
Care Lviv State Administration
IRL
SLO
UKRAINE
Land Salzburg
A
Mr.
Gabor
Kiss
Mr.
H. Dieter
Kleinstoll
Dr.
Othmar
Kloiber
Dr.
Wojciech
Kobielski
Dr.
Birgit
Kofler
Mr.
Mihaly
Kökény
Chairman of
Social Affairs
Ms.
Ruki
Kondaj
Secretary General
Mr.
Peter
Körössy
Head of Department
Goferment official
Mr.
Franc
Kosir
Director General
Health Insurance Institute
Slovenia
Dr.
Jacek
Kossakowski
Vice-director
Agricultural Social Insurance PL
Fund - KRUS
Dr.
Lajos
Kovacs
Managing Director
Railway Health Care Service
Mr.
Boris
Kramberger
Advisor Dir.Gen. for Public Health Insurance Institute of SL
Relations
Slovenia
Prof.Dr. Rolf
Krebs
President
Dr.
Michael
Thomas
Kris
Mr.
Roman
Kunyik
Prof.
Roland
Labonte
NR
Manfred
Lackner
Mr.
Eero
Lahtinen
Ministry of Social Affairs and FIN
Health
Dr.
Tim
Lang
Thames Valley University
Mr.
David
Lansky
FACCT
Ms.
Annemarie Lautermüller
Dr.
Petra
Laux
Director
Pan
European GlaxoSmithKline
Government Affairs
Dr.
Volker
Leienbach
Geschäftsführer
Koordinator
Director
Ministry of Health
H
Patienteninitiative
Ganzheitsmedizin
D
Bundesärztekammer
D
Agricultural Social Insurance PL
Fund - KRUS
People + Dr. Med Money
Health
A
and Hungarian Parliament
Klubsekretär
Ministry of Health
- National Health
Fund Hungary
ALB
Insurance H
of SL
H
International Federation of D
Pharmaceutical Manufacturers
and Associations
MarketingReport Health
D
ÖVP- Parlamentsklub
A
Universities of
Saskatchewan
Landesparteivorsitzender,
Gesundheitssprecher
H
Regina
SPÖ Vorarlberg
CBMG
/
Verband
Brauereien Österreichs
and CAN
A
UK
USA
der A
B
Gesellschaft
für D
Versicherungswissenschaft u. gestaltung (GVG)
304
Public GR
Prof.
Jeffrey
Levett
Ms.
Marianne
Lidbrink
RN BSC Adviser
Professionals
Mr.
Matthew
Limb
Editor
Campden Publishing Ltd
National
Health
School
of
UK
Mr.
Paul
Lincoln
National Heart Forum
UK
Ms.
Susanne
Logstrup
Director
European Heart Network
B
Ms.
Jeanette
Longfield
Co-ordinator
Sustrain: The Alliance
Better Food and Farming
Ms.
Helena
Lovincic
Ms.
Carin
Lyckéus
Prof.
H.
Maarse
Maastricht University
Ms.
Laura
Maclehose
London School of Hygiene and UK
Tropical Medicine
Dr.
Brigitte
Magistris
Ms.
Peggy
Maguire
Director General
European
Institution
Women's Health
Mr.
Reinhold
Mainz
Telematikbeauftragter
Kassenärztliche
Bundesvereinigung
Mr.
Asko
Maki
Ombudsman of Interests
The
Finnish
Association
Dr.
Gloria
Malaspina
Responsible Health Policies CGIL Nazionale - Labour I
Dept.
Italian General Confederation
(Trade Union Confederation at
National Level)
Dr.
Daniela
Manuc
Chief
Ministry of Health and Family
RO
Dr.
Gaspar
Maroth
Secretary
National Health Council
B
Ms.
Annie
Marott
Head of Department
Danish Nurses Organisation
DK
Dr.
Daniel
Mart
Secretary General
AMMD - Association des L
Medecins
et
MedecinsDentistes de Grand Duche de
Luxembourg
Mr.
Berndt
Martetschläger Vorstandsdirektor
Stmk.
Krankenanstaltengesellschaft
mbH
Ms.
Eugenia
Matiushko
Financial Director
LVIV
Regional
Administration
Dr.
Jozica
Maucec
Zakotnik
State Secretary
Ministry of Health
SL
for UK
Radio Slovenija
Senior Adviser
SL
Professionals
NL
of
D
Rheumatism FIN
A
State UKRAINE
Mr.
Stefan
Mayer
Landespressebüro Salzburg
A
Prof.
Mark
McCarthy
University College London
UK
Mr.
Kevin
McCarthy
Prof.
Martin
McKee
Ms.
Sylvia
McShane
Lecturer in School of Nursing University College Dublin
+ Midwifery
Mr.
Peter
Meglic
Präsident
European
Official
Commission The European Commission
B
London School of Hygiene & UK
Tropical Medicine
IRL
Österreichische
Vereinigung A
Morbus Bechterew
305
Dr.
Igor
Melnikov
Pravda (Moskau)
A
Dr.
Bernard
Merkel
European Commission
L
Institute of Public Health
IRL
Welle 1 Salzburg
A
Universität Bremen, FB 11
D
Mr
Owen
Metcalfe
Mr.
Helmut
Millinger
Prof.Dr. Helmut
Milz
Mr.
Rodney G.
Mitchell
Prof.
Maurice
Mittelmark
Dr.
Michaela
Moritz
Ms.
Margit
Moser
Ms.
Jirina
Prof.
Maria
Helena
Ms.
Marjut
Prof.Dr. Richard
Horst
Associate Director
Honorarprof. Public Health
European
Federation
of UK
Crohn's and Ulcerative Colitis
Association
University of Bergen
S
für A
Geschäftsführerin
Österr.
Bundesinstitut
Gesundheitswesen
Musílková
General Director
General
Health
Insurance CZ
Company
of
the
Czech
Republic
Nazaré
Director from Health School University of Aveiro
P
Niemistö
Public Affairs Manager
MSD Finland
FIN
Noack
Vorstand
Institut für Sozialmedizin und A
Epidemiologie
Mr.
Wlodzimierz Nowacki
Mr.
Jerry
Die Apotheke
National Centre for
System Management
O'Dwyer
Former Secretary of State
Mr.
Batt
O'Keeffe
Dr.
Isabel
Oliver
Dr.
Isabel
Oliver
Ms.
Dara
O'Mahony
Prof.
Pauline B.N. Ong
Mr.
Stipe
Oreskovic
A
Health PL
Haughton Institute
IRL
IRL
Departement of Health
UK
Specialist Registrar
Department of Health
UK
Administrator
The Haughton Institute
IRL
Keele University
UK
Director
University of Zagreb Medical HR
School
Mr.
Kim
Ost-Jacobsen Consultant
Danish Nurses Organisation
Ms.
Dace
Ozola
Agricultural Counsellour
Mission of Latvia
European Union
Dr.
Renzo
Pace Asciak
Consultant
Department
Information
Ms.
Julia
Pai
President
The
Association
for the TAIWAN
Advancement
of
Patients
Rights of the Republic of China
Ms.
Grazina
Paliokiene
Chairperson
Lithuanian Catholic Women's LT
Union
Dr.
Vojtech
Parrak
Consultant
University
Bratislava
Ms.
Lili
Pasat
State Inspector
Romanian Ministry of Health RO
and Family
Dr.
Antonin
Pecenka
Deputy of Health Care
General
Health
Insurance CZ
Company
of
the
Czech
Republic
Mr.
Giovanni
Pedini
Manager
Merck Sharp & Dohme
of
to
DK
the B
Health Malta
Komenskeho, SK
I
306
Mr.
Antonio
Perelli
Resp. Ass.
Farmaceutica
Mr.
Govin
Permanand
Editor, Euro Observer LSE London School of Economics UK
Health and Social Care
and Political Science
Mrs.
Teresa
Petrangolini
Tribunale per i Diritti del Malato I
Ms.
Elisabeth
Petsetakis
National
Health
School
of
Public GR
Mr.
Bosse
Pettersson
Director
National
Health
Institute
of
Public S
Mr.
Peter
Pfarrmeier
Director
Kur- und Kongressbetriebe A
Bad Gastein
Prof.Dr. Eva
Pichler
Institutsvorstand
A
Ms.
Audrone
Piestiniene
Ministry of Health
LT
Dr.
Franz
Piribauer
Universität Krems
Stellvertr.
Landessanitätsdirektor
Steiermark, Lehrgangsleiter
KR Dr.
Eberhard
Pirich
Obmann
Fachverband der Chemischen A
Industrie Österreichs
Dr.
Otto
Pjeta
Präsident
Österreichische Ärztekammer A
Ms.
Zinta
Podniece
Ministry of Health and Welfare LV
Ms.
Martina
PoetschkeLanger
Krebsforschungszentrum
Heidelberg
Dr.
Gerhard
Polak
Ms.
Kaja
Polluste
Mr.
Mike
Ponton
Project
Plan
Mr.
Florin
Popovici
Deputy Director of Public Romanian Ministry of Health RO
Health Direction of
and Family
Dr.
Günter
Porsch
Abteilungsleiter
Ms.
Maija
Porsnova
State Secretary
Ministry of Welfare of Latvia
LV
Ms.
Brigitte
Pripisni
Bau-Berufsgenossenschaft
Rheinland + Westfalen
D
Mr.
Hans
Christian
Pruszinsky
Editor
European Hospital
A
Ms.
Iveta
Pudule
Head of Department of Health Promotion Centre
Health Risk Factors Analysis
LV
Dr.
Gyula
Pulay
Administrative Secretary of Ministry of Health
State
H
Gemeinderätin
A
Dr.
Ursula
Püringer
Mag.
Sonja
Ramskogler
Sanitaria
Auslandsreferent
e Regione Umbria
I
A
Ärztekammer für Wien
A
University of Tartu
Director
for
EE
NHS National Assemble for Wales
UK
A
Gemeinderatsausschuss
"GesundheitsSpitalwesen"
Dr.
Peter
Ransmayr
Direktor
Salzburg
Mr.
Andrea
Rappagliosi
Vice President Health Policy Serono International
& Government Relations
Mr.
Bengt
Rastén
Consultant
und
Landesstelle Sozialversicherungsanstalt der A
gewerblichen Wirtschaft
DKK
The
Confederation of
Employees
CH
Danish DK
Municipal
307
Dr.
Mike
Rayner
Ms.
Kathy
Redmond
University of Oxford
Ms.
Helene
Reemann
Ms.
Vera
Reimarova
Hewlett-Packard
Dr.
Anton
Reinl
Austrian
Agriculture
Dr.
Eduard
Ribas
Head of the Technical and Departement of Health and E
Information Cabinet
Social Security
Prof.
Carlos
Ribeiro
Member
Consultant
UK
European School of Oncology I
Bundeszentrale
für D
gesundheitliche Aufklärung
CZ
Chambers
of A
European Economic and Social P
Comittee
Prof.
Gualtiero
Ricciardi
Professor of Hygiene
University of Cassino
I
Prof.
Mary
Rice
Practice Area Manager
Adamson BSMG Worldwide
B
Dr.
Tessa
Richards
British Medical Journal
UK
Dr.
Ricky
Richardson
Richardson Consulting Ltd.
UK
Dr.
Christian
Richner
Owner
RICHNER
Interdisciplinary CH
Health
Care
Consulting
Services
Ms.
Milena
Richter
Senior Consultant
Adamson BSMG Worldwide
Dr.
David
Rickerby
Ms.
Maria
Risi
Junior Secretary
Dr.
Anna
Ritsatakis
Head of The European World Health Organization
Centre for Health Policy
Dr.
Eduard
Rius
Minister of Health and Social Autonomous Government of E
Security
Catalonia (Generalitat)
Dr.
Aileen
Robertson
Acting Regional Adviser for World Health Organization
Nutrition
Mr.
Graham
Robertson
Acting Chief Executive
Dr.
Karin
Rodegra
B
European Commission - Joint I
Research Center Ispra
Merck Sharp & Dohme
B
DK
Health Education Board for UK
Scotland (HEBS)
SF DRS
AG
Chefredakteur
I
/ c/o MSD-Chibret CH
Prof.Dr. Wolfgang
Rohrbach
"Med Diabetes", "Diabetes A
Aktuell", "Uniqa team"
Prof.
Ernst W.
Roscam
Abbing
Ms.
Magdalene Rosenmöller
Mr.
Martin
Rümmele
Dr.
Martin
Rusnak
Ms.
Anne-Marie Sacre-Bastin
Head
Departement
Dr.
Vigan
Saljasi
General Director
Mr.
Gavino
Sanna
Segretario Generale
Movimento Consumatori
I
Ms.
Valentina
Santirocco
Junior Secretary
Merck Sharp & Dohme
I
Mr.
Vincenzo
Maria
Saraceni
Assessore alla Sanità
Regione Lazio
I
Mr.
Fernand
Sauer
Director
European Commission
L
Nederlands School of Public NL
Health
IESE - University of Navarra
E
Redakteur
Wirtschaftsblatt
A
Verwaltungsdirektor
Internationale Gesellschaft zur A
Erforschung von Hirntraumata
International Ministry of Public Health
Health
Albania
Insurance
B
Institute Albania
308
Public B
Ms.
Regina
Sauto
Dr.
Xenia
Scheil-Adlung Programme Manager
International
Association
Konsul
Francois
Schiltz
Vice President
European Foundation for the CH
Advancement of Medicine
Dr.
Walter
Schmidjell
Chairman
AMREF Austria
Dr.
Michael
Schubert
Ms.
Rosemarie Schüchtle
Direktorin
Physiotherapieschule Konstanz D
Mr.
Helmut
Schüchtle
Geschäftsführer
Physiotherapieschule Konstanz D
Dr.
Markus
Schwarz
Wirtschaftsdirektor
Christian-Doppler-Klinik (LNK) A
Mr.
Michael
Sedgley
Editor
LSE Health and Social Care, UK
London School of Economics
Mr.
Fernando
Silio
Ms.
Ilona
Skuja
Social Counsellor
The Mission of Latvia to the EU B
Mr.
Marcel
Smeets
European Affairs
Zorg Verzekeraars Nederland NL
Ms.
Elske
Smith
Ministry of Health, Welfare and NL
Sport
Ms.
Gertrude
Stabauer
ORF Salzburg
Dr.
Alena
Steflova
Ministry of Health of the Czech CZ
Republic
Dr.
Hans
Stein
Referatsleiter
Ms.
Cathrine
Stihler
President
Health
KR
Klaus
Stochl
Generaldirektor
Mr.
Janko
Stok
Assistent to Director General Health Insurance Institute of SL
Slovenia
Mr.
Bernd
Stracke
Leiter
der
Redaktion
Mr.
Paul
Strickland
Dr.
Gerhard
Stummerer
Mitglied des Vorstandes
AESGP - The Association of B
the European Self Medication
Industry
Ms.
Hildrun
Sundseth
Director EC Affairs
Merck Sharp Dohme
Mr.
Brian
Synnott
Officer
European Federation of Public B
Service Unions EPSU
Mr.
Tális
Talents
Under State secretary in Ministry of Welfare of Latvia
Medical Issues
Ms.
Nicoline
Tamsma
Senior Adviser
Nederlands Institute for Care NL
and Welfare
Medical University - Sofia
BG
Presidente
CNAMC
I
Dr.
Kancho
Tchamov
Mr.
Franco
Tempesta
Information
Officer
and
Policy EPHA - European
Health Alliance
Social
Security CH
A
Engelhorn Foundation for Rare L
Diseases
Andalusian School of Public E
Health
Bundesministerium
Gesundheit
Intergroup
on European Parliament
für D
B
Boehringer Ingelheim Austria A
GmbH
Vorarlberg- Forum Gesundheit
European Commission
A
B
B
LV
309
Mr.
Eric
Teunkens
Legal Advisor
Institut National d'Assurance B
Maladie Invalidité
Dr.
Michèle
Thonnet
Mr.
Tilman
Tögel
Landtagsabgeordneter
Sachsen-Anhalt
Mr.
Kutukeev
Toktogazy
Director of Republican Blood Ministry of Health of Kyrgyz Kyrgyz
Centre
Republic
Republic
Mr.
Ricard
Tresserras
Ms.
Gillian
Turner
National CJD
ordinator
Liasion Officer
Ministère du Travail et des F
Affaires Sociales
Ausschuss der Regionen
D
Merck Sharp & Dohme Spain
Case
E
Co- CJD Support Network
UK
Mr.
Anders
Ulstein
Mr.
Andras
Vajda
Ms.
Marja
Valtonen
Mr.
Bram
van der Ende
Mr.
Albert
van
Zeijden
Mr.
Richard
van Oostrom
Guidant Europe
Ms.
Irina
Velinova
Ministry of Health
BG
Dr.
Karen
Vella
Ministry of Health
MT
Mr.
Henk
Vermaat
Mr.
Jean Marie Vlassembrouck Vice
President
Industry Affairs
Mr.
Rüdiger
von Plüskow
Staatssekretär
Ministerium
für
ländliche D
Räume,
Landesplanung,
Landwirtschft u. Tourismus des
Landes Schleswig-Holstein
Mr.
Simon
Vrhunec
State Secretary
Ministry of Health
SLO
Dr.
James
Walsh
Member
Committee of the Regions
UK
Mag.
Evelyne
Walter
A
Mr.
Reinhart
Waneck
Staatssekretär
Gesundheit
Prof.
Morton
Warner
Director
Mr.
Eurocare
Merck
Sharp
Hungary
B
&
Dohme H
Kauneus ja Terveys
Member of the Board
der Chairman
Senior Policy Adviser
Watters
S
Dutch Council of the Chronicle
III and Disabled
International
Alliance
Patients Organisations
of Nl
B
Netherlands Heart Foundation NL
Global Baxter
B
für Bundesministerium für Soziale A
University of Glamorgan
UK
Primary
Immunodeficiency UK
Association
Mr.
Nigel
Webb
Chief Executive
Solihull Health Authority
Mr.
Colin
Webb
Executive Director
European Coalition of Positive UK
People
Prof.
Julius
Weinberg
City University
UK
Ms.
Shirin
Wheeler
BBC
B
D
Mr.
UK
Wiesinger
NTV Berlin
Dr.
Manfred
Wildner
Bayrischer Forschungsverband D
Ms.
Susan
Williams
European Officer
Royal College of Nursing
UK
Prof.
Anna
Wilmowska
Chief Medical Officer
Social Insurance Institution
PL
310
Ms.
Petra
Wilson
Dr.
Robert
Wiraszka
Dr.
Matthias
Wismar
Ms.
Birgitta
Wittorp
Deputy Director
Ministry of Health and Social S
Affairs
Dr.
Andrea
Wolf
Journalistin
Medical Tribune
Mr.
Seamus
Woods
Director of Welfare Services Mid-Western Health Board
IRL
Mr.
Steve
Wright
Head of Division
European Investment Bank
L
Mag.
Alfred
Wurzer
Direktor
Kärntner Gebietskrankenkasse A
Ms.
Agneta
Yngve
Ms.
Diana
Zajec
Journalist
DELO
SL
Prof.Dr. Klaus
Zapotoczky
Institutsvorstand
Joh.-Kepler-Universität Linz
A
Dr.
Zappacosta
Mario
Dr.
Susanne
Ziesenitz
Dr.
Erio
Ziglio
Mr.
Athanasios Zikopoulos
European Commission
B
Doctor in Regional Branch in Agricultural Social Insurance PL
Radom
Fund - KRUS
Medizinische
Hannover
Hochschule D
Karolinska Institutet
A
SE
European Commission, Joint E
Reserch Center
Regional Advisor
Südzucker AG
D
DK
Senior Manager Health Care Merck Sharp & Dohme Chibret CH
Affairs
AG

Congress report - European Health Forum Gastein

Transcription

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