Congress report 1998 - European Health Forum Gastein

Transcription

Organiser:
International Forum Gastein
Scientific Co-ordination:
Gesellschaft für Versicherungswissenschaft
und –gestaltung
Publisher:
International Forum Gastein,
Tauernplatz 1,
A-5630 Bad Hofgastein,
Austria
Editors:
Prof. Dr. Lothar Feige, Gesellschaft für Versicherungswissenschaft und –gestaltung e.V. (GVG), Cologne,
Germany
Monika Kaiser, Gesellschaft für Versicherungswissenschaft und –gestaltung e.V. (GVG), Cologne,
Germany
ISBN-N° 3 – 9500989 – 0 - 9
Congress report
EUROPEAN HEALTH FORUM GASTEIN
Bad Hofgastein/ Austria
30 September to 2 October 1998
Creating a Better Future for
Health Systems in Europe
European Health Policy at the Turn of the Millennium: at
the Cross-roads?
Global Development, National Responsibility and
Regional Challenge
in a Changing Europe
International Networks
with support of:
European Commission, DG V
Austrian Ministry of Labour, Health and Social Affairs
Austrian Ministry of Science and Transport
Government of the State of Salzburg
Committee of the Regions
Table of Contents
Words of Welcome
Pádraig Flynn
Eleonora Hostasch
Prefaces
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Günther Leiner
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Lothar Feige
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Programme European Health Forum Gastein 1998
Speeches, statements and summaries
*
Opening Ceremony
Günther Leiner
Eleonora Hostasch
William Hunter
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European Health Care at the Turn of the Millennium: At the Cross-roads?
*
Frank E. Münnich
Edward R. Roberts
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Visions of the future from the perspective of the World Health Organisation
Mikko Vienonen
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Visions of the future: The European Union's contribution to health, Maastricht,
Amsterdam and beyond:
Cornelia Yzer
Jan Bultman
William Hunter
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Research and development: What role can society play in creating a supportive
environment for R&D?
Herwig E. Reichl
Bruno Hansen
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Development of the health sector
Robert Jones
Walter Holland
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Challenges and opportunities for an enlarged European health sector
Paul Brons
Jef van Langendonck
Christoph Fuchs
Árpád Gógl
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Finance - How to meet the economic challenge
of financing the European health systems
Jürg Ambühl
Martin Pfaff
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Forum I
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Research and Development: What role can society play in
creating a supportive R&D environment?
Statements:
Umberto Bertazzoni
Dario Pirovano
Baldur Wagner
Summary:
Herwig Ernst Reichl
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Forum II
Public health and the single market
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Statements:
Philip C. Berman
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Summary:
Norbert Klusen
Lambert van Nistelrooij
Corrado Sellaroli
Philip C. Berman
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Forum III
Challenges and opportunities for an enlarged European health sectorthe role of the regions
Statements:
Gerhard Buchleitner
Martine Buron
Daniel Mart
Wolfgang Routil
Summary:
Tapani Piha
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Forum IV
Meeting the challenge of a changing economic environment:
How to finance the European health systems in the next millennium
Statements:
Jens Bostrup
Bernard Merkel
Werner Reimelt
Ray Robinson
Wolfgang Schmeinck
Summary:
Günter Danner
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Forum V
The role of the European Union: Legal and institutional framework
of the Union's policy on health
Statements:
Georgios Gouvras
Günther Liebeswar
Sophie Petzell
Summary:
Michael Hübel
Forum VI
Health systems in Central and Eastern Europe and particular health risks
Statements:
Marianna Fotaki
Arun Nanda
Magdalene Rosenmöller
Witold Zatonski
Summary:
Fernando Esteves
Closing Ceremony
Visions of the future
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Patient and consumer groups
Mikko Vienonen
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The point of view of industry
Werner Clement
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Health policy in Austria
Wolfgang Routil
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EU and its future role
Pádraig Flynn
*
Concluding remarks
Frank E. Münnich
*
European Health Forum Gastein: Summary and Outlook
*
European Health Forum Gastein 1999: Draft Programme
*
List of authors, Who is Who
*
List of participants
*
Appendix, Charts
*
Words of Welcome
Pádraig Flynn
I am very pleased to write this preface to the proceeding of the First European Health Forum Gastein, which took
place from 30 September to 2 October 1998 in Bad Hofgastein (Austria) .
The discussions and exchange of experiences there were focused on « Creating a better future for Health Systems in
Europe ». Experts from the Member States of the European Union, applicant countries, Community Institutions and
international organisations participated in this conference, where a number of key issues were discussed including
public health and the single market, research and development of public health, challenges and opportunities for an
enlarged European health sector and the role of the European Union in the field of public health.
In my remarks to the Forum, I stressed the broad challenges facing health systems in the EU, notably, demographic
change, ageing population and decreasing birth-rate, medical advances and new technology, information and the
empowered consumer, enlargement of the EU and finally Economic and Monetary Union. In that context it is
important that the Euro will make transparent the costs of health services in different parts of the Union. It will be yet
another source of information for the consumer/patient. Citizen and health managers alike will be able to make
detailed comparisons of prices of goods and services, resources allocated and outputs of systems. Differences
between countries in the price of goods, such as pharmaceuticals, are already causing concern and are subject of EU
discussion. Price and its relation to quality of service will in future become even more obvious to consumers and
providers alike. The introduction of the Euro is also likely to see cross-border movements of patients and purchasing
of services from and in other countries increasing in scale.
This conference brought together many key players from all the sectors in the field of health to analyse and discuss
the important challenges facing us today. The timing was particularly appropriate in the light of the discussions taking
place on the future course and objectives of European health policy.
The European Commission hopes that the findings presented here will be useful for policy makers in public
administrations and within the health systems, for health professionals, and for all those interested in the development
of health policy at Member State as well as at Community level.
In conclusion, I would like to express my sincere appreciation to all those involved in the organisation of the
Conference. I would like to thank all of the delegates and participants who made the event the huge success it was.
Whether you were present in Bad Hofgastein yourself or have simply heard about this event through the media, I am
sure that you will find the proceedings of great interest.
Padraig Flynn
Member of the European Commission with
responsibility for employment and social affairs
Eleonora Hostasch
In the next decades, the European health system shall be faced with serious challenges in view of a changing
demographic situation and all but unlimited financial resources.
The title given this year's "European Health Forum", "Creating a better future for Health systems in Europe" clearly
shows how important it is to maintain the high level of public health services through a well-structured approach and
co-ordinated development of an appropriate framework.
In dealing with the complex issues of systemic changes, we should keep the focus on a central maxim:
We all work for the people.
For the people, health today means more than just the absence of disease.
The modern concept of health is much more associated with quality of life. The physical, mental, and social well-being
of the people is not only threatened by disease in a narrow sense but also by problems at the workplace, financial
difficulties, or lack of social support.
A comprehensive and future-oriented health policy is social policy and vice versa. Health at the workplace,
rehabilitation into late age, or long-term care provision – just to name a few – are future issues that render necessary
the merging of these two policies for the benefit of the people.
Health care shall remain a public concern and not a private matter in the future.
The dynamics of change in the coming years can only be put to proper use if all actors in the public health service
succeed in developing common strategies.
Common strategies that prepare a future for Europe's health systems in which the best possible provision of health
services in our Member States can be further maintained and improved.
I therefore welcome the fact that the Gastein Health Forum created another "think tank" to support the exchange of
opinions on this issue.
The available results of the 1998 Health Forum contain interesting food for thought and can make a valuable
contribution to future problem-solving strategies.
Eleonora Hostasch
Minister for Labour, Health and Social Affairs
Austrian Federal Government
Prefaces
Günther Leiner
Facing
the
Challenges
Gastein as the centre of European Health Policy
of
Health
Policy
The Gastein valley spa resort is a suitable venue for a fruitful exchange on issues of health policy and shall continue
to be so in the future. During the 1st EUROPEAN HEALTH FORUM GASTEIN in autumn 1998, Gasteiner valley
hosted 235 congress participants from 21 countries, the EU member states and the membership candidates, as well
as from international organisations, that is, the decision makers of health policies of the dawning of the 21st century.
At the end of the conference, Padráig Flynn, EU Health Commissioner, spoke explicitly in favour of continuing the
consultation process in Gastein. Therefore, we can begin processing the results of this first meeting in anticipation of
the 2nd EUROPEAN HEALTH FORUM GASTEIN from October 6 to 9, 1999. The topics of the meeting will be treated
briefly. Allow me to summarise the most important results of the 1st EUROPEAN HEALTH FORUM GASTEIN:
1. EU enlargement - no reason to fear patient tourism
Instead of fearing a flow of patients to the West, current EU member states must undertake all efforts to support the
countries of Central and Eastern Europe, that need improvement in some areas, in developing their health systems.
The situation is serious: The development of mortality rates in the follow-up states of the Soviet Union and a lack of
progress in reducing the excessive number of premature deaths in lower social classes in almost every European
country has lead to the reduction of overall life expectancy in the European Union for the first time since the end of
World War II, plummeting from 73.1 years in 1991 to 72.4 in 1994. It is not enough to increase health expenditures in
order to reverse this trend. The highest health levels can be found in those societies that actively deal with the social
determinants of health (such as poverty, homelessness, unemployment, alcoholism, and smoking), counteract
environmental health hazards, and develop comprehensive programs to control infectious and other preventable
diseases. We shall focus on the central topics of Social Marginalisation and Health and Health Promotion during the
2nd European Health Forum Gastein.
2. Adjusting Health Systems to Patients and not Vice Versa
Moreover, we must not, particularly in view of enlargement, build walls around our national health and social systems
in Europe, making access to these more difficult for patients. We must adjust the systems to the patients and not the
patients to the systems. The EU can help, but also discussion forums like the EUROPEAN HEALTH FORUM
GASTEIN can facilitate the acceleration of this development.
The primary objective of EU health policy is to provide a strong guarantee for the maintenance of health care systems.
In order to maintain and improve health systems, it is necessary to focus not only the quality of health systems but
also on the preservation of high living standards and on factors that account for a good health system: high standards
of hygiene, high-quality foods, and a minimum level of environmental pollution. Unemployment, poverty, and social
marginalisation also pose a threat to general health. Compared to the US health system, the Western European
model stands out in terms of a nearly universal access to health care. At the same time, however, health expenditure
in the EU, currently at 7 to 8 percent of the GNP, is only half of the USA figures. An important economic factor is that
health systems on both sides of the Atlantic are a major employer in innovative sectors such as the pharmaceutical
industry, biotechnology, information technology, and general medical research. Nevertheless, despite the fact that we
in the EU spend less on health, we have a better distribution of health services and better results if we take overall
health figures into account.
3. Health and Social Security
The general challenges facing health policies at the dawn of the 21st century are demographic changes characterised
by more elderly people who need more intensive and costly care, progress in medicine and new technologies, the
cost efficiency of which as compared to existing treatment methods must be thoroughly examined, and enlightened
patients who demand a demystification of medicine and who no longer automatically trust it. The process of European
integration, but also the Economic and Monetary Union and the Euro will render costs transparent, and the
membership candidates will be required to adjust their social systems to the high EU standards, a context in which the
EU will be called upon to act as a mediator. Its role shall be to collect and analyse information, create a quick
communication mechanism on health risk, as well as to employ health promotion and disease prevention initiatives in
order to influence social and ecological factors.
There will be a Europeanisation of health systems in the future and all national social securities must look beyond
their state borders. There can be no separation of markets in those for goods and those for social security services.
The verdicts in the Kohll and Decker cases are just the tip of a large iceberg. Europeanisation shall spring from the
bottom, and in the grey zone – due to the mobility of patients – it is already a fact. A single market for health services
shall offer new opportunities to citizens and health service providers, and in the long run, to the social securities
themselves.
As it was shown in the discussions during the 1st EHFG, the European task in health policy is to reach a consensus on
the limits of basic medical services that must be accessible to all citizens – both upstream and downstream.
To achieve this, it will be necessary to
• create a legal and institutional framework
• develop a transparent, unbureaucratic European health market
• enhance the role of patients (consumers)
• apply comprehensive quality assurance (versus imminent rationing)
• provide the necessary funds for the integration of Central and Eastern European EU candidates
• continue along the path towards a co-ordinated health and health promotion policy.
By and large, these are also the issues that will be discussed at the 2nd EHFG in October.The 1999 European Health
Forum Gastein must continue its work in this spirit and serve as a centre of European and interdisciplinary dialogue. I
look forward to meeting you again in Gastein in 1999.
Dr. Günther Leiner
President of the International Forum Gastein
Lothar Feige
Preface
At the beginning of the third millennium the European health systems are at the cross-roads. How should health care
for the citizens of Europe be shaped in the future?
Scientists, the managers of associations and health policy makers are called upon to develop visions of a European
health system and to describe the actual requirements for such a system. This has become necessary in the view of a
large variety of health benefits on offer, an offer which has been extended both in quantitative and qualitative terms.
Not only have considerably contributed to this outstanding medical, technical and pharmacological developments, but
also the improved possibilities of information. At the same time demand for such benefits is growing. This is not only
due to the fact that today expectations in general are higher but also to the demographic development of the
population in Europe.
Opposed to this is the difficult financial situation which the health systems in many Member States of the European
Union are facing. Health expenditure is gradually increasing in most European countries. At the same time it become
evident that the available financial resources are of a finite nature.
Therefore the European Union should have the aim to support the Member States in all their efforts to organise the
health systems as efficiently as possible. This requires drastic reforms and the search for new possibilities in all areas/
in all sectors of health care. A growing Europe can be the platform for all these developments with the corresponding
opportunities and risks.
In autumn 1998 the "European Health Forum Gastein" outstandingly took the opportunity to contribute to the further
development of the health systems in Europe. Scientists, representatives of industry and many associations and
politicians together debated about the issues of the future of the health systems in Europe. In this context it became
clear that the illustrated problems can only be solved if it is possible to determine and to implement sustainable
strategies to organise the health systems to be fit for the future so that the health situation of the population in Europe
can be protected and improved.
The cross-border interdisciplinary exchange of opinion has brought up many questions and discussed possible
solutions. It raised the awareness that health policy can be developed in the future only in accordance with the
Members of the European Community and in close contact with those countries that are intending to enter this
Community.
The Gesellschaft für Versicherungswissenschaft und –gestaltung (GVG), which was responsible for the scientific
organisation of the first European Health Forum Gastein, considers this documentation not only as a stock-taking of
the current discussion but also as an impulse to continue the dialogue that was started in Bad Hofgastein.
Prof. Dr. Lothar Feige
und -gestaltung
Opening Ceremony
Günther Leiner
Dear Ladies and Gentlemen,
the Gastein Valley is situated in the heart of Europe.
As early as the Middle Ages international politics was
made in Gastein, and this was for a large part Europe
at that time. The First Gastein Treaty of 1365 between
von Görtz and the Archduke of Bavaria (Friuli/ AustriaBavaria; the Treaty clarified the corresponding
possessory interests); and the Second Gastein Treaty
of 1865 (the division of Schleswig-Holstein between
Germany and Austria). It was signed by Bismarck on
behalf of Germany and by von Blom for Austria - in the
Hotel Straubinger.
We are following this tradition and will give important
and constructive incentives for the future of Europe in
the next few days.
The spirit of Europe has its home in this part of
Salzburg.
Europe cannot be put on the same footing as the EU.
Europe is much more:
- it is the citizens, the communities, the regions from
the Atlantic Ocean up to the Urals.
The young democracies have found their way home to
the European family and I am especially looking
forward to meeting them.
Especially here and today the common European
awareness is an important linking element.
It is due to one of the great European personalities Commissioner Padraig Flynn - that this event is taking
place. For it was him who has encouraged me to
initiate the "European Health Forum" in its crossborder concept. And it was him who has energetically
supported us by creating the financial preconditions
and who made it possible to draw up such a
programme by putting at our disposal the wealth of
ideas of the Commission's officials.
I am looking forward to be able to welcome
Commissioner Padraig Flynn on Friday.
However, I would like to express my gratitude and my
appreciation today because it would not have been
possible to carry out this event without the support of
the European Commission.
The Gastein Valley in the heart of Austria has been
the meeting place for European politicians, aristocracy
and society since the Middle Ages - and still is in our
modern times.
In the 19th century primarily Eastern Europeans came
to the Gastein Valley. Many Russians and Hungarians
came to this place and determined European politics.
Bad Gastein even had its own Russian Café.
At present Austria, though the youngest Member State
of the Community, is bearing major responsibility
within the European Union.
I am glad to welcome here her excellency Federal
Minister Lore Hostasch who represents the Austrian
Government and the EU Presidency.
I would like to thank her very much for her patronage
and support, as well as for her committed interest.
Lore Hostasch will officially open the event.
The wealth of Salzburg and the affluence of the
Gastein Valley can be attributed to the gold and silver
mining industries and its early importance as a health
resort which attracted many tourists and patients.
In the 20th century health tourism was combined with
"white gold" - snow and our marvellous ski slopes.
The economic competence of the people in this valley
has contributed to its international reputation.
Politics and industry have always been two important
factors for shaping our lives.
The spirit of the springs in the Gastein Valley has not
only been a remedy for bodily harms for many
centuries, but it also inspired artists and was a
stimulus for poets, musicians and scientists to give
their best.
Franz Schubert composed his Symphony in C minor in
Bad Gastein. The sound of the waterfalls and the
gorgeous mountains inspired Franz Grillparzer to write
his novels. Menzel und Alt painted the beauty of
nature in wonderful colours on canvas.
Paracelsus, who was the greatest physician of the
15th century, studied the power of the Gastein spring
water and described its healing factors and
substances.
In this sense I would like to welcome all those who are
dedicated to the art of healing, directly as medical
doctors like Professor Fuchs from Germany and all
those scientists who are indirectly shaping health
policy by producing social, economic and ethic
scientific results.
I have deliberately depicted three important forces of
our society when describing the historic development
of the Gastein Valley. These are politics, science and
industry.
It is the leitmotif of this symposium to bring together
this triad in health policy matters at a high-ranking
European level to use this platform as a forum for
debate.
No one of us either intends or believes that we could
ever force upon the individuals of all the regions of
Europe the same harmonised health policy.
We are all convinced that the individual character of
the regions and the Member States is to be
maintained, but beyond this individualism there are
ethic, economic medical and quality-oriented issues
that require a certain solidarity and common action for
the benefit of our citizens.
Economic reasons formed the very basis of European
integration.
In the last few years important further topics that are
adequate at least have been included into the
European concept.
We would be burying our heads in the sand if we did
not include the pressing issues of health and social
policy into the EU's catalogue of problems.
In Amsterdam an important step was made to achieve
this.
-
-
transfers responsibility towards the citizens as
closely as possible, according to the principle of
subsidiarity
carries on the dialogue on quality and ethical
standards at the highest level
encourages a common market for health services,
products and employees and
an investment-friendly climate for research.
Science has imposed itself under ethical self-control
and must therefore draw up those limits which are
good for mankind.
Industry will demonstrate the technical and
pharmaceutical possibilities.
Politics has the aim to explore how much money the
citizens are prepared to spend on their health, what
burden the citizens can be expected to bear within the
social system and which preventive measures can be
carried out by the citizens on a self-responsible basis.
I am looking forward to interesting contributions, lively
discussions and future-oriented propositions for
solutions.
Ladies and Gentlemen,
during the next few days we have a wealth of
experience, knowledge and contacts at our disposal.
A Better Future for Health Systems in Europe
At the beginning of the next millennium the issue of
health will become a major topic for politics and
society.
Medical
progress
and
demographic
development are just as great challenges as the
Union's enlargement, the Internal Market and the
economic constraint of public budgets.
At the turn of the millennium European health policy
will be at the cross-roads: Will it follow the model of
the USA and provide high-tech and expensive medical
treatment for only a few and create a wide-meshed
social net? Or will it stir its own European course for
the health sector.
The aim of creating a European health sector means
unison for the provision of services to all citizens on
the basis of a fundamental ethic consensus and
according to European quality standards.
The aim of our consultations on the occasion of the
European Health Forum Gastein is to create
prerequisites for a health system in Europe that
- guarantees the best medical services as possible
for all citizens
Representatives of 26 states and many regions and
NGOs are taking part in our Congress.
Please take advantage for the abundant discussions
and the exchange of opinion.
I wish you to feel at home in the Gastein Valley, in a
hospitable atmosphere protected be the gorgeous
mountains of the Gastein Valley.
Welcome to the Gastein Valley.
Eleonora Hostasch
I would like to thank you very much for the invitation. I
am pleased to be able to speak on the occasion of
such a high-ranking event.
In my opening speech I would like to address the
challenges which the European health systems will be
facing over the next few decades.
The title of today's symposium "Creating a better
future for health systems in Europe" illustrates how
important it is to further secure the high level of health
care by proceeding in a structured way and by
creating the corresponding framework conditions in a
co-ordinated manner.
One cannot deny that in countries such as Austria,
where three quarters of health expenditure is covered
by public means, demographic changes have led to a
further increase in costs and that this increase has to
be financed by earned incomes that are not growing at
the same pace.
When dealing with the complexity of changing the
systems, we should always keep in mind one essential
principle:
In this area of tension the principle of solidarity is put
to a severe test. However, solidarity in coverage and
solidarity in the balance between all social groups
have to be superior aims of our health policy.
We are all acting on behalf of human beings.
The individual has to be in the centre of our efforts.
Today good health means more for the individual than
just the absence of disease. In a rapidly changing
society health threads and the framework conditions
for successfully coping with everyday life are also
undergoing change. Today the modern notion of
health includes to a large extent the quality of life. The
physical, emotional and social well-being of the
individual is not only threatened by disease as such,
but also by difficulties at work, financial worries or the
lack of social structures.
A comprehensive and future-oriented health policy
means social policy and vice versa. Occupational
health and safety, rehabilitation up to an advanced
age or provisions for long-term care - just to mention
only a few examples - are topics of the future, which
make it necessary that for the benefit of the individual
these two policy areas should grow together.
Dear Ladies and Gentlemen: Health care is a public
affair and not a private one!
For this reason I would like to focus on the following from my point of view very important - aspects of a
possible future health policy:
Every citizen, young or old, with high or little income,
has the right to equal, comprehensive medical care
that reflects the latest state of technology.
Against this background further improvement of
effectiveness and efficiency of the health services are
to be supported, in order to actively counteract
tendencies towards two-class medical care.
In the view of medium- and long-term effects on social
balance those ones responsible for the design of
health services are particularly called upon to develop
social models that include the possibility of further
development and that do not break with the principle
of solidarity.
In this context I would like to draw your attention to
something quite essential: Especially against the
background of economic considerations it is often
advocated that the individuals themselves should
assume more responsibility and more obligation to
take care of themselves.
However, I explicitly say no to the obligation to insure.
I support the compulsory insurance system. It is a just
system of solidarity which guarantees the long-term
funding of the high level of health status in our country.
First of all I would like to
illustrate the tensions between economic possibilities
and the access to health benefits for everyone.
Second I would like to
emphasise the importance of quality assuring aspects
for the performance of our provisions.
now I would like to concentrate on the second issue:
I am firmly convinced that quality assurance in the
health sector should form a central part of all
strategies and concepts.
Please let me explain why this is my opinion.
Please let me now focus on the first major issue:
My first approach is as follows:
Health benefits
everyone
have to remain accessible for
The increase in efficiency purely on the basis of cost
savings and cost containment is limited. For this
reason it is clearly visible that measures of quality
assurance and quality improvement become the major
principles for action. Quality management is a large
pool of resources.
Quality assurance of individual activities at the EU
level in the health sector has been a tradition for many
years.
In this context I would like to mention in particular the
harmonised provisions concerning pharmaceutical and
medical products.
From the Austrian point of view the subject matter of
blood and blood products is of particular importance.
In this area efforts to create harmonised provisions
have been undertaken. Questions of self-supply within
the EU while ensuring highest quality requirements
can only be taken account of by this form of coordinated action of the Member States.
In the course of British EU presidency a
recommendation concerning the suitability of blood
and plasma donors and the screening of blood donors
in the European Union was adopted.
In order to promote the activities in this area a highranking expert conference was organised in Baden
near Vienna in July 1998 following the initiative of the
Austrian EU presidency in co-operation with the
Commission. Experts from all Member States
elaborated and agreed upon new propositions for
harmonised action concerning "Quality Management
for Collecting and Processing Blood and the
Distribution of Blood Components in the European
Union".
The intensive expert deliberations were collected in a
summary which is the basis for further proposals of the
Commission, which could perhaps be submitted in the
next few months - as is my wish in the interest of
further quality assurance in this very sensitive area.
Apart from the aspects of quality assurance, which are
already taken into consideration in the mentioned
areas of the EU acquis, further effort is absolutely
required to reinforce quality management in all EU
Member States.
For this reason I am particularly delighted to be able to
inform you about the initiative of the Austrian
Presidency, which made it possible to carry out an
exchange of opinion on quality assurance across the
whole EU.
On the occasion of an expert conference at minister
level which took place in July in Burgenland a
comprehensive discussion was led about the quality in
the health sector.
With the help of the experience gained in the individual
Member States "the possibilities and limits of cooperation at EU level to achieve a high level of health
protection in the Member States" were extensively
discussed.
Prior to this event some Member States showed a
certain reservation against this topic, since, to a farreaching extent, the provisions for health systems are
part of the competence of the individual Member
States of the European Union.
This means that the Member States are not obliged by
EC legislation to harmonise their national provisions.
The transfer of competence towards the EU is not
desired in this area.
The principle of subsidiarity in the health sector will not
be questioned in future either. From my point view,
too, EU-wide harmonisation would be opposed to the
appropriateness and the need-oriented character of
the specific national range of benefits.
The results of this first informal consultation brought
about very positive reactions in the Member States. It
was noted that it was desired to continue such an
exchange of opinion.
I am very glad in particular that Germany, which is
succeeding the Presidency of Austria, has signalled to
be prepared to continue this initiative launched by
Austria.
information and exchange of opinion will be major
tasks in the field of public health on EU level, too.
In this sense one of Austria's main issues during its
presidency is to deepen and to continue the
discussions at a formal level about a new Community
framework for public health. This framework is based
on the perspectives opened up by the Amsterdam
Treaty. It should be flexible enough to include
strategies in the health sector in relation to the
enlargement of the European Union.
In the field of public health we have entered a sort of
transitional period.
On the one hand a first cycle of specific action
programmes have to be finalised and the experience
gained in this respect has to be evaluated. On the
other hand a new framework for future actions has to
be determined. This new framework is to profit from
the experience gained in a coherent way and is to be
flexible enough to meet future developments and
challenges.
The first consultations about this topic have led to the
result that we intend to follow more intensely
horizontal approaches instead of the existing vertical
individual programmes. Health promotion and
intensified information about health relevant issues are
the major model for this new framework.
It will only be possible to take useful profit of the
dynamic changes that will occur over the next few
years if we are able to develop common strategies.
Common strategies which will pave the future way for
health systems in Europe, which will continue to
guarantee and improve optimal medical care for
everyone in our Member States.
I am very glad that the Health Forum Gastein created
a further think tank to further promote the exchange of
opinion regarding this issue.
I wish the consultations and discussions to be a
success and declare the Health Forum Gastein to be
opened.
William Hunter
Mrs Hostasch,
Dr Leiner,
Ladies and Gentlemen,
Allan Larsson, Director General of DG V, has asked
met to convey his apologies that he is unfortunately
unable to be present at the opening of this important
Health Forum. In his absence, I would like to say a few
words today on behalf of the Commission.
Your event comes at a particularly crucial moment for
the development of health policy in the European
context.
First, the European political landscape is rapidly
changing. Everybody here in Austria knows only too
well about the exciting new developments in Central
and Eastern Europe. Indeed, the European
Community will be soon expanding its membership to
bring in a number of states each with ist
own distinctive health situation.
Second, the health policy competence of the
European Community is being progressively
strengthened. The Treaty of Amsterdam, which should
soon come into force, contains a new and broader
public health Article. In response, the Commission has
recently published a Communication on the
development of public health policy and the debate
launched by this document is now in full swing. I am
confident that this conference will contribute to
bringing forward the debate.
Third, our societies are all facing similar challenges
such as ageing populations, economic upheavals,
globalisation and unemployment. Health systems are
not isolated from these problems. It is therefore a
particularly good time to come together to look at how
health systems can work in the most efficient and costeffective manner in order to protect the health of our
citizens. There is a special benefit in exchanging
experience from each of our countries about what
kinds of health intervention have worked and what
haven’t. For all reasons, the Commission was pleased
to be able to contribute towards the setting up of this
Forum. We are greatly looking forward to the results of
the discussions and I am sure that these will be three
stimulating and rewarding days which we will spend
here together.
Finally, let me say particularly to Mrs Hostasch how
pleased we are that you have given so much attention
to making health a main priority of this first Austrian
Presidency of the European Union.
European
Health
Care at the Turn of
the Millennium: At
the Crossroads?
Frank E. Münnich
At the turn of this century technological, economic,
and social forces are at work which will lead to
profound revolutionary changes comparable in extent
and range to the renaissance and the upspring of
industrial capitalism during the last century. They
occur at a tremendously increased speed in an
extremely short span of time. There are important
developments both within as well as outside of the
healthcare system which will shape its future structure
and appearance within the next to decades to a far
larger extent than could be anticipated still a few years
ago.
Two important endogenous changes can be observed.
They are on the one hand the changing spectrum of
diseases which is due in part to the successes of
modern medicine and in part to an ageing of our
populations and which will necessitate the
development of new organisational structures for the
provision of healthcare. On the other hand changing
attitudes of physicians and patients toward sickness
and healthcare will lead to a new medical paradigm, to
soft medicine (“more caring besides curing”), and to
diverse types disease management. At the same time
quality assurance and evidence based medicine will
gain great importance.
Exogenous factors might prove to be even more
important. Technological revolution is going on in two
areas: in microelectronics and information technology
as well as in medical / pharmaceutical technology, the
most important of the latter being bio- and genetechnology. While these are of direct importance to the
diagnosis and therapy of many hitherto incurable
diseases is information technology influencing
healthcare both in an indirect as well as a direct way.
The direct effects stem from the development of telemedicine like expert systems or information and
accounting
networks
in
social
healthcare
organisations. The general influence of information
technology is in enhancing the effects of general
globalisation.
Globalisation must be understood not only as an
economic phenomenon but as a profound change in
political and social philosophy as well: a resurgence of
an earlier variety of capitalism. This has important
consequences for the European type of social
healthcare systems. The balance between private and
public will be tilt toward a re-privatisation of sickness
and the provision and funding of healthcare. Pressure
on labour costs and employment will increase resulting
in an erosion of the tax base. The spread in the
distribution of income and wealth will increase leading
to tremendous distributional struggles. All three of
these developments will undermine a sound funding of
healthcare and required far reaching reforms of the
existing systems.
Europe’s further integration must include the
development a new social order on the European
level. Mobility of people, goods, capital, and services
will not stop at the provision and perhaps also the
funding of healthcare. Already now networks for the
provision of healthcare are transcending national
frontiers.
I conclude that the endogenous factors will lead to a
rather smooth progress in the provision of medical
treatment in the proper sense. But the external factors
will force hard decision upon the governments of the
members of the European Union and the Union itself
on how to organise and fund the social security
systems concerning healthcare.
Edward R. Roberts
Good Evening, Ladies and Gentlemen,
European Health Care at the Turn of the Millennium
An American friend of mine used to remark: „Where
you are at, tells you where you are coming from“,
translated into English, one’s previous experiences
give an indication of your views on the future.
Therefore, before I dwell on the future, let me reflect
on the past and in particular my own personal
experiences in the pharmaceutical industry.
I started some forty years ago as an apprentice in a
Welsh pharmacy and my first task in the morning was
to make up gallon bottles – the day’s supply, of Aspirin
mixture, cough medicine, (with enough morphine in
them to be declared illegal today), Potassium Bromide
+ Valerium mixture – supposedly effective in all central
nervous complaints, and gallons of an Antacid Mixture.
The pharmacy market in the UK was essentially a
generic market, and most of the proprietary medicines
which were available with the exception of a few
antibiotics were not terribly effective.
All of this was reflected in the hospitals which served
Rhyl, although a small town, we had five hospitals
nearby, an isolation hospital, now closed as the result
of new vaccines eliminating diseases such as polio, a
TB hospital, now closed as a result of new
pharmaceuticals. A much feared “Asylum for the
Insane”, heavily locked doors, barbed wire fences,
recently closed because of lack of patients, and two
smaller general hospitals dealing particularly with
acute cases; pneumonia etc., also now closed. There
exists today a new hospital, certainly with fewer beds
than existed in the other institutions, and with a focus
more on chronic conditions, hip replacement,
pacemakers installation, and obvious a variety of other
conditions.
All of which leads me to make the following
observations:
firstly
new
technologies
have
enormously benefited patients, and secondly health
care costs should be regarded in their totality, not
separating one aspect, namely pharmaceuticals
without regard to their impact for example on hospital
care. We should also not be too short term in our
outlook, preventative medicine which may impact
today’s budget will reduce future costs, for example
new therapies for the prevention of osteoporosis.
“Where I am at”, has obviously been influenced by
where I have worked, and my career has been divided
between a major US pharmaceutical company, and for
nine years, until my retirement in July, head of worldwide pharmaceuticals for a German company, E.
Merck. The major change over these thirty years has
been in research, from research often rewarded by
chance, the chance discovery in the 60s of an
organism in the sewers of Sardinia leading to a new
class of anitbiotics, cephalosporins to targeted
research driven by the new technologies. Genomics
providing specific targets in difficult to treat diseases,
combinatorial chemistry exploding the number of
candidate compounds, high throughput screening
making the whole process more efficient, and now
pharmacogenomics, allowing the detection of
population / patient variation with respect to drug
absorption and metabolism, why some drugs work on
certain patients and not on others, and improving the
relevance of the drug target for disease. For the first
time as a result of these technologies we see not only
improved therapies for difficult to treat diseases such
as cystic fibrosis, where patients rarely survive beyond
30 years of age, but of eliminating the disease through
gene therapy.
Pharmacogenomics could improve the efficiency of
drug therapy, by indicating which products are likely to
be effective. Innovation is the key to controlling
increases in health care costs.
Companies in the industry are in a race, an expensive
race, to keep abreast of new technologies. In the past
15 years the amount pharmaceutical companies have
invested in R & D has increased fivefold, it takes 12
years and costs about ECU 400 million to bring a
newly discovered substance to the market. All of which
has led to a consolidation within the industry. Not so
much in my opinion as a result of the so-called “critical
mass factor”. I have yet to hear of a company with a
good pipeline complaining of critical mass. However,
companies who may have a periodic fall short in their
pipeline, look for synergy cost savings by merging with
other companies until things improve.
There have been winners and losers, and the clear
winners have been the US companies. In 1980 the top
20 pharmaceutical companies held a market share of
44 % of the world market, in 1997 that has moved to
53 %, although it is still important to note the leading
company has only 5 % market share. During the same
time period the US companies in the top 20 moved
from 23.5 % of the world market to 29.5 %. European
companies in the top 20, and here – and I hope they
forgive me – I have not included the Swiss in my
definition of European, have also improved and now
hold 17.4 % of World Market Share. If I did include the
two Swiss companies this would move to 24 %.
It is interesting to note that between 1980 and 1997
US companies in the top 20 in the European market
improved their market share from 10 % of the
European market to 18 %. What do all these numbers
show, there is a steady remorseless concentration in
the pharmaceutical industry, not as dramatic as people
may think, and the US companies have gained market
share.
Why have the US companies been successful and
why have some, not all, European companies slipped?
Why has this happened, well to quote Shakespeare:
“The fault, dear Brutus, lies not in our stars but in
ourselves.” Certainly it is true in some cases
management missed the impact of the biotechnology
revolution, also luck may have played a part. When
asked who were his best generals, Napoleon replied:
“The lucky ones.”
However, the success of the US industry cannot be
explained by luck alone. Researchers in US
universities were the first to recognise the importance
of the new technologies, they were more willing to
participate in the commercialisation of the new
technologies, and the financial institutions were willing
to provide risk capital. Europe is changing, there is an
emerging market for biotechnology, venture capital
companies are springing up everywhere, but a lot still
needs to be done. Let us not forget we are comparing
ourselves to a moving target, the US research industry
continues to grow and expand. Today there are
27,500 people employed in Biotech in Europe
compared to 118,000 in the US.
Apart from the research environment the government
environment played an important part.
The US Government and
I would suggest
governments in the UK have been willing to support
the industry. As I recall a Minister in a UK government
telling me many years ago, he wore two hats, one as
the sole customer for pharmaceuticals, where he was
concerned with values for money, the other to support
a strong technology-orientated export industry. Too
often it seems to me European governments wore one
hat, and that was “cost”, forgetting that there are over
half a billion people employed in the industry and that
the industry generates a trade surplus which in 1996
amounted to 13.3 billion ECU. Again the US
Government took a reasonable approach regulating
biotechnology, whereas it has taken too long for
sensible European biotechnology legislation to be
effected.
Finally there is the market environment, a successful
emerging US Biotech Company had to convince one
regulatory body that its product made merit and then it
could approach customers, the decision on pricing
being their own. The market is still competitive, new
products being constantly introduced, and the large
purchasing groups exercising their buying power.
Compare this to Europe, thankfully we now have a
new European regulatory authority doing a fine job,
but we have a pricing jungle, with parallel imports
making a mockery of the term “Common Market”. Now
if you were CEO of a large pharmaceutical company,
be it European or American, with 2 billion dollars to
invest in research, which environment would you
choose? It may be purely coincidental but the three
European companies in the top ten, Glaxo, SKB and
Hoechst, have free pricing in their home market.
Hoechst were No 1 in 1980, “der Apotheker der Welt”,
today number 9, certainly not helped by the past
attitude in Germany to biotechnology.
Are things improving, yes, the recently published
Boston Consulting Company Report, published by the
VFA, in Germany clearly shows this to be the case –
but particularly in pricing and parallel imports a lot has
to be done. Commissioner Bangemann has been
enormously helpful, and the Frankfurt Round Tables
sponsored by him, allowed the ensuing debate to
recommend solutions, but we need action.
Finally let me say a few words about PPBH,
Pharmaceutical Partners for Better Healthcare, an
organisation founded by the CEOs of the 34 leading
pharmaceutical companies in the world, US,
European, Japanese whose research budgets account
for 80 % of the research expenditure for the entire
pharmaceutical industry. I have been Chairman for the
last four years.
The two primary goals of the organisation have been
to perform research into Health Care Reform, a
landmark study financed by PPBH was the NERA
study (National Economic Research Associations), an
independent review of the Health Care Reform in 12
major countries. The results were published in 1992 in
two volumes and although priced at over $ 300, is into
its third publication, it has been so successful that we
have been approached by other countries to perform
similar studies, and the total number of studies in
countries now stands at 22.
At the end of this year we will complete an update
looking at what has occurred since our first review and
can we learn anything from the new experiences of
various countries. It would be difficult to generalise
what has come out of this research, but it does show
how important it is to involve the patient in health care
choices.
To this end we have studied co-payment systems and
a very specialised study on risk sharing. Our aim has
been to put together a body of information that allows
us to become better partners during the discussion on
health care reform.
The second goal was to create alliances, with a
particular emphasis on patients. One of our first
meetings was in Atlanta, USA, where we met with
representatives of patients’ groups representing 40
million patients world-wide. From this meeting our
work with patients has grown from strength to
strength, patients with our support are now publishing
a Newsletter, The Patient’s Network, which is
circulated in 80 plus countries, and have formed a task
force to form a world-wide patient organisation,
I.A.P.O.,
International
Alliance
of
Patients’
Organisations.
During my time in office I have spent a great deal of
time with patient groups, for whom I have enormous
respect
-
For their courage in facing what in many cases are
life-threatening and in every case life quality
reducing diseases.
-
For their knowledge, through their own networks,
through the internet, through the media. Their
knowledge of the diseases is impressive, but more
importantly as they put it, the patients are experts
in living with the disease.
-
For their independence, they are willing to work
with the industry, with the medical profession, with
providers, but on their terms.
-
For their positive influence, they are beginning to
recognise their power and are utilising it.
All of this is driven by increases knowledge, leading to
increased confidence. This knowledge is coming from
patient organisations, the media, and the Internet. It is
estimated that 37 % of US users of Internet use is for
health care information, the NHI website has over a
million visits a day.
It is not a US phenomenon, the FAZ (Frankfurter
Allgemeine Zeitung) on Sunday 13th September listed
over 20 major Websites giving Health Information, and
more in preparation for example the Frankfurter Uni
Clinic Search Machine with access to 10,000 pages,
and there are hundreds of Websites from patient
groups, and thousands of Chat Groups among
patients so if you think about the Millennium we have
to recognise this increased knowledge and expertise
amongst patients particularly with chronic diseases.
I am convinced that one of the most under-utilised
resources available in health care reform are the
patient organisations.
So let me summarise and tell you “where I am coming
from” at the European Health Forum Gastein.
Our focus has to be the patients, we have to involve
them more closely in our research, in our research, in
our marketing in terms of better, clearer information
and in terms of health care reform. Our interest and
theirs coincide when we are focusing on solutions to
their problems as a result of innovative research.
According to an article in the FAZ (Frankfurter
Allgemeine Zeitung) on September 6th 50 % of US
families have access to computers, 25 % have access
in Germany, but the GAP is closing. By the millennium
we will have the ability to interact with patients on an
unprecedented basis.
With this increased authority of patients will come
increases
responsibility.
An
awareness
that
prevention, be it diet, exercising or whatever, is better
than cure. Increased compliance, estimates today
show that compliance by patients in therapy is often as
low as 50 %. Patients where possible will have to
contribute financially to health care, recognising that in
certain cases the State will have to provide a “Safety
Blanket”.
As to the industry, the winners in the new millennium
will be those who are successful with innovative
research. In an article I once read in the Harvard
Business Review some 30 years ago, “The only thing
we are sure about the future it will be different, and the
other is, we don’t know what will happen anyway”. So
the emphasis is on flexibility with outsourcing
becoming more frequent. Here is the opportunity for
Europe to help create these small service companies
be they research, production, or IT providers.
Finally, the role of the government is to recognise that
they will be unable to meet this increased demand for
health care services, caused by the ageing population
and new technologies unless they work closely with
their partners, the health care providers, the industry,
and above all the patients.
Innovation and the support of research must play a
central role. Industry has offered constructive ideas for
how to create “head room” for wider use of new
therapies. They include greater acceptance of
generics, the regulations on registering generics on a
European basis are still not clear, and in many
countries generics still have to go through a time
consuming price approval process instead of allowing
the market to function. In addition, the industry has
questioned the continued payment by providers for
OTC products, often so called “comfort products”
which account for up to one third of some European
country pharmaceutical budgets. The need for new
thinking in new direction is urgent, but the end point is
clear, we have to move towards the conditions of a
normal market, i. e. market pricing. Innovation is the
key, in 1996 the average share of public
pharmaceutical spending allocated to patented
products was 22 %.
Whatever short term benefits governments achieve by
squeezing the cost of innovative pharmaceutical
products, the long term effect of such measures is to
reduce the research capability of the pharmaceutical
industry in Europe. Reducing the availability of
innovative products to patients is a certain recipe to
increased future costs. The signs at the cross-roads
are clear, continue the present road, or take the road
of innovative partnership.
I remain optimistic, we have come a long way, this
conference provides an opportunity to go further.
Visions of the Future
Mikko Vienonen
The widespread nature of health care reforms suggest
that they are being generated by broad secular trends
crossing national boundaries. In many cases, health
care reforms are not an isolated phenomenon but are
instead part of wider structural efforts to reform various
state-supported welfare and other social sectors.
Health policy in Europe over the last two decades has
been increasingly bedevilled by the growing cost of
care. The ageing population associated with higher
levels of chronic diseases and disability, the increased
availability of new treatments and technologies, and
rising public expectations have exerted an upwards
pressure in overall health-related expenditures.
In 1996 WHO/EURO organised a Ministerial
Conference in Slovenia with 46 European Member
States. Based on an extensive analysis of the situation
in health and the health care sector they came up with
the Ljubljana Charter on Reforming Health care in
Europe stating that within the European context health
care systems need to be driven by values (such as:
human dignity, equity, solidarity and professional
ethics), targeted on health, centred on people, focused
on quality, based on sound financing, and oriented
towards primary health care. In order to manage the
change, the countries would need to develop a
national health policy, listen to citizen’s voice and
choice, reshape health care delivery, reorient human
resources for health, strengthen management and
learn from experience of others. These principles
encompass the WHO vision for future health care
systems which in our view must include both “the heart
and the brain”. The evidence that WHO/EURO has
accumulated, clearly indicates that health care
systems cannot be left to the mercy of market
mechanisms alone, if – as we should – our main
focus is the health gain of populations, including the
vulnerable groups, and not just short term economic
wins.
Reforms pursued on the supply side (for example,
allocation and production components), have fared
relatively well. Efforts to change provider behaviour
include public contracting for hospitals, along with
capitated or mixed models of payment for GPs. In the
area of production, relatively successful measures
have included provider-oriented initiatives such as
continuous
quality
improvement,
technology
assessment, practice guidelines, and substitution of
less intensive for more intensive services. Conversely,
the reforms have been less successful when they
have been focused on the demand side, on the
application of market-style incentives. The issue of
“state or market” has shown that the greater the
reliance on market mechanisms, the greater the need
for a reinvigorating state role. Our vision of the future
is that the lower down in the public sector power over
the health system is decentralised – including
privatisation –, the more important it becomes to have
a central structure to set standards, monitor and
evaluate performance, and prevent opportunistic
behaviour.
Another growing movement is the issue of patients’
rights and citizens involvement in their care decisions
and also in the administration of their health services.
The WHO Declaration on the Promotion of Patients’
Rights in Europe (Amsterdam 1994) and the
Convention of Human Rights and Biomedicine (1997)
of the Council of Europe provide a good direction for
further development towards better health systems for
the European people.
A true challenge will be in how to move from health
services reform to health reform. Health care services
in fact are relatively limited in how much health gain
they can bring about, and therefore a stronger
emphasis will be needed on broader public health,
community health and environmental health. The
importance of public health is clearly recognised in the
EU, and based on the Maastricht and Amsterdam
Treaties, as affirmed in Article 152, we expect the
development of a coherent EU public health policy and
related programmes and actions.
Collaboration
between the Commission and WHO has in fact been
growing in many areas, as reflected by recent
communication on public health of the Commission to
Member States. WHO welcomes this collaborative
partnership for health, as it will have an impact on all
policies and activities of the Commission, and we will
contribute to it in the light of the principles of the
renewed Health for All Policy “Health 21”. Taking
these issues and responsibilities forward, WHO will
continue to commit itself to offer its expertise,
networks and experiences to this common cause of
sustainable health achievements in Europe.
(see Annexes 1-4)
Cornelia Yzer
Chairman, Good Morning Ladies and Gentleman. I am
very pleased that I have given this opportunity to
develop some thoughts and visions on the impact of
pharmaceutical industry on Europe and Health Care in
Europe. For more than 50 years we have witnessed a
slow but constant process of increasing of European
Integration. Today Europe already has a strong impact
on medicines registration and on the framework of
R&D in Europe. Europe and the World have changed
dramatically in the last decades. Globalisation is a
password of the 90ies but it is not only a password it is
reality. On the bring of the 21st century the world
economy becomes increasingly more competitive.
During the past decades, when Europe grew up, the
scope for health care has also undergone a revolution.
However, there are still numerous diseases modern
medicine cannot cure. Millions of patients and their
families know that artritis, cancer, heart disease, many
tropical diseases and new threats, that continue to
arise are still challenges to human life. Aids is the
most obvious example of that. Just imagine about
30.000 different diseases are known today. Only for
roughly 1/3 we are able to provide adequate forms of
therapy. I think this figures make clear to everybody
that there is still a lot of work to do. The public expects
that industry develops new high quality medicines to
treat diseases and to increase the quality of live.
Industry is living up to that expectation. More than
80.000 people are employed in pharmaceutical R&D in
Europe and between 1979 and 1993 are in dispensing
sort of high fault increase. And there is another figure
illustrating the promising results of the enormous R&D
activities research based pharmaceutical industry in
Europe is involved then. At least 160 substances are
presently either going through face 3 of clinical
research or marketing of the procedures or about to
be launched on the market. Besides there are the
reasons, why Europe needs a thriving pharmaceutical
industry. The pharmaceutical industry is a high tech
industry par excellence and that is exactly what
Europe needs today. As we all know traditional
industries in Europe can’t create the Jobs of the
future. Many traditional Industry cannot compete
anymore other nations take advantage of the new
opportunities and emerge as competitors. The high
level of unemployment is an alarming sign in many
European nations. Pharmaceutical industry is able to
provide high skill, high vague
employment
opportunities in Europe. The social returns are most
compelling for the long term significance of a high tech
pharmaceutical industry. So, for different reasons
Europe should offer an environment with long term
prospects for world-class pharmaceutical industry.
Undoubtedly progress has been achieved. In recent
years significant advances have been made. After
more than 10 years of discussion the biopotent
directive had finally been adopted. It is an essential
prerequisite for the development of innovative
pharmaceuticals and will improve the treatment and
quality of live of millions of patients in Europe and
world-wide. It‘s adoption is a sign that Europe remains
internationally competitive and a prime location for
research and production. The proposal for a clinical
drug directive and the northen drug regulation are two
other European regulative projects which deserve the
part. Great efforts have been made towards
completion of a single market in pharmaceuticals in
Europe. Let me just remind you once more of the
European
medicines
evaluation
agency,
it’s
centralised European registration is a great success
story and an asset for available European
pharmaceutical industry. However, the single
European market for pharmaceutical products still
lacks it’s completion. Pharmaceutical manufacturers
are still subject to a number of price regulations in
many member states there are still bureaucratic
hurdles causing delays why companies strike to
introduce new innovative medicines and make them
available to patients. The most pressing issue we have
to deal with is attentions between national price setting
and the free movement of goods in the European
Union. The pharmaceutical industry has been
confronted with this dilemma for decades there is
nothing new about it, however, political decision
makers and courts have started to pay more attention
to this issue only lately. Critics might say, what is so
special about the situation of the pharmaceutical
industry? Are not other industries subject to the same
economic and legal framework in Europe? Well,
pharmaceutical industry cannot be compared to carproducers or more generally speaking to capital goods
of consumer products manufacturers. The situation
pharmaceutical industry has to deal with is quite
unique. On the one hand we have a homogenous
product, a drug, on the other hand we have a
heterogeneous environment with 50 member states
each carefully guarding it’s national prerogatives in the
field of price setting and reimbursement policy. At the
same time European institutions namely the
commission and the European Court of Justice try to
foster the single market. Every locationer coming back
from one of the Mediterranean member states knows
about the price differences in pharmaceuticals in the
European Union. However, the reasons for them and
their implications are wide reaching and known only to
a few insiders. Well, to put it into a nut shell today’s
price differences especially for older products are the
result of currency relayments and government price
control mechanisms for pharmaceuticals. Apart from
the direct influence of administrative prices there are
the side effects rising from the conflict between
national cost-cutting measures and the principals of
the free movement of goods. This conflict is the cause
of the so called parallel imports. Parallel imports
normally arise, if price arbitrage exists for a product.
According to economics, text books, arbitrage,
favours, consumer interests and is generally
considered away to improve overall health care. Well,
this commonly held view of arbitrage is challenged in
the particular circumstances pharmaceutical industry
is in Europe. The basic reason why the concept of
arbitrage is not applicable to pharmaceutical products
in Europe is obvious. There is no market for medicines
in Europe as I have pointed out earlier nearly all
member states have national price fixing or price
control systems - that is no market, that is
reimbursement. Consequently arbitrage has a totally
different meaning in a regulated price context. The
incentive for this kind of trade a medical product is due
to price differentials caused by politically motivated
government and intervention. In fact parallel trade in
pharmaceutical products in Europe does not result in
significant savings for consumers in so called high
priced countries, it rather benefits this tribution mainly
the whole sellers little or not benefits comes to the
individual consumer of the reimbursement authority. I
would like to remind you that developing costs of a
new pharmaceutical product amount to an average of
500 Million. Where can the vanues which are required
for the development be generated? Primarily this is
only possible in the treat for example in Western
Europe, Japan and the US. However, the
administrative price controls of some member states of
the European Union have direct or undirect negative
implications and make it increasingly harder to
generate sufficient financial resources for future
innovative pharmaceutical treatments. I think that we
have to agree that the situation I have just described
cannot be considered conducive to the long term
prospects of an industry. The resulting distortions may
lead to the diminishing competitiveness of European
pharmaceutical manufacturers in world markets. The
European Commission and certain members said I
increasingly becoming aware of this danger. In this
contact I would like to mention the last two round
tables under the hospices of Commissioner
Bangemann in December 1996 and 1997. This
dialogue between representatives of industry, member
states and European Institutions has helped to
heighten the awareness of the peculiarities in the
market for pharmaceuticals and the research base
pharmaceutical industry is looking forward to
continuing this exchange of ideas in December in
Paris. We also hope that is a forthcoming commission
communication on the pharmaceutical market will take
into account to positive steps which could be on
disarched in the council conclusion of May 1998. The
latest decision of the European Court of Justice on the
freedom of movements of goods and services show
that slowly but constantly step by step the room for
decisions of the national level becomes more limited
and national prerogatives become hollow. Health
services and health products will become increasingly
tradeable in Europe. This trend towards a more market
driven environment is very ceased by industry it is a
step towards more individual responsibility and more
personal
freedom.
The
research
based
pharmaceutical industry in Europe strongly supports
the completion of a single, competition based market.
Until that goal is achieved there remains an incurrent
and fundamental conflict between the free movement
of goods principal and national laws governing
pharmaceutical prices. However, it should be pointed
out that a prerequisite for a freecoming market are free
national submarkets. What are the rembaties for that
situation? How can national regulations be reconciled
with treat until the requirements to build up competition
based market for medicines. I think that the regulation
seems to be the adequate answer. Member states
should start with reliberialising the respective natural
markets. The regulation prices for over the counter
medicines and developing a liberalised competition
based off patent and in patent segment will surf as
measures to improve the management of drug
spending in general. Any savings achieved by more
efficient allocative effects would remain with inhales
care budgets and allow for headroom for renovation.
Cost constrestrains and access restrictions sometimes
applied to be the newest and often most cost efficient
drugs would become obsolete. Coming to my
concluding remarks I would like to stress that the
European research based pharmaceutical industry
looks optimistic into the European future. It is an asset
with regard to economic research and technology and
health care policy. This industry can make a
difference, it can help Europe to become more
prosperous and a better place to live. To achieve this
common goals we are not asking for subsidies or any
other financial assistance to conserve outer dated
economic structures. What we are asking for is a level
playing field so that we can compete with US and
Japan. What we need is a framework which is equally
fair to all parties involved and takes into account the
interests of industry the limited public and finances
and the wish of the public for high quality innovative
medical treatment. We would like to remind European
political decision makers that research and
technology, health and industrial policy are community
policies and that is the pharmaceutical industries
economic viability and potential contributions to public
health should be sufficiently taken into account. A
simplistic approach mainly focussing on short term
coast cutting does not seam to be the long term
solution we need. What we need is a holistic approach
overcoming the pure cost management of the past.
The research based pharmaceutical industry is able
and willing to become partner in the integrated cost
and quality management of the future more market
driven European health care system and we would like
to call upon the commission to become more
supportive to country specific solution. We all have to
be open minded and we have to be ready to take new
pass. Why not Lexus agreement which was made
with the Spanish wholesalers? Thank you very much.
Jan Bultman
Health risks
Health will remain the first priority for many Europeans
in the next millennium.
Many health-threathening conditions are crossing
borders, not only between the member-states but also
between the EU and its neighbours. Therefore, it
makes sense that in the Amsterdam-Treaty the
obligation is stated to take health into account in every
EU-policy and in the policy of its member states.
Not only physical, chemical and biological factors are
important, but also socio-economical circumstances.
In the EU the differences in morbidity and mortality
related to socio-economical status are striking.
Social justice
The EU should take the lead in advocating social
justice between its member states, but also in dealing
with the new-coming members.
Integrated policy
The EU should develop an integrated policy towards
the different risk-factors influencing the health status of
the European citizens. The EU must try to balance
economic development and employment-policy with
health needs?
Regulating new technologies
The EU must organise an adequate balance between
the industrial policy of the EU, laying emphasis on the
free movement of goods not to be hindered by
national policies restricting the introduction and use of
new costly technologies, and the EU health policy :
trying to maintain an affordable health care system of
good quality within reach for the whole population?
How to deal with the technology imperative, the
enormous push from the “medical-industrial complex”?
EU efforts to organise and stimulate a common
framework for the evaluation of the added value of
new health care technologies would be most welcome
as would be a common research policy towards an
“evidence based health service”.
Stimulating research
Scientific research related to health should not be
prioritised only according to the interests of the
European health care industry
(pharmaceutical,
electro-medical etc.). Therefore, the initiative of the EU
to develop an orphan drugs policy and to stimulate
research towards “orphan diseases” can be
welcomed.
Stimulating comparative research, evaluating the
adequacy of health policy measures to enhance
quality and efficiency in health care delivery would be
welcomed also. Evidence based health policy making
should be the norm.
Portability
The EU must develop a policy to organise the
portability of (insurance) coverage from one country to
the other beyond the present EU-regulations and
should do this also concerning the private health
insurance sector.
Choice of providers
Freedom of choice for patients regarding the various
service providers is a valuable thing
In this respect the judgements of the EU Court in the
Decker/Kohll cases offer some perspective for the
citizens of Europe.
Free choice of provider and free movement across
borders presupposes well-informed patients, knowing
where to get good quality care. In this respect the EU
policy should not stop at the level of the mutual
recognition of diploms of professionals, but go for a
European Quality Initiative: a European system of
accreditation.
Accountability
Health is too important to leave it to doctors and
paramedics! Given the public money spend by them,
accountability and transparency of providers should be
the reverse side of their professional freedom
For many present-day interventions in health-care the
scientific basis is weak or even absent. Given the
financial pressure caused by new technologies the
need for reviewing existing ones will increase in order
to get rid of the non-effective or too widely used
technologies and to save money. A concerted
European initiative: a European Institute for Health
Technology Assessment and a European Clearing
House for validated clinical guidelines, would be
welcome.
Nursing care
Future health care in Europe is not only technology.
It’s also compassion with suffering people, trying to
alleviate their pains and worries. This has always been
the heart of the European nursing care. Where is the
EU intiative to strengthen the position of nurses? To
come with new stimuli towards a more independent
role for nurses in the community (nurse-practitioners
etc.).
Future developments
The strong points of the health care systems of the
various EU-member states should be maintained:
solidarity, universal coverage and access to needed
health care facilities of good quality. Adequate
management of systems, according to the principle of
subsidiarity, must use explicit decision-making about
new technologies before introduction into the system.
The introduction of market-elements in the health care
(-financing) system of some member states must be
carefully evaluated on possible negative side-effects
(risk-selection, better access for employees in
employer-based health benefits). Is there a need for a
European Accounting Office for the insurance
business, working across borders?
Sometimes health-professionals are just like human
beings: they like to have normal working hours in order
to take part in normal social life. Reducing working
hours must be compensated by adequate extra
manpower since many activities in the health care
sector cannot be replaced by machines. Society must
be prepared for paying for it.
William Hunter
It was only in 1993, by the ratification of the Maastricht
Treaty, that public health was added for the first time
to the Treaty. At that time, the European Commission
proposed a framework for action in the field of public
health.
Since then eight public health programmes have been
proposed by the Commission. Five of these have been
adopted by the European Parliament and the Council
and are being implemented. The three others are in
the course of being adopted.
The programmes that have been adopted run for a
maximum of five years, and are due to finish from the
end of the year 2000 on.
In addition the Community is confronted with a number
of important developments and challenges in the field
of public health. These include emerging health
threats, increasing pressures on health systems, the
enlargement of the Community, as well as the new
public health provisions in the Treaty of Amsterdam.
In order to reply to these various developments and
challenges, the Commission has put forward recently
its communication on the development of public health
policy in the European Community. It is hoped that the
ideas presented in this communication will stimulate a
broad debate on the future Community public health
policy.
Research and Development
Herwig E. Reichl
A short comparison of EU and US Life Sciences
industry shows the latter in a much more advanced
state, attributable primarily to a better socio-economic
climate.
It also shows that most R&D spending (in % of
turnover) and most rapid progress are made in small
and medium-sized enterprises (SMEs)). However,
many of them , especially start-up companies, cannot
finance R&D from profits made in existing business
areas like larger, established companies do.
So measures are necessary to stimulate R&Dintensive SMEs in Europe !
These should start at the EDUCATIONAL sector – the
roles of universities could be much more prominent if
they acted as INCUBATORS for new ideas and
developed more TEAM SPIRIT and economical skills
(and responsibility) at many levels. Quality
management systems should be developed and
implemented at all levels.
FUNDING of R&D – intensive start-ups is another
measure to stimulate their growth.
Tax incentives can only be useful if offered to the
investors, as start-ups usually are years away from
making profits.
Venture capital, which hardly exists in Europe, cannot
be the only answer, especially as R&D funding is highrisk funding.
“GENEROUS ALLIANCES” between SMEs and large
companies (or other institutions) should be
encouraged, e.g. by tax incentives.
ATTITUDES – which are much more difficult to
change than tax laws – must nevertheless be
changed. But instead of starting with the most
controversial topics (e.g. patenting of human genes),
consensus topics should be defined and generally
agreed.
Commercial and scientific organisations need clearly
defined “prohibited or danger zones”, and these
definitions have to be provided by society, not by
themselves.
REGULATIONS are another prime target for proposed
changes :
Many of them impede progress and necessary
changes. As an example, any change in the
production of a biological drug necessitates a new
registration of this drug. Consequently, companies
avoid the introduction of new steps which would
increase viral safety as long as possible – with
disastrous consequences, as witnessed in the last
decade.
A proposed model of interactions between industry,
R&D-intensive SMEs and universities utilises the
strong points and advantages of each partner and tries
to avoid their weak points :
Universities not only performing basic science, but
also nurturing (as incubators) start-up companies
Large established companies offering “generous
alliances” to SMEs as a next step
R&D-intensive companies offering high-speed, highquality services in newly emerging fields to larger
companies and also to universities
Society must bear in mind that new jobs and better
products in the health sector are mainly created by
small and newly emerging companies, which,
however, do not have the potential to bring new
products to the market successfully.
At present we are mainly doing R&D in the field of
TSE research, co-ordinating 3 EU-funded projects in
this area, but we are also contracted by major
pharmaceutical companies for R&D (as well as
trouble-shooting) projects, mainly in protein stability
and downstream processing in combination with virus
and prion inactivation.(HÄMOSAFE® patent)
Usually, Bio-Industry is represented at symposia by
speakers from large pharmaceutical companies. They
of course present their point of view.
As the organisers asked for controversial opinions, I
will advocate mainly measures which will benefit
SMEs (small and medium-sized enterprises) in the
BioSciences, and trust that the “big brothers” are
strong enough to help themselves.
In the European Union, there are altogether 18.5
million SMEs in all economic sectors.
Together, they employ 66 % of all European
employees and make 60 % of total turnover !
Pharmaceutical industry in recent years has
concentrated by fusion and merger. Synergies
resulting from these mergers and acquisitions were
not used to make new, better or safer products, but to
reduce the number of jobs and increase shareholder
values.
What are characteristics of SMEs ?
Size
Speed
Closer co-operation of all three “pillars”, but also within
each group, are needed.
European initiatives and programmes for R&D cooperation are the most direct and valuable way to
stimulate this.
Flexibility
High motivation
The disadvantages are : small size and lack of “cash
cows” esp. with start-ups
Research and Development – What is the role of
society to create a supportive environment for
R&D? - A commercial perspective
It is obvious that a newly emerging field like BioIndustries sees large companies diverting into this
area, and alongside mainly start-up companies.
I want to thank the organisers for the invitation.
All of you know the company I am replacing today :
SmithKline Beecham – one of the largest
pharmaceutical companies worldwide.
However I am quite sure that not all of you know
HAEMOSAN, the company I come from.
Haemosan is a small enterprise in the Biomed/Biotech
field, has been founded 10 years ago.
A comparison between US and European Bio-Industry
shows (in a nutshell) :
US Bio-Industry has 10 x more : turnover
companies
jobs
European Bio-Industry 10 x more increases
This indicates that the Industry is much more
advanced in USA than in Europe !
This is in part due to an earlier start, different socioeconomic conditions, but also different public
perception (new technologies seen as chances or as a
threat) and different ways of funding.
We must not forget that it were these differences
which made most European pharmaceutical
companies move their research centres for Life
Sciences to the USA in the late eighties.
This short comparison of EU and US Life Sciences
industry showed the latter in a much more advanced
state, attributable primarily to a better socio-economic
climate.
It also shows that most R&D spending (in % of
turnover) and most rapid progress are made in small
and medium-sized enterprises (SMEs)). However,
many of them , especially start-up companies, cannot
finance R&D from profits made in existing business
areas like larger, established companies do.
So measures are necessary to stimulate R&Dintensive SMEs in Europe !
These should start at the EDUCATIONAL sector –
Training in basic biotechnological skills must not be
restricted to universities:
In the USA, high schools teaching agricultural science
are now building biotech laboratories – not necessarily
to do world-class science, but definitely to introduce
these new ideas and methods (and opportunities!) to
the future generation(s) of farmers.
In Austria, several towns have 2 universities: the
“classical” one for pure science – and the Technical
University for IMPURE science?! Can we still afford
this duplication?
I believe strongly that students and industry alike will
benefit if both basic AND applied aspects are covered
both in teaching and research!
Another topic is specialisation: while other sectors are
forming Centres of Excellence and Clusters, too many
scientists at universities are looking for and defending
ecological niches, sometimes even looking for the
least interesting areas to suffer from minimum
competition.
Of course, they will experience little contact with
industry (or even funding), and might even be
jealously watching
institutes or colleagues with
different attitudes.
The roles of universities could be much more
beneficial if they acted as INCUBATORS for new
ideas and start up companies! Project work should
accompany, if not replace, individualistic training of the
students.
These projects could develop into project jobs (e.g. for
a PhD thesis) and gradually into start-up companies,
students, graduates and senior staff would for some
years enjoy infra-structure, equipment, stimulation,
basic research and new ideas offered by the university
incubator.
If the new business fails, they could (for a limited
period of time) be granted the right to return to their
job at university, as they still fulfil part of their duties
during that time.
I know exactly ONE Austrian start-up company lucky
enough to enjoy this type of genesis.
By contrast, American universities are proud of their
incubators, and many recent success stories have
started there.
Quality management systems should be developed
and implemented at all levels of university.
FUNDING of R&D – intensive start-ups is another
measure to stimulate their growth.
It is important to realise that high-tech start-ups have
to invest a major proportion of their funds in R&D,
often even in basic research. As they operate in very
complex areas like the health sector, return on
investment will – if ever – happen only after years,
even decades. Normal loans are therefore inadequate
measures.
Tax incentives can only be useful if offered to the
investors, as start-ups usually are years away from
making profits.
Venture capital, which hardly exists in Europe, cannot
be the only answer, especially as R&D funding is highrisk funding.
So, Public funding is needed for basic research as well
as for marketing steps later on, as a frequently
encountered problem is the fact that more money is
needed for the initial phases, and start-ups run out of
funds when they try to conquer the market.
There are several approaches on national levels, and
it is difficult to compare and evaluate them. I want to
caution, however, to use the “success rate” of start-up
companies (e.g. survival after 5 years) as a measure.
A success rate of 80% only indicates that the most
interesting and risky projects have been eliminated.
Success rates like this can typically be found with
general practitioners and peep shows.
I want to introduce another model for funding, which I
want to call “GENEROUS ALLIANCES” between
SMEs and large companies (or other institutions)
should be encouraged, e.g. by tax incentives. An
example was given by a European pharmaceutical
company, which generously funded small Biotech
start-ups (unfortunately only in the USA). These
companies were “spoiled” with plenty of money,
enough to allow them to concentrate on R&D for
several years, provided several milestones were met.
The only condition: after several years, the “big
brother” had the option to acquire either the majority of
shares, or had an exclusive or non-exclusive right to
use the technologies developed. This may sound like
a treaty with devil, but turned out to be very beneficial
for the junior partners: when the “hot” R&D phase is
over, other aspects gain importance: patenting, scaleup, process engineering, clinical testing and
registration, and finally – world wide marketing.
No start-up company can possibly perform all these
parts without coalitions with a large player, anyway!
So what is required are rules, maybe just a “codex”, to
establish fairness in these alliances, and maybe extra
tax incentives to make them more attractive.
would have to register our main products again, and
that would take many millions of pounds, dollars,
Marks, etc.. As regulatory authorities do not require
inactivation of prions, we are not going to do it.”
This reasoning was correct and economically sound,
but might have consequences similar to other delays a
decade ago.
Another area where regulations are inhibiting mainly
smaller companies: The European Patent Law! More
than 99% of all international scientific and technical
publications are in English; no scientist or engineer
could succeed without understanding written English.
Nevertheless, all European patents have to be
translated into 15 European languages before they are
granted. The costs for these translations are twenty
times higher than the costs for the European or US
Application, and are more than 20.000 ECU for a short
patent! As R&D usually leads to more than one patent,
these unnecessary costs become very inhibitive.
Conclusions:
ATTITUDES – which are much more difficult to
change than tax laws – must nevertheless be
changed. But instead of starting with the most
controversial topics (e.g. patenting of human genes),
consensus topics should be defined and generally
agreed.
As a sound majority of citizens favours application of
gene technology in the field of medicine, but is
cautious of its use in food production, it should be
possible to agree along those lines.
Plant biotechnology when used for non-food
applications (e.g. fructanes from sugar beets) could
also be included.
Commercial and scientific organisations need clearly
defined “prohibited or danger zones”, and these
definitions have to be provided by society, not by
themselves.
REGULATIONS are another prime target for proposed
changes :
Many of them impede progress and necessary
changes. As an example, any change in the
production of a biological drug necessitates a new
registration of this drug. Consequently, companies
avoid the introduction of new steps which would
increase viral safety as long as possible – with
disastrous consequences, as witnessed in the last
decade.
HÄMOSAN is a witness of this problem: our
HÄMOSAFE® process, developed to inactivate
viruses and prions in biologicals, was ignored for
several years, and the stereotype answer was: “We
A proposed model of interactions between industry,
R&D-intensive SMEs and universities utilises the
strong points and advantages of each partner and tries
to avoid their weak points :
Universities not only performing basic science, but
also nurturing (as incubators) start-up companies
Large established companies offering “generous
alliances” to SMEs as a next step
R&D-intensive companies offering high-speed, highquality services in newly emerging fields to larger
companies and also to universities
Society must bear in mind that new jobs and better
products in the health sector are mainly created by
small and newly emerging companies, which,
however, do not have the potential to bring new
products to the market successfully. I hope this will
also influence Austrian government decisions on
biotech funding.
Closer co-operation of all three “pillars”, but also within
each group, are needed.
European initiatives and programmes for R&D cooperation in co-ordination with the respective national
initiatives are the most direct and valuable way to
stimulate this.
Bruno Hansen
The strategic elements for public health research in
the European Union have been challenged in two
important meetings organised with the support of the
BIOMED Programme, namely in Celle (Germany) at
the end of 1994 and in Noordwijk in April 1997 on the
occasion of the Netherlands’s EU Presidency.
The main conclusions of the Celle meeting were
centred around the necessity of defining relevant
health objectives and indicators by considering the
main public health goals and strategies. In fact the
suggestion of adopting a broad interpretation of these
research areas and tasks was retained in the « Public
Health Research » sector of the BIOMED 2
Programme which has been successfully implemented
during the years 1995-1998 by supporting 80 projects
in areas such as efficiency of health services and
health care quality.
The more recent Noordwijk meeting, which has
witnessed the direct participation of Commissioner Mrs
Edith Cresson, pointed to the common concerns that
European countries are facing : an ageing population,
the threat of re-emerging and new infectious diseases,
the increasing burden of mental and neurological
diseases, growing concern for the safety of food and
exploding health care costs. These considerations
have clearly been taken into account in the Fifth FP. In
fact one of the main research themes is focusing on
the « Quality of life and management of living
resources » and the problems of achieving safer and
healthier food, of controlling the emerging and reemerging infections and of preventing and treating
age-related diseases and disabilities correspond
exactly to the objectives of three key actions of this
theme. It is important also to note that these key
actions are well complemented by specific activities of
a generic nature, such as research into genomes and
genetic disorders as well as into neurosciences,
addressing problems that require a joint European
effort in order to find solutions.
The development of networks in the different areas of
biomedical research has been one of the major goals
of the BIOMED Programme and it has been
successfully achieved since the average project is
involving the participation 10 different partners. This
trend will be strengthened in the Fifth FP with the
formation of clusters where a defined group of projects
addressing main objectives in the context of a key
action or a generic activity will be encouraged to coordinate their efforts towards a common goal.
The problem of education, teaching and learning, has
been one of the major aims of the Fourth Framework
Programme and has been tackled by both the
Programme Training and Mobility of Researchers and
within each specific programme. In the case of the
BIOMED 2 Programme, 150 fellowships were awarded
to young researchers to move to European
laboratories and to perform training and research in
the different fields of biomedicine and health. This
problem will be carefully addressed also in the future
Fifth FP where the system of Marie Curie fellowships
will be adequately enlarged and improved.
An important complement to the key actions and
generic activities will finally be provided in the Fifth FP
with the support to research infrastructures which will
allow, among other objectives, to make optimum use
of databases and collections of biological materials
and of centres for clinical research and therapeutic
trials.
As far as Health Research is concerned, the new
approach of the Fifth FP with a new structure, a
reduced number of concentrated programmes,
focused research tasks and improved management
will allow the EC research programmes to be closer to
the citizen and address the real health problems of the
European population.
As such they will be able to create a solid base for
both science-driven and problem-solving research and
allow the scientific community and the society to
interact in a favourable environment.
Development of the
Health Sector
Robert Jones
“The Approach to New Healthcare Policy”
Our panel is charged with offering some thoughts on
the development of the health sector in the European
context.
My remarks will be influenced by my
pharmaceutical industry experience, and will refer to
two separate but connected phenomena - on the one
hand the potential we see now for dramatic scientific
advances in medicine, and on the other hand the
stress experienced by public sector financing due to
the growing demand for healthcare.
The connection between these two things is quite
direct, and there is a tension between them which, I
will suggest will, intensify in the coming years.
Science and technology
[It is sometimes said that we are now seeing the
creation of a third generation of pharmaceutical
research and development. The age of chemistrybased innovation (1940’s-1960’s) was followed by the
biology/pharmacology-based wave of innovation
(1970’s-1990’s). Today’s third generation is propelled
by genetics, automation and informatics. (See Annex
5, Illustration 1)
We have not time today to explore all the implications
of the new understandings of genetics and molecular
biology but they already seem likely to have a huge
effect in two directions:
They will lead to the more efficient discovery and
development of new medicines. It will be possible to
identify a genetic basis for many diseases. And this
knowledge will enable more efficient and accurate
development of drugs to treat the disease. (See Annex
6, Illustration 2)
At the same time, new genetic understandings will
have impact in the doctor’s surgery. They will enable
more accurate diagnosis - either by genetic mapping
of infective organisms, allowing their quick
identification; or by genetic mapping of the patient
him/herself, assisting identification of the disease. In
either case, the outcome will be more accurate, more
effective therapeutic intervention.
What I would like to focus on is the effects this will
have on demand for healthcare, and its implications
for public policy for healthcare delivery.
Demand for healthcare
Setting aside current - but temporary - setbacks in
global economic development, the underlying trends of
continued and even accelerating growth in demand for
healthcare seem irreversible.
There are four drivers of demand See Annex 7,
Illustration 3):-
First of all demographics. In the developed countries,
ageing populations are driving medical demand
upwards - in particular for treatment for chronic
diseases.
Longer life expectancy, linked with
increasing post-retirement income, and expectations
of a higher quality of life, contribute to this. In the
developing economies, population growth is a strong
positive demand factor combined with improving per
capita income.
That is the second factor - income per head. There is
a clear relationship between incomes and healthcare
expenditure. All around the world as people get richer
they want to spend more of their income on
healthcare. At the same time, in many countries
healthcare delivery is handled through governmentsponsored systems, and this has made healthcare
expenditure a political issue as well as an economic
one.
The third factor for growth is healthcare expectations.
People demand the healthcare interventions which
they know to be feasible - and they want them almost
as soon as they are known to be available. In most
developed economies there are high and growing
expectations of what constitutes our “right” to
healthcare. This relates both to complex and costly
medical or surgical interventions in life-threatening
disease and also to interventions which are now
classified as “lifestyle”.
Many serious conditions which as little as ten years
ago would have been accepted as “Acts of God”, are
now capable of amelioration by medical intervention.
And because that can be done, there is social demand
that it should be done. People expect the best
healthcare. In lifestyle medicines, we are now seeing
an increasing number of interventions which may have
a mixed clinical and social basis - for example, some
treatments for obesity, for male-pattern baldness, sex
change surgery, and, of course, Viagra.
And the final factor driving greater demand for
medicines is the availability of new and better drugs
and medical technologies, capable of treating more
diseases with wider patient benefits - developments
which inevitably tend to be more expensive than the
treatments which they displace.
Looking at these four factors, it is hard to see how any
one of them can be paused or reversed. Moreover, it
is hard to say that any one of them is not a good thing.
Increasing life spans, increasing wealth, high
expectations for higher standards of healthcare, and
availability of new and better medicines are all
fundamentally to be welcomed.
The financial tension
However, the higher demand for healthcare which they
create it isn’t always welcome, because many
healthcare delivery systems in many countries of the
world - particularly in Europe- have genuine difficulty in
meeting the increase in demand.
Greater demand means the need for more schillings,
pounds, dollars, marks, francs, kroner, to pay for it. In
many countries, where government directly or
indirectly sponsors this process, this creates a fiscal
stress. While citizens, as patients, demand the best
that healthcare can offer, the same citizens, as tax
payers, resist increasing government expenditure.
Healthcare administrators therefore have a difficult
juggling act to perform; and a variety of policies are
invoked to achieve the balance - cost cutting,
expenditure caps, delays in availability of new
interventions, rationing, queuing systems, co-payment,
etc.
It has also lead to the persistent idea that there is
some “proper” ceiling for healthcare expenditure as a
percentage as a country’s gross national product.
There seems to be no social or economic basis for this
notion. In principle, there seems no reason why
societies should not spend increasing proportions of
their wealth on healthcare if they want to. The
difficulty only arises because of the method of
healthcare financing, which in many countries is still
founded in the public sector
So in general terms, what we are seeing here is a
mismatch between a market - where the supply of
healthcare goods and services meets a demand which is developing and changing much faster than
the policy and systems which manage healthcare
financing.
The European public policy environment
In general, the criticism I have of public policy thinking
in healthcare today is that it is incapable of addressing
the long-term. Short political horizons always impose
short-term “fixes”.
Public policy thinking also tends to assume that old
social dispensations will persist - that the traditional
way of financing and providing healthcare cannot be
challenged or re-invented - even the Thatcher
governments in the UK, which in many other respects
were very radical, did not really challenge this.
Healthcare public policy therefore fails to try to think in
terms of new models - it merely tinkers with the old
ones, and attempts to relieve the fiscal stress by an
incessant series of short-term measures - in the case
of the pharmaceutical supply by a new round of “price
cuts”, or in the case of surgery by fiddling with the
queuing or eligibility system.
From the point of view of the pharmaceutical sector,
the problem with this approach to public policy is that
there is a high risk attached - it assumes that
pharmaceutical companies can carry on researching,
developing and producing important new drugs no
matter how many cost constraints are in place, or how
many price controls. There is perhaps a cynical
political view behind this which comforts itself with the
thought that even if innovation is really jeopardised by
current policy, the adverse effects will not be obvious
until after the next election but one (and so I won’t be
blamed!).
New policy-models: the industry’s proposals
The European pharmaceutical industry sees these
tensions very clearly and this is the reason why
through its European Federation, EFPIA, it advocates
a range of policies which it contends will take us in the
right direction.
In some aspects these policy models will not be
politically popular - because they imply that citizens
(and hence voters) must accept change to familiar
traditional systems of healthcare provision. But we are
approaching a point where there is no alternative. The
old dispensations will not hold. (See Annex 8,
Illustration 4)
The policy questions which the industry suggests
should receive serious thought include:
transition to mixed markets so that social provision of
healthcare becomes balanced with private purchasing
we need to consider how private purchasing can be
facilitated, through insurance, and how transitional
incentives can be put in place
recognition in public policy of the growing patient
participation in healthcare decisions arising from:
social trends
-
demand to know/be informed in healthcare
decision-making;
increased economic participation in the purchase
of healthcare;
how this will generate a need for new thinking
-
-
about provision of information to consumer/patient
(which
includes
direct
advertising
of
pharmaceutical products
regarded as anathema by many, but potentially a
positive force) Budgetary “headroom”
design of public expenditure policies which aim to
beneficially displace expenditure from one area of
healthcare to make it more efficiently available to
another, such as:
indication-linked reimbursement schemes copayments elements (with appropriate safeguards)
delisting of medicines and other interventions
from social provision (e.g. OTC switching in
pharmaceuticals) new approaches to resource
management.
Which healthcare interventions - which budget heads provide the best value for money? How can evidencebased medicine - holistically assessed - lead us to
more effective use of resources?
And, most fundamentally, policy thinking on whether
and how the social provision of healthcare should shift
from attempts at universal provision at the outer
envelope of healthcare feasibility to guaranteed
minimum provision by the State to which citizens can
add according to personal needs and expectations.
Some of these ideas will be dismissed as self-serving,
ideological; but as an economist rather than an
ideologue, I simply forecast that, whether we like it or
not, the twin pressures of demand and of technological
feasibility will force these choices upon us.
It is surely better if we face such choices on the basis
of sound preparatory thinking. And that thinking needs
to be encouraged and sponsored now.
I commend the International Forum of Gastein and the
sponsor of this Conference for seizing the opportunity
of the Austrian Presidency to create this first European
conference on health issues - and I hope that a
renewed interest in longer-term health-policy thinking
will be one of the consequences.
Walter Holland
Trying to predict the future is always hazardous. Most
attempts are usually found to be wrong – either by
failing to predict momentous events, failing to be
optimistic or the reverse by suggesting changes that
are not feasible or unrealistic. The only way that I
consider that it is realistic to approach the future is by
starting with the past and considering what changes
have occurred and should happen because of current
gaps. It is not my intention to try to deal with the
development of new drugs, new diagnostic tools or
new treatments – partly because as I am an
epidemiologist/public health physician I am likely to be
out of my depth, but also because it is important to
outline general issues – and then seek solutions,
rather than the other way round. I will also not deal
with the impact of new genetic advances partly
because they are unlikely, in my view, to have a major
impact on the common diseases, but also because we
are still ignorant – and whatever happens other factors
are as, or more, important.
Perspectives
Looking at the past 100 years, two central points
are clear – the changes and similarities. Firstly there
have been dramatic changes in terms of the
improvements in health, in health services, in the
environment and in quality of life over that time. The
changes have been particularly dramatic in terms of
increase of life expectancy and reduction in some of
the hazards to health
Secondly, there is much that remains similar. Many
of the problems of the past still bedevil us to day,
sometimes in a less serious or different way, and new
problems have emerged.
The improvements can be linked to changes in
expectation. People are no longer willing to accept
conditions that were commonplace – crowded, badly
heated accommodation, dirty towns, indifferent
medical treatment, decrepit hospitals and unsafe
working conditions. People are unwilling to tolerate the
“poor house” conditions in hospitals or general
practice. That is the positive side – but in many ways
life is more complicated and less safe. Homeless
people continue to live rough on our streets, and
although conditions in our industries have improved,
we still have unemployment, job insecurity and
increased stress.
Let us consider the major issue influencing health
which continue to require attention.
1.Housing
Some of the housing factors which contribute to
illness are due to faulty design which can cause falls
or fire, inadequate heat or light, dampness which leads
to growth of moulds and mites linked to chest disease
and lack of safe amenities for recreation. In spite of a
great deal of effort in all our countries, major problems
in housing stock remain in terms of quality, availability
and affordability.
2. Nutrition
One of the major influences on the health of any
population was and remains on how and on what it
feeds itself. Nutritional status can be influenced by
illness and other factors and is not solely determined
by diet. In turn it can influence resistance to infection
and health and growth, especially in children.
Before 1939, under-nutrition was the main
problem. The emphasis has switched to over-nutrition
and consequently overweight and obesity which is
associated with hypertension, hypercholesterolaemia,
non-insulin dependent diabetes, certain cancers and
has adverse effects on health and longevity. “overnutrition is greater among the poorer sections of
society – and greater in women than men.
3. Morbidity and Mortality
Infectious Disease
During the 20th Century the decline of infectious
disease has been the most important cause of
increased life expectancy. But, it is still a very
important problem. Tuberculosis, one of the most
feared diseases of the past, is still with us, and in each
of our European countries it is an avoidable cause of
death. In addition we now have tubercle bacilli that are
resistant to many of the current antibiotics. Although
typhoid and other forms of intestinal infection are less
common in some countries, there has been an
inexorable rise in cases of food poisoning, often
associated with either new agents, or old ones, e.g.
E.coli 157, in a different form. We have powerful,
effective immunising agents – but in most countries
have not been successful in achieving adequate rates
of immunisation to eradicate such diseases as
mumps, rubella or measles. New agents have
appeared, most dramatically HIV, for which adequate
immunising agents or methods of treatment are
deficient.
Chronic Disease
Some conditions such as rheumatic fever, arthritis and
respiratory disease have diminished greatly, mortality
rates from digestive, genito-urinary and nervous
system diseases have decreased. As against these
declines there have been increases in mortality from
circulatory diseases, cancers and asthma.
Maternal and Child Mortality
One of the most dramatic changes over the years has
been the reduction in maternal and child mortality,
including maternal deaths, but we now have to tackle
the problem of infertility, child abuse, and adolescent
behaviour.
4. The Environment
The most dramatic environmental change has
been the improvement in air quality in our towns and
industrial areas. We no longer have the episodes of
“smog” reported in the Meuse Valley, London or the
industrial areas of the RuhrGebiet. But, in spite of this
major improvement in air quality, the problems of air
pollution are still a matter of considerable concern.
Although there have been reductions in smoke and
SO2 there have been increases in levels of pollution
from road traffic, giving rise to an increase in other
pollutants, such as nitrogen dioxide and carbon
monoxide.
Past problems with domestic and public hygiene in
terms of adequate water supplies, sanitation and
sewerage have largely been tackled, but other
environmental issues have become prominent – e.g.
lead in the environment, in paint and in food, the
impact of the use of pesticides, the content of animal
feeds, the siting of waste dumps or the building of
houses on sites formerly used for waste disposal.
5. Behaviour
Tobacco – Scientific evidence of the harmful effect of
smoking cigarettes has been available since 1950. In
Europe it is probably the most important single cause
of death and disease. In the UK it is reckoned to be
responsible for at least 100,000 deaths (about 20%)
each year. Although smoking had diminished
considerably in most European countries, it is still
practised by at least a third – and of most concern is
that in recent years there has been a rise in the take
up of smoking in the young, particularly girls. Also,
smoking is much commoner in the less affluent and
less well-educated sectors of our society. Few
countries in Europe have had the political courage to
introduce effective anti-smoking policies.
Activity – With improved transport systems, more
advanced technology, increased leisure and very
widespread ownership of TVs and videos, another
problem has been created. In the past most leisure
and work entailed a certain amount of physical
exercise, fewer do so now. The lack of exercise has
meant that risk factors associated with conditions such
as coronary heart disease, stroke and arthritis have
increased.
Reproduction- Abortion and fertility have changed –
and one of continuing concern. Whereas in the past
abortion was illegal and practised illicitly in some of
our countries, it is now legal, and in some areas as
common as normal births. Whether this is appropriate
or whether other methods of controlling fertility, such
as “the pill”, should be further developed is an
important ethical issue.
Mental Illness – Mental illnesses have been a
continuing concern – and will remain so. Whereas in
the past most mental illness patients were cared for in
institutions – often in virtual isolation – most patients
are now looked after in the community. This has
caused concerns to some because of a number of
high profile events. The balance between care in a
“safe” environment for some and care in the
community for others still needs resolution. The advent
of powerful drugs, since largactil in the 50’s, has
completely changed the methods of treatment and will
undoubtedly lead to further developments.
Alcohol as an addictive agent and cause of much
disease, including mental illness, has been a
continuing concern – and no country, like for
tobacco, has had the courage to develop an
adequate policy. Politicians have been far more
concerned with other addictive drugs such as
cocaine, heroin etc. – which undoubtedly lead to
major health problems – but are of far lesser
importance in terms of numbers, or effects, than
alcohol.
Violence – Including child abuse, has been present
over the years and there is little evidence of any
profound change in incidence or effective methods of
prevention.
Accidents – There has been a marked reduction in the
rate of home, work and road accidents and
improvements in the methods of treatment of those
involved. Nonetheless, there is still great scope both to
reduce the frequency and improve the methods of
acute care and rehabilitation.
Drug/Medicinal Treatment - With the increase in the
availability and use of effective drugs there has also
been a rise in the side effects they can cause. These
have led to much more stringent safety testing of new
drugs before they are introduced. But there is also a
need to have more adequate systems of surveillance.
6. Poverty
Poverty stands out as a factor of major impact on
health in the past. There has been an indisputable
improvement in standards of life and in provision for
those in need. But even with these changes,
inequalities in levels of health between the various
social groupings have remained in all countries to the
detriment of the more deprived and are unacceptable
at the end of the twentieth century. One of the major
tasks confronting all our countries is to tackle these.
7. Organisation and the Provision of Health
Services
There is no doubt that the provision of clinical services
can and does improve health status. But it must be
recognised that the factors discussed earlier are more
important for the improvement of the health of the
population. Most countries are concerned with the
inexorable rise in health care expenditures fuelled by
both consumer and provider demands. As a public
health practitioner I consider that the greatest
challenges facing the clinical services are:
(a) Equity (service in relation to need) rather than as at
present when we discuss equality – meaning all get
the same.
Identifying effective methods of treatment, care and
rehabilitation – so that we can restrict the provision of
ineffective and wasteful forms of treatment.
Educating the population in the demands they make
on clinical services – that those in need demand and
receive effective modalities of treatment (e.g. That the
rates of immunisation in the poorest children are as
good as that of the affluent) – and that they do not
demand that medical services provide ineffective
therapies (e.g. antibiotics in the treatment of the
common cold).
Manpower – that we have an appropriate number of
adequately trained health professionals and that they
undertake those tasks for which they have been
trained. This must be linked to continuing professional
education. In view of the advances in treatment,
diagnosis etc. no health professional can rely on what
he was taught before qualifying, when practising ten
years later.
Teams – a major change, which has happened in my
lifetime, has been the need to develop team working if
we are to deliver the best care to individuals. This
requires the development of specific training and
appropriate methods of organisation
Specialisation – with the enormous increase in
knowledge two opposing trends require to be tackled.
There is a need for development of specialisation and
superspecialisation – but equally there is an increased
need to have individuals responsible for general, nonspecific care, for referral to the appropriate specialist
and for the continuity necessary to provide long-term
care and surveillance for those with a chronic disease.
Technology – I have not dealt with the problems of the
introduction, evaluation and assessment of new
technology, be it imaging, drugs or operative
procedures. There is no doubt that many changes will
occur, but their scope is beyond my brief.
Information – this is required to inform the individual or
patient on how to attain an optimal level of health,
enable judgements to be made by the population,
patients and professionals, on the quality of the
service, to make assessments of equity of access and
on priorities, and make it possible to collect valid
information and make it available for research and
development.
In none of the European countries do we yet have an
adequate system to satisfy these needs – but to
describe how this can be done requires much more
time.
Communication – a great deal of research and
education is required of health professionals to
improve their methods of communicating both with
patients on the consequences of the care and
treatment they are receiving as well as with
populations on the concepts of health risk
Conclusion
I have tried to outline some of the major factors which
have and continue to influence health and which will
need to be tackled if we wish to improve the health of
the population of Europe. Perhaps the single most
important factor for all our countries is the reduction in
the disparity of levels of health between the affluent
and deprived sectors of our populations.
Challenges and Opportunities of an Enlarged
European
Health Sector
Paul Brons
Europe moves, at the end of the century! Ambitions to
turn Europe into an “empire on which the sun never
sets”, have been fuelled by decisive events at the turn
of each century. In our times, it was the fall of the
Berlin wall, that re-ignited the ambition of building a
unified and strong Europe.
The European pharmaceutical industry has a positive
role and contribution to make in realising this ambition,
in terms of both the healthcare sector and the
industrial sector. This will, however, require the
acceptance of certain hard truths and the resolution of
some difficult questions.
“EU Enlargement and Opportunism” Inaccurate and illfounded suspicions on both sides can be - indeed,
have to be - overcome and opportunities seized.
EU Enlargement: the challenge of it! By building
consensus and working together, opportunities
presented by EU enlargement can be realised. This
would feature solidarity and industry in healthcare; the
availability of affordable quality healthcare across all of
Europe; an innovative, dynamic, and prosperous panEuropean healthcare industry - overseen by fair rules
to ensure a “level playing field” for all parties.
Whilst this is easier said than achieved, key decisions
and steps to reshape the European Community and
build Europe mean that by early in the next century the
EU will have both “deepened” and “widened”. Most
strikingly, this will feature an enlarged EU and a single
currency. Europe’s pharmaceutical industry has
already invested significant time, effort, and resources
in the candidate countries to share in the economic
expansion of these countries, to the benefit of both
parties.
But let us respect the differences! As is true regarding
differences between the EU and CEEC “regions”, so
there are great differences within them.
Differences in public health Like their western
counterparts, CEEC public authorities will have to set
priorities - not least in the allocation of available funds
- that tailor healthcare services to country-specific
circumstances.
Differences between “governmental” and “industrial”
priorities The capacity of the pharmaceutical industry
to sustain the R&D levels that are vital to therapeutic
breakthroughs, or normal economic objectives such as
returns on investment, must not be compromised by
short-term market-distorting policies.
The difference between funds available and health
expectations In reconciling limited resources with
virtually unlimited demand for healthcare, the
industry’s wealth of experience can contribute in
seeking an optimum balance among economic, social,
and ethical interests and possibilities.
Pharmaceutical industry contribution to the debate The
pharmaceutical industry is both ready to contribute to
the debate, and has structures to promote dialogue
and accompany EU enlargement. Via EFPIA’s Priority
Action Team, the industry seeks to input the
Commission on progress in transposing the very
extensive pharmaceutical acquis communautaire into
candidate countries’ national laws; advise and support
candidate countries in this task; and seek appropriate
solutions through dialogue to avoid developments that
would not be “sustainable”. The need for appropriate
temporary measures to address difficulties that do not
justify delaying access to the EU should be
recognised.
In practical terms, EFPIA is especially attached to
intellectual property protection, the key to future
innovation; rapid market access for new medicines;
free and fair competition - enforced by rules that are
consistent with measures that protect public health
and with those that protect intellectual property.
Conclusions
While an “empire on which the sun never sets” may be
somewhat ambitious, we can however meaningfully
contribute to “a Europe where the sun shines every
now and then over a peaceful community where both
the sick and the underprivileged, the industrious and
the scientists feel at home”.
Jef van Langendonck
1. European integration
At the heart of the European integration, as embodied
in the European Communities, the European Union
and the European Economic Area, one finds the
unshakeable belief that the market economy is the
best possible provider of welfare for all. In the postWorld War II period, when the European economies
had clearly lost their dominant position in the world,
the makers of the European Communities were
convinced that they could improve the performance of
their economies in a significant way, by giving them
more market and better market.
More market meant enlarging the size of the market
across the narrow national borders. In this larger
market capital, goods, services and workers should
move freely, in search of the best returns, prices and
wages. This would give both investors and consumers
a wider and better choice, and it would increase the
efficiency and productivity of the European economies,
resulting in more and better paid jobs for their
population.
Better market meant that a strong supranational body
had to be set up, with sufficient powers to establish
and to enforce the rules of free and fair competition on
this market. These rules were directed not only against
monopolistic and restrictive practices by actors on the
market, but also against subsidies and protective
measures by national governments.
This is the model the European governments still
believe in. It has attracted an increasing number of
countries to join the Community, and it has allowed (or
even forced) it to grow into an always stronger social
and political Union.
But this model has known some important exceptions,
from the beginning. The Common Agricultural Policy,
for instance, is not based upon market economy. It is,
in fact, an interventionist policy, not without similarities
to the former soviet-style Sovkhozes, serving more
political than economic purposes.
The other important exception is that of the public
service. Freedom of movement of workers does not
include employment in the public service, and free
movement of service providers can be limited by
considerations of public policy, public security and
public health. The Commission and the Court of
Justice have done their best to limit the scope of these
exceptions. They maintain a strict definition of public
service. National governments can not be allowed to
ignore the rules of the internal market by simply
declaring certain matters to belong to the public
service or to public policy (as the French tried to do
with their "service public hospitalier").
Health care is in all European countries a matter of
public policy, and at least to some extent a public
service. Does that mean that it remains outside the
scope of the internal market and of the E.C.
competition rules? Yes and no. Health care is a
borderline case, where a delicate balance has to be
struck between the advantages of competition on the
enlarged market, and the necessities of national health
policy.
The E.C. has already taken a number of positive
measures to promote freedom of establishment of the
medical professions throughout the Community,
notably by the Directives concerning the recognition of
diplomas. More recently, some decisions of the Court
of Justice have imposed on national health insurance
systems the duty to apply their financing mechanism
to medical services provided in another member
country, without the previous consent of the fund. But
on the other hand, public health measures are still to a
large extent uncoordinated, and the
public health services and national health insurance
schemes of the various countries still operate
according to their own rules.
The Maastricht Treaty, despite its move towards more
community social policy, has left social security in the
realm of national policy. "Social security", in E.C.
terms, includes public systems of financing of health
care, such as national health insurance and national
health services. In these matters, the Council of
Ministers can only regulate by unanimous decision,
which becomes increasingly difficult in a Community
with 15, and soon even more members. The
Community has only a limited competence in the area
of co-ordination of national schemes, which is
necessary because of the free movement of workers
and of citizens in the Community. It has also imposed
some general non-discrimination rules in this area,
concerning equal treatment of nationals of the various
member countries and concerning equal treatment of
men and women. And the Court of Justice of the E.C.
has made several decisions concerning application of
Community competition rules in social security,
including the provision of health care services.
All of this means that the health care sector has
remained largely within the competence of the national
governments. It is not an integrated sector. It remains
to a large extent a fragmented market, dominated by
the necessities of the public systems of financing and
organisation of care. As a consequence of this, it does
not benefit fully of the advantages of a large European
internal market.
It would appear that the national health services and
national health insurance schemes are rather reluctant
to open their systems for an integrated market,
because they are afraid of an influx of "social tourism",
which would increase their already problematic levels
of expenditure. In the logic of the European
Communities one should ask the question whether
more and better market could not improve productivity
and efficiency, thus contributing to the solution instead
of aggravating the problem.
2. The peculiarities of the health care sector
The debate on the future of health care in our society
is dominated by the fact that health care is not a sector
of economic activity like all others. It has its own
particular characteristics, which make that the market
economy can not operate here in the same way as in
other sectors of the economy.
In the first place there is the important fact, that the
right to health is recognised as a basic human right,
which has to be implemented by the national
governments. This requires from the national
governments a policy and legislation providing for
availability and accessibility of health care services for
all citizens. These matters can not be left simply to
market forces, which by their very nature would
provide services according to the consumers' ability to
pay. One could say that the existence of the right to
health obliges governments, even the most strongly
committed to the market economy, to go contrary to
the market.
In earlier times it was accepted that the obligation of
the public authorities could limit itself to supplementing
the market services with publicly supported services
(public assistance) for those who are unable to pay for
them. These services could be at a basic level,
providing only for the most essential needs. In a
modern social policy perspective such a double
standard in the provision of health care is no longer
acceptable. The right to health is understood
nowadays as a universal right, which all citizens enjoy
in an equal way. The government not only has to
guarantee all citizens access to health care services,
they must have equal access to them. The
government can not be content any more to provide a
subsidiary health service for the indigent, it has to
organise and finance rational and acceptable health
care services for the whole population. This may be
done in various ways, which may make use, to varying
extents, of the existing market services. But it must
certainly involve a significant departure from the
market mechanism as a principle of allocation of
resources.
Apart from this legal rule, which does not allow
governments to rely on the market mechanism in the
matter of health care, there are other, more intrinsic
factors, which make it difficult to apply the market
mechanism to health care.
The first and maybe most important one is the
insufficiently recognised fact that one of the primary
functions of medicine, and of health care in general, is
to deal with anxiety in the face of suffering and death.
In that sense, it is true that medicine has replaced
religion, and that doctors are the priests of modern
times. This means that much of the behaviour of
patients (and of providers of care) is of an irrational or
even of a ritual nature. When a serious health problem
appears, which threatens a person or his relatives with
pain, physical or mental damage or loss of life,
something has to be done, even if rational thinking
would lead to the conclusion that not much, or nothing
can be done. The purely rational response will very
often be unacceptable, both to the doctor and to the
patient or the patient's family.
This phenomenon is certainly responsible for the fact
that such a large percentage of the expenditure of
health care systems is concentrated in the last weeks
of life of terminally ill patients, which in itself is
responsible for much of the high levels of expenditure
in health care systems.
It also helps to explain the extraordinary lack of price
elasticity in the demand for health care services and
products. People who buy out of anxiety or even in a
panic are not influenced by an increase in the cost at
the time of buying. Sometimes even it would appear
that they buy more when it is more expensive. In the
absence of reliable and accessible assessments of
quality, consumers tend to take the price as the best
indicator of the effectiveness of the quality of care and
of the effectiveness of the service or product. The
basic market mechanism, according to which demand
goes up when prices go down and vice versa, seems
not to work, or work in the opposite way, when it
comes to health care.
To this should be added the serious problem of
asymmetry of information. This problem is widely
recognised in all areas of economic activity, but in
health care it plays a very special role.
There is, of course, the obvious problem of the lack of
medical knowledge on the part of the patient. From the
very days of Hippocrates, the medical profession has
sought to keep the secrets of their art from the public.
At first they did this to protect themselves and their
patients from the doubtful practices of all sorts of
quacks (who have not disappeared to-day). At the
present time they do it more out of fear of malpractice
suits.
The patient is expected, and to a certain extent
compelled, to "trust" his doctor. This allows the
providers of care to influence very strongly the
patient's "demand" for services. When a doctor tells
his patient that he should have an operation or a longterm treatment, the patient can ask some questions,
but he can not argue to the contrary. Or in other terms:
in health care, supply creates its own demand.
But the asymmetry of information also goes in the
other direction. Doctors and other providers of care
very often suffer of a severe lack of information about
the patient. For a certain part this concerns strictly
medical knowledge. Medical records do not follow the
patient wherever he goes. They are very often not
available to another provider of care, who may be
called to treat him, for instance after an accident. For a
not negligible part this concerns non-medical
information, such as information about conditions of
work and about the situation at home. The essential
importance of this information for the diagnosis and
the treatment is generally admitted. But little is done to
improve the situation in this respect.
One can, obviously, not train all patients in medicine,
even if doctors could give their patients more medical
information about their own cases. And one can not
train all doctors to be social workers, even if they could
find out more about the relevant background facts of
their patients. In contrast to the high cost of medical
technology, it will very often appear as a waste of time
and energy, to have highly paid and specialised
professionals simply sit and talk to patients. And the
remuneration systems of most health insurance
schemes (both public and private) tend to discourage
practitioners from doing this.
One of the most troublesome aspects of health care is
the remarkable lack of objective scientific standards
for it. There are, certainly, a number of diagnoses to
which physicians over the whole world follow (more or
less) the same standard treatment. But these are the
minority. Despite the spectacular advance in medical
science and technology, it is still impossible, in most
cases, to describe the correct medical response to a
given health defect. One observes a staggering
difference in medical practices from one location to
another, between countries, regions and even
neighbouring institutions. These differences apply not
only to the use of diagnostic means or to the choice of
therapeutic procedures, they even affect the types of
diagnoses and of symptoms. One wonders whether it
is the same scientific medicine which is being
practised in all of these places.
The result of this is, that no objective budget can be
made for health care services, and certainly no
planning of numbers of practitioners and institutions
can be made on any objective grounds. Such
budgeting and planning, where it is found, is based
invariably on the existing levels of expenditure and on
the observed numbers of practitioners and institutions,
to which politically acceptable rates of increase are
applied. The target figures are surprisingly different
from one country to another. This can hardly be
considered a rational basis for the development of a
health care delivery system.
But it also means that hardly any objective normative
control can be made on the competitive behaviour in
the health care market. What is normal practice and
what is an intolerable abuse, can rarely be described
in objective terms. It has to be left to subjective
assessment by peer review groups, which is always a
delicate matter, to say the least.
One should bear in mind that most decisions on
diagnostic and therapeutic services are determined on a
probability assessment concerning the symptoms of the
patients. Most physicians consider it not justified to
spend large amounts of money (and of physician time)
on specialised diagnostic tests in order to eliminate one
or more hypotheses of a very low degree of probability.
But if a physician chooses to order such tests because
he does not want to take the risk to miss the improbable
but possible diagnosis of a very serious condition, who
can say that he is wrong? To what an extent does a
physician have the right to be anxious? This question
can always be asked, for every individual test or form of
treatment. If computer profiles can show a large number
of statistically excessive medical services, the number of
cases where the performance or the prescription of
these services cannot be justified in any way, will be
very small.
Measuring the efficiency or the productivity of health
care services, is also a very difficult matter. The first
thing one needs, when one wants to compare the
inputs and outputs of any system, is a definition of the
product. And that is exactly where the difficulty is.
What is the product of a health care service? Is it
health? In that case, if one would accept the definition
of "health" by the World Health Organisation, no health
care has ever been productive. Is it an improvement in
health? Or the absence of deterioration of it? How
could this ever be substantiated or measured? There
is no measurement for the degree of a person's
health. There is no way of comparing the usefulness of
inputs in terms of personnel, goods or services,
between different situations. This means that there is
no exact way of deciding about priorities, and
certainly, when there is a shortage of personnel, beds
or products, there is no objective way of deciding
whether the same input should be devoted to one
patient or to another.
3. Competition and solidarity
a) Public, semi-public or private provision
If there is no objective way of establishing the right
number of health services of all types to be supplied to
a given population and the amount of money to be
spent on them, this will have to be determined in
another, less adequate way. Which is the best
possible system?
There are basically three possible models: the public
service, the non-profit ("social profit") organisation and
the market. These models are characterised by
fundamentally different principles. The activity of
commercial companies in the market is steered by the
pursuit of profits; non-profit organisations are directed towards the development of their own activities; and the
public service is dominated by the need of politicians to
gain power in the democratic elections.
This is at the core of the question. How well the health
care system works and which interests it serves less or
better, will in the end be determined by the basic
principle underlying its organisation. All other considerations are unconvincing. Private, non-profit and public
services can be economical or wasteful, can give good
or bad service, can protect certain groups better or
worse, can be well or badly organised, reliable or
unreliable. But the actions of politicians will in the end be
commanded by the fear for loss of votes; those of nonprofit organisations by the fear of loss of membership;
those of commercial companies by the fear of financial
losses.
This asks the question: which is the best principle for the
delivery of health care services?
Elections are at the basis of our democratic system,
considered in our society as irreplaceable - even if they
are subject to a lot of criticism. They must make sure
that the elected officials at all levels act in the best
interest of the people, who can vote them away if they
are not satisfied. This is a very strong argument for the
public service model in general.
But one has to think of the fact that there is an enormous
distance between the moment of an election and the
actual running of a public service. Only a few of the
many activities of the public officials come to the
attention of the public and are of influence on the result
of the elections. It is often very difficult to interpret the
results of elections in terms of approval or disapproval of
policies pursued in specific matters. Much depends on
the information at the disposal of the electorate at the
time of the elections, and on the influence of pressure
groups on public opinion. Democratic elections are not in
all respects the ideal steering mechanism. They are a
very highly valued principle, but with only limited
practical effect.
The profit motive is in our society a good and respected
principle. Everyone has the right to pursue his own
interests as well as he can, by offering his services to
consumers who need them, and who pay for them of
their own free will. The profit motive is the "invisible
hand" which, according to Adam Smith, directs the
whole of the economy to the best possible results.
It differs from the democratic principle by being of a
rather low order of things. It has to do with simple and
straightforward self-interest. But it is of a striking
effectiveness. In no other way can one make sure that
consumers receive the best possible service at the
lowest possible cost.
For an optimal operation of the profit motive one needs a
market situation where all consumers are free to buy or
not to buy, and are well informed on the choices offered
to them. In reality one will find producers of goods and
services trying to protect their interests by monopolies,
or by lobbying with the government for protection of their
business against competition, and by supplying biased
information to the public. In such a situation will the profit
motive not produce its optimum results. There will at
least be a role for the government to protect weaker
groups against stronger ones. The profit motive is
effective, but it very often works in the wrong
environment.
effective is the profit motive in private health care
providers and health insurance companies?
The
answers to these questions are not easy to give. They
vary with time and place, they will be different between
one specific type of benefit and another, and they will
depend very much on the attitude of the beholder.
The increase in membership is the criterion of success in
non-profit organisations. It has to do with freedom of
association, one of our fundamental liberties. Everyone
has the right to create or to join organisations to promote
the aims he believes to be worth pursuing.
b) Costs and expenditure
Voluntary organisations have as strong an interest in
developing their membership, as commercial companies
in producing profits. This will similarly induce them to
offer the best possible service to their members, at the
least possible cost - in which they will be advantaged by
the fact that they do not have to pay dividends to
shareholders. And their aims may be of a nature to
make them more civic minded than commercial firms,
and less inclined to mislead the public on their activities
or their services.
But one should also keep in mind that the interests of
voluntary organisations can never be the same as those
of individuals. Even when an organisation was created
with the sole aim to protect the interests of its members,
it still is a distinct entity, with interests which can come
into conflict with those of individual members. And
certainly the organisation will only protect its own
members, to the detriment of other groups in society,
who may be more in need of protection. Here again, the
state will have a role of protector of the public interest, in
order to avoid that stronger groups, through their
organisations, obtain for themselves an advantageous
position at the expense of weaker groups in society.
The choice between these formulas is not easy to be
made. One must accept that in the real world each of
these three steering mechanisms will have its own
justification and its own field of action. Certain activities
will be best left to the government under the rule of the
political democracy; others will be of the realm of nonprofit organisations striving to increase their influence;
and others may be left safely to commercial companies
trying to maximise profits.
Thus the debate concentrates on the borderlines
between these fields of action. It will be a debate on the
effectiveness of each of these steering mechanisms.
How well does the democratic principle work in the
public health services? How well does the principle of
promotion of the members' interests work in private
health care or health insurance organisations? How
The predominant feeling everywhere (even if some
doubt can be expressed about this) is that there is a
health care cost "explosion" and that something should
be done to control this alarming phenomenon.
It is imperative, in this respect, to distinguish between
costs and expenditure. Costs are the necessary input for
producing a certain output. It is clear that in any rational
organisation of production, the production cost per unit
of output has to be reduced as much as possible. This is
true in all models of organisation, private or public.
In reality, the production costs in health care is already
rather low, much more so than most people realise. The
technical progress has produced increases in
productivity in health care as in all other branches of
economic activity. In fact, the technical progress is rather
stronger in this area than it is in society generally.
Particularly the hospital sector can be seen as a high
performance industry.1
It is certainly true that economies in terms of costs can
still be made. In certain sectors of the health care
production one finds monopolistic structures, which tend
to inflate prices and incomes of providers. There are
clearly also elements of waste in the form of irrational
use of services. These should be limited, as much as
possible. They can never be completely eliminated.
But one should not, in the name of cost containment, try
to limit the output of the system. To the contrary: the
health care system should be encouraged to produce
more and better services and products, to provide better
health for the consumers. No one could pretend that our
populations have reached an ideal health situation, so
that additional amounts of care could be called
superfluous. One should not waste resources in the
production of health care services, but that does not
mean that health care services are a waste in
themselves!
c) Cost containment
1 J.P. Poullier, "Hephaistos' last torment", in: Health Care in
Social Security, Proceedings of the European Institute of
Social Security, Leuven, Acco, 1988, 191.
What exactly can be done to limit production cost in
health care? Governments have already taken many
sorts of measures of a wide variety in this respect. They
generally tended to confuse costs and expenditure. We
give a rapid overview of the most important types of
such measures.
The first wave: control of fees and prices
Historically, the problem of increasing health care
expenditure under health insurance has been treated as
a problem of moral hazard. The first measures taken by
governments were controls of fees and prices in health
care.
This can be done in two ways: either by imposing price
controls, in the same way as it is done in many countries
for a large number of goods and services, or by way of
agreements with the providers of care. Such agreements
are rather difficult to reach, and have given rise in many
countries to a lot of unrest, strike movements and
protests among the medical profession, and among
other health professions. They are also hard to enforce,
insofar as providers are paid by patients who receive
reimbursement from the health care institution (indirect
benefits), in which case providers can very easily exceed
the agreed rates. Price regulations may be more direct
and effective, but they produce their own problems.
They lead to lobbying with the government for higher
prices and to sometimes perverse effects on resource
allocation.
Control of rates of fees and prices is generally of little
efficiency as a means to reduce the overall expenditure
on health care. If the unit cost per item of service is
frozen or reduced, providers obviously tend to increase
the number of services and to shift towards more
expensive types of services, in order to maintain their
usual level of income. The experience of most countries
over many years is there to confirm this.
expenditure only goes down if this shift acts to reduce
the level of consumption by households.
This latter point is far from sure. The experience with copayment has shown that it does not significantly
influence consumption. We already mentioned the very
low price elasticity in health care. Increases in copayment may temporarily influence the consumption of
certain types of care, but the original consumption curve
will soon be resumed. Consumers may even tend to
switch to other types of care which are more expensive.
This will be the case, for instance, when higher copayment rates are set for outpatient services then for
hospital care, or for GP rather than specialist services.
Certainly co-payment goes against the idea of
prevention in health care, in that it may deter patients
from seeking early advice or treatment for a relatively
minor condition, which can then develop into a much
more serious illness, requiring more intensive treatment
and higher expenditure. How important this effect can be
is not certain. But this is an area in which a responsible
government should not want to take any chances.
Another important argument against co-payment is that
hardly any equitable formula can be found, which would
divide the cost in an acceptable way over the various
households who need and consume care. The classic
co-payment in the form of a percentage of the cost or of
a flat-rate charge for each item of service is to the
disadvantage of beneficiaries with several dependants
and can pile up to a heavy financial burden for
chronically ill persons. It also is relatively more hard to
bear for low-income than for high-income households.
The only satisfactory formula from this point of view
seems to be a deductible to be calculated as a percentage of annual household earnings. But such a formula
is technically not very easy to realise and would face a
lot of resistance among the population.
The third wave: control of the supply
The second wave: cost sharing
A second type of expenditure limiting device is to be
found in various forms of co-payment or risk sharing by
the consumer of care, called in French "ticket
modérateur".
Such a system does, of course, reduce expenditure from
the point of view of the health care financing scheme
(health insurance or public health service). But it does
not necessarily reduce the total expenditure on health
care. Part of the financial burden is simply shifted to
households or individual consumers. The overall level of
A third type of measure consists in the limitation of the
supply of services. Health economics have discovered in
the 1960s that in matters of health care supply creates
its own demand. Once this rule was generally accepted,
it became obvious that to limit health care expenditure
one should not try to reduce the demand for services,
but to limit the supply.
This can be done at a very early stage, by restricting
admission (numerus clausus) to medical schools and
schools for other health professions. Most industrialised
countries have in recent decennia, usually at the
insistence of the medical profession, adopted such
policy. But it is not without problems. Germany offers a
good example of the tensions and conflicts such a policy
carries with it. The most serious criticism of it is that it
results in an artificial bias in the choice of study and
profession: those who can go to medical school feel
compelled to do it, whatever their talents or inclination
may be. The best talents are drawn into medical school
and away from other occupations, where they would be
as much needed as in medicine. The policy also tends to
maintain a very high social and financial status for the
medical profession, which is a severe handicap for policy
makers who want to limit the expenditure on health care.
Similar criticisms can be brought against policies of
limitation of the right to practice in medical professions.
Such rules may go contrary to national constitutional
freedoms, and to the freedom of establishment and the
free delivery of services in the E.C. Here again a
limitation of the number of practitioners authorised for a
specific type of service would create a monopoly
situation strengthening very much the position of the
admitted practitioners, who are tempted to translate this
position of power into financial advantages to the detriment of the health care system.
Policies of limitation of supply appear to be most popular
in the area of hospital care and other types of
institutional care. All European countries and most other
countries in the world have legislation imposing
mandatory hospital planning and most of them extend
this planning to heavy medical equipment in (and in
some cases even outside) hospitals.
Hospital planning can certainly be very useful in
spreading hospital services over the whole country and
making sophisticated modern equipment available to all
parts of the population, however remote from the main
urban centres. Whether it actually reduces expenditure
on health care, by limiting the number of hospital beds,
or at least restrain the projected increase in that number,
is not so sure. The introduction of mandatory planning
creates an urge with hospital administrators to extend
their institutions as much as possible, and to lobby with
the government for the largest possible provisions for
their institutions in the planning.
In reality one cannot see that many savings in terms of
health care financing have been realised through
compulsory hospital planning. If and when it would
realise such savings, one would very soon see the inevitable signs of insufficient supply of hospitals, with waiting
lists, ambulances turned away from hospital gates, and
scandals reported in the media. If central planning is
detrimental to the performance of all other branches of
the economy, one does not see why it should be good
for health care.
The fourth wave: budgeting
A more direct form of control of expenditure consists of
fixing a direct budget limit for health care financing,
limiting the number of goods and services to be provided
and/or the amount of money to be spent on certain types
of care or on care generally.
In a certain way, such a policy is necessary and inherent
to any form of public financing in health care or in any
other area, be it by way of a social insurance or of
spending from the state budget. Never can such a
scheme undertake an open-ended commitment to pay
for whatever demands are made on it by the public. Both
a national health service and a social health insurance
scheme have to adopt an annual budget and to balance
their accounts at the end of the year.
But we mentioned already the lack of objective
standards in health care. There is no way of determining
in any exact way what the right budget or the right
amount of services should be for a given population at a
given time. Such budgets are usually the result of
political negotiations, on the basis of the existing levels
of expenditures, with an agreed rate of increase.
Strict measures to keep within the adopted budget are
also hard to enforce. It is not easy to tell a patient that he
can not have his treatment because the quota is already
exhausted or the budget is already spent. In most
countries where such types of strict budget limitation
have been expressly imposed (U.K., France, Germany,
Belgium,...) it has been the general experience that the
prescribed levels are regularly exceeded, for a variety of
excellent reasons. When they are more or less strictly
enforced, they produce unjust and unacceptable results,
and cases of hardship, provoking unwelcome scandals
and protests.
The fifth wave: competition
In desperation, governments have turned towards the
neo-liberal doctrine of competition, in order to achieve
cost reductions by higher efficiency in the health
industry. Britain has taken the lead in this respect, by a
far-reaching reform of the National Health Service under
the inspiration of Lady (then Mrs) Thatcher, introducing
internal market elements in the public service. The
Netherlands have been the first to follow suit on the
continent. Their long-extended reform, starting with the
Dekkers-Committee Report in 1987, has instituted some
competition in the health insurance market, including
private insurance companies and social insurance funds.
Germany has followed in a cautious way, by exposing
their public health insurance funds to some form of
competition.
The European Court of Justice has added its grain of
salt with a series of decisions extending the rule of free
international competition in the internal market to some
agencies providing services under social security, such
as (public) employment agencies, or (private) health
care insurers or pension insurers.
All these elements of competition have, however, much
to the chagrin of the neo-liberal economists, not
produced any noticeable improvement in the situation.
The crisis in health care provision remains as it was. The
expenditure continues to rise.
The fact is that the British NHS has introduced elements
of competition between providers of care, which have
always continued to exist in most continental schemes.
In most other cases (Netherlands, Germany) the
competition element is limited to the management of the
health care financing, not to health care itself. And in the
health care financing mechanisms, the rates of
contribution and the rates of benefit are very strictly
controlled.
The
competition
between
insurers
concentrates essentially on the quality of the service to
the insured persons. However important this may be in
itself, it can not exert a strong influence on the nation's
expenditure for health care.
Our conclusion is that all of these measures to limit
expenditure on health care have failed. In all countries
the expenditure on health care has continued to rise and
to raise alarm, throughout the years when the
governments have taken all these types of measures.
Maybe the overall expenditure in these countries would
have been slightly higher without these measures, but
we do not believe that the difference would be very
important. In the mean time they have carried an
enormous load of disadvantages, in terms of injustice,
inefficiency, bureaucracy, administration cost and bad
resource allocation - this being true even in the case of
the increased competition schemes - which would be
reason enough to do away with them.
4. Some essential steps in the right direction
a) Quality control
Is there nothing that can be done to control the cost
element in the increase of health care expenditure?
Yes, there is something. One can and one should
control the quality instead of the quantity of care.
All health care financing systems, both in national health
services or under social health insurance, pay for a
mixture of good and bad care. The largest part of the
expenditure, so one may assume, goes to appropriate
and necessary care. But a not negligible part of it is
certainly spent on uncertain, less adequate care,
sometimes unnecessary and useless care, or even
really bad and damaging care. At the same time some
necessary and useful care is not accessible, and
therefore not paid for. This is what has to be changed by
monitoring quality of care.
If a system could be set up to make sure that only (or
mainly) good quality care is paid for, there would be no
need for any other measures of cost containment. But
every penny spent on bad quality care is a penny spent
too much and should be eliminated.
Quality of care also has to do with quantity and with cost.
It has to do with real improvement in health, if health is
understood in the classic definition by the World Health
Organisation. In this sense, quality equals effectiveness.
Unnecessary care is bad quality care. Eliminating unnecessary care is improving the quality of care and saving
expenditure at the same time.
How can quality of care can be controlled? Much has
already been written on this subject. The American and
Scandinavian experiences in this respect can teach us
valuable lessons. These examples show that quality
control can be done and that it can save money. Clearly,
it also provokes some expenditure of its own: it requires
certain examinations before certain procedures are
taken, it requires some rehabilitation after certain
operations, it may impose the consultation of a second
physician for certain cases, etc. But more importantly it
prevents unnecessary and harmful procedures from
being performed, which in their turn would have
worsened the condition of the patient and made
necessary more examinations and more treatment. And,
essentially, it makes sure that all the money is well
spent, and that in the end this expenditure really benefits
the health of the patient.
Organisation of quality control
Quality control is not an easy thing to organise or to put
into practice. Only the fact that it is absolutely necessary
will force us to overcome these difficulties. What is
needed for a good system of quality control?
First of all, data on the medical activity have to be collected in a reliable and a comparable way, which is certain-
ly not the case at the present time in all countries. pursuit
of better quality of care.
Second: health care services should be supervised by
appropriate bodies, with regular checks at random. Such
control body must be acceptable to the providers. This
can be achieved in a much easier way if they are set up
by their own organisations.
The real problem resides in the lack of objective
standards. If it cannot have objective standards, quality
control must be based upon subjective assessment and
human judgement. Therefore it is essential that the control is performed by a committee of persons whose
judgement can balance each other and who each by
themselves or at least as a group is and are acceptable
as competent, respectable and conscientious persons.
The normal way of constituting such a committee is by
election among their peers.
A further element is that the control must be effective,
and therefore the control committee has to be invested
with some authority. If the controls are to be taken
seriously there should also be a possibility of material
sanctions, such as a fine or even a suspension of the
right to practice.
Colleagues will not be tempted to play such a role unless
they are well motivated to do so. Part of this motivation
should be in the improving of the quality of service itself.
The second motivation should be remuneration. Persons
serving on quality commissions should be paid for their
work in an equivalent way to the payment for the
services normally performed during the same period. A
valuable extra motivation could come out of a
mechanism to link payment by health insurance to the
result of the quality of care controls.
Germany has made an interesting experience in this
respect, where medical committees assessed the
necessity of care given by physicians working for the
sickness fund, in such a way that the individual
payments to practitioners making excessive claims
("Kassenlöwen") are cut by the committee, and the pay
for all physicians is proportionally increased. Even if one
does not want to go so far, payment of physicians could
be linked to quality control in the agreements between
the health service or the health insurance and the providers of care, and payments could be reduced if certain
services would be found to be deficient in this respect.
b) Informing the patient
A last element of quality of care which I would like to put
forward in this discussion is informed consent. In all
countries it is a firm rule that physicians and other health
care practitioners have no right to examine or to treat
without the consent of the patient. There is no real
consent if the patient has not been informed of all
relevant aspects of the proposed procedure. Very often,
in practice, physicians speak to the patient with the aim
of persuading him to submit to what they consider as the
necessary treatment. When the patients' judgement is
influenced by the way of presenting the situation, there is
no real consent, and therefore the entire procedure
becomes unlawful. In such a case one can not speak
anymore of good quality care. This is a point which
should be taken very seriously.
c) No-fault medical accident insurance.
There is a lot of resistance among the health professions
and administrators of health care institutions against
such information, and against extensive data collection
about their practice. Much of this resistance finds its
origin in the fear for malpractice claims, which can be
ruinous for the practitioner or the institution concerned,
not so much in a financial way (everyone has a liability
insurance), but for their professional reputation.
This can only be changed if the matter of medical liability
is approached in a totally different way. It is important
that liability for damage caused by health care services
should be dedramatised and objectivated in much the
same way as damage caused by industrial or road
accidents, without long, costly and unpredictable battles
in the courtroom. Such reform would allow medical records to be used in a very different way than as evidence in court in malpractice cases: they could find their
real use in the prevention of unnecessary and harmful
treatment and in improving the quality of care generally.
The Swedish experience is there to show that it is
feasible and beneficial.2
It is self-evident that such a reform would gain
enormously from a co-ordinated European approach,
instead of separate and mutually incompatible measures
taken by the individual member countries.
Christoph Fuchs
2 L. Westerhall, An introduction to medical malpractice law in
the United States and Sweden: the rights of patients,
Norstedts Juridik, Stockholm, 1992, 146 p. See also:
Marilynn M. Rosenthal, Dealing with medical malpractice: the
British and Swedish experience, London, Tavistock, 1987,
270 p.
1. Introduction
There can be no doubt that the enlargement of the
European health sector involves a host of challenges
and opportunities. Before turning to the details of the
individual challenges and opportunities, I would first
like to point out that the European health sector can be
regarded as enlarged in two respects:
On the one hand, by the convergence of Europe within
the current territorial structure, and on the other hand,
by the enlargement to be expected in the coming
years, particularly in Central Europe - the possible
accession of Malta need only be mentioned
incidentally.
Consequently, I would like to structure my paper as
follows:
Development of public health policy in the European
Community.
Possible consequences arising from the judgements of
the European Court of Justice in the Kohll/Decker
cases with respect to social protection, subsidiarity
and the territorial principle.
Consequences resulting from the introduction of the
Euro.
Consequences of opening towards Central Europe.
2. Development of public health policy in the
European Community
2.1 In this context, the Commission this year submitted
a communication to the Council, the European
Parliament, the Economic and Social Committee and
the Committee of the Regions, which opens up
important prospects and attempts to go into new
developments. One of these developments is that the
national health systems are exposed to increasing
pressure. These include the increase in life
expectancy, the expense of medical progress and the
demographic trends in individual Member States. In
some Member States, the income side of the social
security systems is inadequate as a result of high
unemployment. Attempts to achieve savings on the
expenditure side are insufficient for avoiding a decline
in the quality of the health care available to the public.
In its communication, the Commission rightly
draws attention to the questions arising from the public
health provisions in the Treaty of Amsterdam. With
these in mind, it arrives at the conclusion that
priorities, structures and methods of action are in need
of fundamental review and reformulation. This also
applies in relation to the enlargement of the European
Union.
The Commission ultimately formulates three key fields
or strands of action. In particular, it mentions
Improving information for the development of public
health,
Reacting rapidly to threats to health,
Tackling health determinants through health promotion
and disease prevention.
This communication from the Commission is intended
to stimulate a broad debate on the direction of
Community public health policy. Concrete proposals
cannot be expected until this debate has been
concluded and the Treaty of Amsterdam ratified.
2.2 In reply to this communication from the
Commission, the Economic and Social Committee
(ESC) drew up an opinion, the essentials of which I
would now like to explain.
The
ESC
welcomes
the
Commission's
communication as an important document in the
current situation. This is partly due to the fact that a
number of EU promotion programmes have reached a
stage permitting analysis. The challenges from outside
have grown. The ESC is of the opinion that
Community policy in the public health sector must be
intensified. The public's expectations have increased as have their concerns regarding health care. The
BSE crisis is just one example.
Incidentally, the ESC had already named fields of
action to be incorporated in future Community policy in
earlier opinions, such as that on the communication
from the Commission on the "Framework for action in
the field of public health" in 1994. These fields of
action include:
Specific problems of age in young people or the
elderly,
Particularly vulnerable groups, such as the migrant
population or otherwise underprivileged groups of the
population,
The link between health policy and the socio-economic
dimension (e.g. unemployment).
2.3 In relation to the public health provisions arising
from the Treaty of Amsterdam (Article 152 new), the
ESC emphasises that these establish the basis for all
future development.
It is particularly significant that the provision stating
that "A high level of human health protection shall be
ensured in the definition and implementation of all
Community policies and activities" has been moved to
the beginning of the Article. This can be interpreted as
a guideline. The Treaty explicitly mentions the fields of
action
Improving
public
health,
Preventing
human
illness
and
diseases,
Obviating sources of danger to human health.
2.4 The ESC is of the opinion that adequate resources
alone are not enough for fulfilling these highly
demanding tasks and principles. The ESC additionally
proposes to the Commission that the fields of activity
in public health be reorganised. Specific reference is
made to co-ordination with other Directorates General,
the assignment of the responsibility for all healthrelated matters to a single Member of the
Commission, and an increase in the human resources
of Directorate General V.
2.5 The host of tasks which are already foreseeable or
which are still to be expected in the future makes it
necessary to set priorities in the fields of public health
as well. This gives rise to the question of the
objectives and principles to be applied in setting these
priorities. I shall return to this point later on.
2.6 The ESC formulated detailed comments on the
three strands of action mentioned earlier.
2.6.1
Strand 1: Improving information for the
development of public health
The ESC has absolutely no doubt that great
importance must be attached to the data situation as
regards public health. It is a prerequisite if priorities
have to be set. In addition to health promotion and
disease prevention, the ESC would like to see
activities which promote the development of public
health and health care as a whole. The ESC
particularly stressed that the establishment of an
information system is intended to serve the Member
States. This implies that a centralistically managed
data cemetery is undesirable, because it would bring
no added value for the health care of Europe's
citizens.
2.6.2
health
2.6.3
Strand 3: Tackling health determinants
through health promotion and disease prevention
The ESC has also come up with differentiated
approaches on this subject. It is of the opinion that the
measures proposed by the Commission need to be
supplemented and formulated in more concrete terms.
The ESC is of the opinion that actions and measures
influencing knowledge, attitudes and behaviour, giving
examples of developments relating to tobacco, alcohol
and drug use, as well as nutrition, are not enough. The
examples should also give consideration to healthy
lifestyles, physical activity, social behaviour and
mental health.
2.6.4
Finally, the ESC sees a need to establish
a fourth strand of action, dealing with the integration of
health requirements in all Community action. A
"horizontal approach" of this kind could be taken into
account if it is ensured that every Commission
proposal includes an assessment of its impact on
public health.
3. Possible
consequences
arising
from
the
judgements of the European Court of Justice (ECJ) in
the Kohll/Decker cases with respect to social
protection, subsidiarity and the territorial principle
The Treaty of Amsterdam also confirms and
emphasises that the health systems are to remain
entirely within the sphere of responsibility of the
Member States.
The emphasis on the principle of subsidiarity is of
great importance in this context. However, the different
interpretations of the meaning of subsidiarity then
become apparent. While many Member States
interpret subsidiarity as meaning that an institution
may not take action as long as the smaller, upstream
institution is in a position to solve a problem, the
Commission seems to interpret subsidiarity as
meaning that action must be taken by the institution
which is in a better position to solve the problem in
hand. In this case, tensions can arise if the experience
gained with the more centralistic administrative law
makes people blind to the advantages of federal and
decentralised control mechanisms.
Strand 2: Reacting rapidly to threats to
In view of the epidemics occurring recently, and
also other threats to health, the ESC advocates
expanding the competence of the Commission in this
field.
The judgements passed by the ECJ in the Kohll
and Decker cases on 28 April 1998 illustrated further
differences in the points of view.
In the one case, a health insurer refused, on the
basis of a national rule, to reimburse the cost of a pair
of spectacles purchased in another Member State, on
the grounds that this purchase required prior
authorisation. In the opinion of the ECJ, this is a
violation of Articles 30 and 36 of the EC Treaty (free
movement of goods).
In the second case, the assumption of the cost of
dental treatment by an orthodontist established in
another Member State was made contingent upon the
authorisation of the insured person's social security
institution. The ECJ regarded this as a violation of
Articles 59 and 60 of the EC Treaty (free movement of
services).
These judgements of the European Court of
Justice show that the ECJ, in applying the principles of
free movement of goods, services, capital and persons
enshrined in the Treaty, has adopted rulings which
have a direct impact on the health care systems of the
Member States. The jurisprudence of the ECJ can
thus have an influence on the national health care
systems.
The ECJ judgements are primarily based on Treaty
provisions concerning economic co-operation. Social
protection provisions in the Treaty are limited and,
hence, social protection is regulated only to a limited
extent. In this connection, the ESC is, for example, of
the opinion that the consequences of "free movement"
cannot be considered solely on the basis of market
criteria. The market rules should not adversely affect
the health care systems in the Member States.
In principle, it is a welcome fact that the freedoms
offered by the single market also apply to patients and
service providers. This supplements the cross-border
right of establishment and the opportunity for
employment in Member States of the European Union,
which has existed since 1975.
However, the conditions for this cannot be derived
solely from the rules for the creation of a single
market, but must also reflect the requirements of
social security, ubiquitous health care and the qualityassured rendering of services. In this respect, it would
be a welcome step if the rules concerning the common
market were to be supplemented by rules for
protecting the social systems and guaranteeing
international co-operation.
The future of the European health systems lies not
in their commercialisation and subordination to the law
on competition, but in their collaboration and
convergence.
The fact must not be overlooked that the extent of
social protection is a question of national decisions
and economic capacity. This is the reason for the
diversity of the national health systems in Europe.
Consequently, the process of European unification
is not simply a matter of purely economic aspects, but
also of the interests of the people in Europe. Public
health has a protective social function in this context.
Above and beyond international co-operation
between the social systems and the health sectors,
one of the main aspects in future will be clear-cut rules
concerning technical adaptation and convergence.
Harmonisation tending towards levelling would entail
major risks for the process of European unification.
Cross-border competition for quality is also to be
welcomed, as is protection for health systems which is
equivalent to the rules concerning the single market.
There can be no doubt that the right to the crossborder rendering and utilisation of medical services on
a voluntary basis is to be welcomed.
This development must be actively shaped in the
medium and long term. The health care of the people
in the European Union should not be governed by
judge-made law alone.
4. Consequences resulting from the introduction
of the Euro
The introduction of the Euro will have a foreseeable
impact on the health sector. The cross-border
rendering and utilisation of medical services on a
voluntary basis will increase.
This particularly applies to health care services traded
or offered on an international basis, such as elective
surgery or rehabilitation measures which can be
reached by mobile insured persons. This could lead to
erosion of the territorial principle.
The introduction of the Euro will increase the
economic pressure on the social sector when the
providers of social security become business
enterprises and begin to base their actions on market
conditions alone. The social aspect will disappear
completely if the rules of competition are the only rules
that apply.
It might be assumed that the introduction of the Euro
will lead to comparable prices for health-related goods
and medical services. However, upon taking a closer
look, it can be seen that this is only true in part. It
applies, for example, to medicinal products, such as
cardiac pacemakers or endoprostheses.
The prices for caring for a patient with a cardiac
infarction, for example, depend on additional factors,
including access to the health care system, availability,
the expense associated with this availability, the
quality of care or the standard of care. In statistical
terms, for instance, a kidney transplant in a 20 yearold patient is cheaper than in a 70 year-old recipient. If
persons over the age of 60 are excluded from such
treatment in one Member State, but not in another, the
transplant costs are not comparable. It would be totally
misleading to believe that the introduction of the Euro
will permit comparison of the efficiency of the health
care systems. The situation is far more complex than
that, as the examples show.
However, once the prices become transparent, those
health systems which operate at a high service and/or
cost level will be exposed to pressure to justify
themselves.
Insured persons living close to national borders will
particularly take recourse to health services in
neighbouring EU countries if they are cheaper there,
or if they can reduce the amounts they have to pay in
their own countries.
It should be emphasised once again that the rules of
competition must not be allowed to override the
principles of social protection for patients who really
are needy and incapable of migration and, in some
cases, incapable of deciding for themselves.
5. Consequences of opening towards Central
Europe
The development of public health policy in the context
of the enlargement of the Union in Central and Eastern
Europe constitutes an enormous challenge. Even
though the available data and the reliable information
concerning the state of health of the population in
Central and Eastern Europe are incomplete and
contradictory, a number of indicators suggest that the
level of health care in Central and Eastern Europe is
far lower than that in Western Europe. These
indicators include infant mortality and life expectancy.
The concerns of social protection were emphasised on
the basis of the preceding considerations regarding
the European Union in its current territorial boundaries
and this must logically also apply to the applicant
countries in Central and Eastern Europe.
The objective must be to establish social security
systems in these countries and to stabilise the
circumstances prevailing there. For this reason, the
ESC proposes in its aforementioned opinion that the
applicant countries be given every possible
assistance, rather than just seeking legislative
rapprochement. These countries must be integrated in
the existing health programmes and the overall EU
public health policy at the earliest possible time.
In a further step, it would be helpful if the Commission
were to draft a report assessing the health care
situation prevailing in the applicant countries, as
previously done in the communication from the
Commission on "Environment and enlargement". This
could identify possible areas for early co-operation and
technical support. What the ESC has in mind in this
context is the exchange of information and expert
assistance for existing programmes. In this
connection, it would also be recommendable to fall
back on the experience of the WHO, which has
already been co-operating with individual applicant
countries for decades.
All other possible contacts with international
organisations and bodies must also be exploited in this
context. Common sense dictates co-operation and the
avoidance of duplicate work if this major challenge is
to be coped with in the coming years and decades.
Health-related activities within the European Economic
Area and the G7 framework are of particular
importance here, as well as Euro-Mediterranean cooperation. Continued close co-operation of the
Commission with the WHO, the OECD and the
Council of Europe is imperative. The role of PHARE
projects should not be underestimated, and it can only
be hoped that there are no cutbacks in the support in
the health sector.
6. Conclusions
In the long term, the social systems in a converging
Europe will also come closer together. In order to
promote the development of coherent social structures
and to increase the acceptance of the EU by Europe's
citizens, it would appear indispensable to fulfil two
requirements:
The rules concerning the common market must be
supplemented by rules for protecting the social
systems, while guaranteeing international cooperation. The future of the European health sector
lies not in its commercialisation and subordination to
the law on competition, but in its collaboration and
convergence.
Bundling of the responsibilities for the health policy
sector in the EU administration.
Fulfilment of these demands is an essential
prerequisite for a unified and strong Europe in the
health sector. Only if strengthened in this way will it be
possible to provide the necessary assistance upon
enlargement in Central and Eastern Europe.
Àrpád Gógl
Mr. President, Distinguished Representatives of the
Member States and of the Institutions of the European
Union, Respected Colleagues, Ladies and Gentlemen,
I am privileged and honoured to have the possibility to
address this distinguished audience and exchange
views on how we, representatives of different
countries,
central
and
local
governments,
organisations see health challenges of the
enlargement of the European Union. I would like to
speak of basic tendencies, the overall picture, rather
than go into details in some specific questions.
Before starting my actual presentation, let me share
with you what I was thinking of while driving from
Budapest to this marvellous part of Europe which saw
so many historic events and persons. I tried to look
into the future and imagine a situation: I am a
Hungarian medical doctor coming over to find
employment in Austria sometimes around or after
2010. I asked myself a number of questions. Shall I
receive equal treatment of employment? Will my
medical diploma be accepted? What will be the
opinion of the Austrian Medical Chamber and of the
Austrian doctors? Will there be a major difference
between my Hungarian and Austrian wage? Shall I
find a totally different health service, with strong
national characteristics in Austria? Shall I find the
Hungarian pharmaceutical products and medical
devices on the Austrian market, can I prescribe the
Hungarian medicines and have them reimbursed?
What kind of social security benefits will I and my
family be entitled to? We could list still a number of
further questions to many of which we do not yet have
the exact answers.
I would like to focus my presentation on similar issues,
some general trends related to health and
enlargement.
Health represents a complex area in the integration
process. It is an issue of outstanding importance, with
strong intersectorial characteristics, bearing in itself a
positive impetus for further developments in key health
areas as well as a number uncertainties.
I will touch upon the following issues:
Subsidiarity in the EU and how it is reflected in the
integration process:
- regulated and non-regulated areas
- priority setting during the pre-accession period
The future: the enlarged European health space
- the free movement of persons and services
- the free movement of goods
EU public health policies, co-operation possibilities
Challenges and expectations concerning enlargement
Subsidiarity in the European Union, community and
national responsibilities - harmonisation, co-operation
or convergence
In the European Union the Maastricht and Amsterdam
Treaties create new prospects for actions in the public
health field, but still a major part of health issues, in
harmony with the principle of subsidiarity, remain a
national responsibility. When examining the question
from the point of view of a candidate country, our
health authorities find themselves in the situation that
under community "public health sector" we can identify
a very limited part of what one traditionally means by
health policies and strategies (quite understandably,
as they remain on national level). At the same time,
we are faced with a major public health "acquis" in
other community sectors, related to the free movement
of persons, goods and services and aiming at
protecting the life and health of humans. This
phenomenon exercises a decisive effect from several
aspects.
Public health gains a new dimension in the integration
process. A significant shift in priorities and resources
is induced. Although Hungary has a traditionally well
developed legislative and institutional public health
framework, the transposition and enforcement of
community acquis in the field of health at work,
environmental health, chemical safety, product safety
(with special reference to food, medical devices,
pharmaceuticals, cosmetics, toys, etc.), the need for a
strengthened public health laboratory network, and
consumer health protection and market surveillance
services requires extensive institutional developments.
May I emphasise here that I consider it to be a very
positive process in promoting a higher level of health
protection for the population; a deeper rooted, better
established and more expanded intersectorial
approach, as well as, hopefully, a better recognition
and prestige of public health among health
professionals resulting in an in-flow of young experts
to the public health field.
At the same time, the mentioned mixture of regulated
and non-regulated health areas arises a number of
questions during the integration process: What is the
scope of the integration process? Is it enough to
concentrate on the transposition and enforcement of
the acquis, or, if it is not the case, how to handle
health policy and health care issues? If there is a need
for "health convergence or cohesion", how to identify
its scope and promote and support this process? May
I refer here to the evident need for health policy and
health services reform and development in our
country, the latter appearing in the Commission's
opinion on Hungary. The problems we are facing are
very similar to those in EU Member States:
demographic
problems,
unhealthy
life-styles,
premature death due to non-communicable diseases,
dramatic rise of health expenditure, etc. The situation
is burdened by the poor health status of the
population, low life-expectancy as well as limited
financial resources. Hungary started to renew its
health policies and reform its health services years
ago, we have long been connected to and actively
participating in the international activities, our policies
and reform strategies are in line with international
trends. Hungary is member of the World Health
Organisation since its foundation, and became
member of the Council of Europe in 1991 and of
OECD in 1996. In these organisations we are involved
in the professional exchanges, and benefit from their
expertise through a number of networks and projects.
In Hungary, similarly to EU Member States, an
emphasis is put on health promotion and disease
prevention, we intend to strengthen the gate-keeper
function of family doctors, made steps to reduce the
size of the hospital sector, introduced productivity
based elements into health care financing to promote
cost-effectiveness and cost-containment; just initiated
a programme of developing emergency care; and
based on the traditionally high level of medical training
we intend to develop training in health management
and public health. It is always difficult to identify
financial resources for health services development.
But it is even more so under the circumstances of
restricted internal resources. Health development is a
national, and also an international interest, and we
have to find the very sensitive balance of resource
allocation, both internal and international. I am
convinced that providing financial support to
developments in the non-regulated areas, including
health, could essentially contribute to the success of
the pre-accession strategy.
The enlarged European health space
When we look into the future and try to imagine what
an "enlarged European health space" will mean,
allowing for the free movement of persons (including
health personnel and even patients), of services
(including health services) and of goods (including
medical devices, and pharmaceuticals) we do it with
great expectations and also a number of concerns on
both sides. Many concerns, on both sides, are related
to the free movement of workers, in our case the free
movement of health personnel. We are proud of the
high standard of the physician training in Hungary, and
of the professionalism of our allied health staff.
However, we do not expect a mass out-flow of health
personnel even with the present major differences in
wage levels between Hungary and that of the EU
Member States. Most of the highly qualified (and
mobile) experts are relatively well established in
Hungary as well, and the number of vacancies in the
EU is not high. Naturally, we are aware of the
importance of the need to settle the wage issue in the
health sector, which I personally regard as a top
priority. On the other hand we have to mention that
Hungarian health experts may be concerned as well of
a probable in-flow of professionals from the Member
States. And, could not we Hungarians be worried
about loosing our top experts? I am convinced that
these concerns, though understandable, are not
justified, and an acceptable balance can be
established.
Concerning issues related to the free movement of
goods,
specifically
medical
devices
and
pharmaceuticals, liberal trade regulations have already
long been introduced in Hungary , with a major impact
on the sector. There has been a dramatic growth of
imports, as well as of prices, contributing to the growth
of health expenditure with a simultaneous fall in the
marketshare of Hungarian products. A change in
prescribing patterns and reimbursement regulations
followed and further changes are still forseen and
planned. Product safety, quality control, conformity
assessment in these areas has always been at a high
level in our country, especially in the pharmaceutical
field. We hope, our products will preserve and regain
competitiveness in the future in the internal market.
EU health
accession
policies,
co-operation
possibilities,
Before the end of this year we can join the EU public
health programmes, and we would be pleased to be
connected to further EU health policy activities. We
attach great importance to co-operation in all fields,
but they have a special value in the non-regulated
areas.
We share the views expressed in the recent
Commission communication concerning future public
health priorities, and we also attribute great
importance to the proposal to develop future actions
based on community wide networks supporting health
reform. Our recent experiences have shown that in
times of major policy, strategic and organisational
reforms the exchange of experiences (both successes
and failures) is of remarkable importance. A proper
balance of national, regional and local actions is
evidently the basis for the success of the health
initiatives.
Accession of
expectations
Hungary
-
challenges
and
Hungary is looking forward to EU membership with
great expectations. The enlarged European health
space would open up new prospects, and we would
like to benefit from belonging to it. Candidate countries
are diverse, we do have different values, advantages
as well as a number of shortcomings in respect to
being compatible with EU norms and policies. Hungary
is also facing great challenges in the integration
process, and many times it is not easy to cope with
them. We know, the transposition of the acquis is only
the first step, and we have to change the institutional
system, or the practice supporting its implementation.
It takes time and needs patience, as often the positive
results can be experienced only at a later stage. And,
at the same time, we would bring with ourselves our
knowledge, experiences, achievements, our special
values, which we would like to preserve and share
with the EU: let me mention in the public health field
the good epidemic situation in Hungary, the well
established and mandatory vaccination system, as
well as the early introduced donated blood screening
system, which essentially contributed to the low
HIV/AIDS prevalence in the country. We are
convinced that the enlarged European Union will be
able to carry on and develop the common European
ideals and policies, while preserving the specific
values on national, regional, local or individual levels.
Finance – How to
meet the economic
challenge
of
financing
the
European
health
systems
Jürg Ambühl
Health Care Expenditures and Patient Needs
For the debate on financing health care systems, it is
common to use data on a macro-economic level to
generate indicators for the quality of a health care
system such as comparisons of total expenses as
percentages of gross domestic product, comparisons
of the supply of hospital beds or of physicians per
capita. But what about the patients’ views?
The few available public opinion polls on the
satisfaction or need for reform show that in countries
paying a high share of the GDP for health care people
are not more satisfied with their national health care
system than people in countries with a lower share.
Denmark spends a lower percentage of the GDP on
health care than other European countries. But the
Danish are more satisfied with their health care
system than other nations. This seems also to be true
if you look at supply indicators. Germany has the
highest supply of hospital beds and spends the
highest share of the GDP on health care. However,
Germans are less satisfied with their health care
system than the people in five other European
countries. Austrians, as well, show medium
satisfaction despite a comparatively high supply of
hospital beds among European countries. Only for
Belgium and Spain the ranks for satisfaction, hospital
supply and share of the GDP are close together3. The
ranks for the number of hospital beds per capita is
only one example demonstrating that there is no
Thank you for your kind attention!
3
Kolb
Walter
“Struktur
des
österreichischen
Gesundheitswesens; Benchmarking im Gesundheitswesen –
Daten im internationalen Vergleich” IWI-Arbeitsheft 28,
Industriewissenschaftliches Institut 1997, Wien
relationship between the supply of health care and the
satisfaction. Similar results could be obtained if the
numbers of physicians or of drug prescription were
used.
In terms of productivity, health care spending and
supply are only the input. There is a lack of data
measuring the output or productivity of health care
systems. This top-down view is true not only for
analysis but also for the organisation and financing of
health care systems.
The following considerations are based mainly on the
situation in Germany, but with minor modifications are
true for most other European countries.
Top-down Driven
Resources
Allocation
of
Health
Care
Because health care has a high priority for all
governments, there is high political involvement in the
decision process on budgets for health care provision.
In the upcoming decade, the major issues for health
care systems will be the enhanced life expectancy with
the morbidity of aged people and medical technical
innovation imposing increased financial requirements
on societies.
The increasing costs for health care caused a dynamic
growth of regulations controlling the budgets. The topdown organisation of the system led to a top-down
allocation of resources. Exaggerating, one could say
budgets are allocated according to the provider
sectors’ needs almost regardless of the patients’
needs. In order to stay within the budgets, the sectors
have a tendency to act as closed shops and organise
the provision of health care services around their
budgets. Assumptions on patients’ needs are derived
from this utilization of services, though this neither
reflects the actual needs of patients, nor the objective
disease-related
needs,
nor
their
individual
preferences.
Will more or better regulations solve these
problems?
Reality in the Industry: Patient-Oriented Targeting of
Resources by Competition
The monopolistic structure of health care systems
allows a top-down allocation of resources because
there is a general lack of competition.
From an industrial point of view, the financial basis of
an organisation lies in its responsiveness to the needs
of customers. Competition requires a thorough
analysis of customer needs. The better an
organisation meets the specific needs of customers,
the better are its chances of success.
In a competitive environment, customer needs are the
key for success. Based on analyses, targets are set,
strategies designed, corresponding budgets allocated
and the implementation is continuously monitored.
Only an organisation holding a monopoly may have
the opportunity to neglect this constant process of
adjusting strategies and budgets.
Because competition is based on quality and price, i.e.
value and costs, a further requirement in a competitive
environment is the search for efficiency improvement
in the processes enabling the organisation to meet
targets at lower costs. For this reason, consolidation
through mergers and acquisitions has started in
certain segments of the health care system, for
instance among sick funds in Germany.
Medical Quality and Financial Efficiency through
Outcome-Oriented Competition
Is competition a viable concept for a health care
system?
Yes, because real competition will shift the view from
input to output, so that priorities in the form of health
targets and desired medical outcome become the
driving aspect for the allocation of resources.
It is not that we don’t have any competition in the
health care system today, but we need more elements
of competition and we certainly need a different type of
competition than we have. Today we find competition
between the sectors of the health care system for the
scarce resources. In the future, we need crosssectoral competition to contribute to health care
targets and medical outcomes. Examples of health
targets could be to reduce cardio-vascular morbidity
and mortality by a certain percentage in five years or
to improve health care for the elderly or the poor
patient.
Often, a loss of quality is predicted in case of more
competition between the providers. This could be
critical without standards for quality. Evidence based
medicine is the key to setting these standards. The
methods of evidence based medicine are a valid
technique to differentiate between effective and noneffective measures. Studies delivering results on the
clinical value of medical interventions are a solid basis
for decisions on reimbursement. Today, such studies
are much more frequently conducted for drugs than for
other medical interventions. Future research needs to
be focused on this deficit of studies according to the
standards of evidence based medicine. The findings of
evidence based medicine provide hard facts and
transparency on the performance of medical
interventions, which can then be applied to decisions
on the allocation of resources.
It is also often said that setting health targets will divert
resources and disadvantage patient groups not
included in health targets. Experience shows,
however, that setting targets does not divert resources
nor call for additional resources, but leads to a more
focused use of existing resources to reach a target.
A competition-based offer of services will direct the
budgets closer to patients’ needs based on their
diseases and to the outcomes provided by various
types of medical intervention. Processes in the
provision of health care will become more rational and
more efficient if the systems become more flexible to
support closer co-operation and networking within and
especially across sectors. If provider groups are
allowed to compete on the basis of their professional
contribution to results and not only to increase their
budgets, efficiency in health care will be much
improved, for instance through establishment of
disease management programs.
Better informed patients will use the increased number
of choice offered by providers. For example, in
Germany, it is common that surgeries are performed
by hospitals as in-patient care. It is obvious that a
good deal of surgery could be supplied by office-based
physicians at lower costs without a loss of quality. At
the same time, there is no doubt that patients would
prefer to avoid a hospital stay for many reasons.
However, the sectoral budgets for hospitals and for
ambulatory care prevent a broader supply by
ambulatory surgeons.
Health Care
Deregulation
System:
Target
Setting
and
A better analysis of patients’ needs in terms of
morbidity and consumption of health care resources is
necessary. We need to better analyse disease areas
and the corresponding burden for the social systems.
Results of such an analysis will lead to a better
understanding of the costs of health care and of
potential savings if the results of evidence based
medicine outlining efficient processes and supply of
health care are applied. Both concepts offer a frame
for setting targets. Health targets based on political
consensus will support a concentration of all efforts
aimed at improving health care and management.
Regulations set narrow limits to creativity. The highly
regulated health care systems curb the search for
optimised processes. Deregulation where socially
acceptable could foster competition requiring creativity
of all participants in health care targeting efficiency
improvements with the given resources. However,
competition will become a threat for a health care
system if it is limited to the providers’ side.
Competition between sick funds is the indispensable
complement for building an efficient and competitive
health care system. Joint and unanimous contracts
between sick funds and providers as in Germany are a
strong barrier against effective competition.
Transparency and hard facts derived from evidence
based medicine are a valid source for rational
decisions based on political consensus on what should
be paid for by public funds and what shouldn’t.
Improved transparency by setting targets and patientoriented competition in the public system will provide a
framework for decisions on public and private
financing of health care. Successful management
through targets and competition will lead to headroom
to finance the future issues of health care in the
European countries.
The European Union and the EU-Commission would
render outstanding services to the European patients
by taking the leadership in designing a framework for
setting health targets and to liberalise the national
health care systems. Such a framework would shape a
European environment for financing health care in the
next millenium and provide for free movement of
goods and services in the health sector between the
European member states. (see Annex 9,10)
Martin Pfaff
The scientific evidence available about the different
forms of financing health care and about the effects of
different mechanisms on health outcomes is
necessary but - in my mind - only of limited use when
attempting to answer the following question: "How do
we want to finance our health care systems in the
future and how many resources or how much of the
resource base we want to utilise?" In making this
statement I am not trying to belittle the very useful
work undertaken by scholars; in fact I have worked in
this field myself over the years. Comparing different
forms of financing health care systems is in fact a very
important work, and it offers a starting point for any
systematic inquiry. Nonetheless, as I shall point out,
the question of how to finance our health care systems
in the future, to my mind, is essentially a political one
and I would like to approach this question by making
several propositions.
First proposition
The macro-economic challenge facing health care
systems is really rather straight forward and scientific.
The empirical evidence available points to the
following pattern: The wealthier a country is, the
greater will be both the absolute level of health
spending and also the share of health spending in
GDP. When plotted on a graph, we note a linear
positive relationship between the level of health
spending per capita and the absolute level of GDP per
capita. We also note a positive relationship between
the percentage of health spending in GDP and the
absolute level of GDP per capita which is referred to
as the "superior goods hypothesis" (When plotted in a
graph, we note a rather stable curve, going from the
lower left corner to the upper right corner).
Second proposition
Nonetheless there are deviations around this trend.
They show the effect of differences in organisation,
provision, financing and the steering mechanisms
employed within the system. We can test this
hypothesis by comparing tax-funding vs. contributory
funding or predominantly private funding of health
care. For example, we find that tax financed health
care systems are more cost effective if effectiveness is
measured by overall outcome. And while some
contributory-funded systems are more cost effective
than others one general trend emerges: Systems in
which private payments, prices and private insurance
co-payments play a major role, show health care costs
which are generally higher not lower than would be the
case in other systems. This pattern contradicts the
presumptions and the claims of those who would
introduce the market elements solely to have more
cost effective health care systems. I suspect, however,
that this effect is not due to the very nature of prices or
price-type steering mechanisms. Rather, higher costs
in these systems is a consequence the lacking
countervailing power on the demand side.
The question therefore is, how far is society able to
organise countervailing mechanisms against the
growth of health spending.
Third proposition
Health care spending - measured as a share of GDP has stabilised in most OECD countries. In the
following proposition I only refer to health spending as
an indicator because satisfaction date, however
interesting, are really not that useful if they are not
related to some objective anchoring point. I therefore
propose that, at this point, we should look at the
objective indicators and we see that health spending
has stabilised in OECD countries as share of GDP, but
the basis on which these funds are being raised have
undergone substantial changes. We have had
tremendous societal changes, culture, social, political
and economic changes and therefore the stresses
have risen in some of these countries.
I take the example of Germany. In the Federal
Republic of Germany , the employees' share in
national income (wage rate - share of wages in
national income) has decreased significantly since the
early 1980s. Let us assume that all other relevant
factors were to remain constant. As the German health
care system - and in fact the whole social insurance
system - is financed on the basis of contributions
which are levied onto wage income, this trend alone
would have - and indeed has - put a tremendous
pressure on contribution rates to rise.
This example demonstrates my main point: As long as
countries stays within the limitations imposed by the
overall level of development, the challenge of
financing health care is not so much an economic one
(in the narrow sense of the word). Rather, societal
factors have to be considered as well, and the
challenge of financing concentrates on the financing
mechanisms. The question of financing is a larger
question of political will, of political judgement, that is
my central hypothesis. The economical potential of a
country is measured by its overall level of wealth and
welfare, and as long as a country stays within the iron
economic or empirical economic laws, the amount and
the share of funding that is allocated to health care is a
matter of political determination.
Fourth proposition
The factors which are generally pointed out as
dynamic factors which impose severe problems for
financing are:
demographic changes;
technological changes;
changes in the pattern of lifestyle and also in the
pattern of illness.
These factors have a long term impact, no doubt, but
in the short and intermediate run their impact is often
overstated by interest groups for obvious reasons.
Nonetheless: There is but little doubt that
technological advances, changes in the pattern of
morbidity and demographic changes - specifically an
increasing share of the aged among the total
population - generally will tend to increase the demand
for health care services in the long run and thereby to
exert pressures on health spending.
Similarly, changes in family size and composition specifically the increase in 1- or 2-person-households together with changes in the work pattern such as
increased labour force participation of women, the
erosion of the traditional („normal“) employment
pattern etc. - will tend to reduce the family’s ability to
cope with the health-problems of their members
without relying on professional health services.
Fifth proposition
Sometimes it is therefore concluded by some
observers that:
that the financing pressures are bound to grow out of
proportion in the future,
that either some form of rationing of health-care
services will necessarily be called for, or else,
that an ever larger share of health-care costs must be
born by the sick person at point of service utilisation
(„cost-sharing“ or „co-insurance“), or even
that changes in total systems - from more sociallyoriented types („Bismarck-Model“), or welfare-statetypes („Beveridge-Model“) to more privatised forms of
health-care provision and financing will necessarily be
called for (Example: USA).
Now empirical evidence leads me to the opposite
conclusion: The alternatives indicated would worsen
rather than improve the situation of financing health
care in socially orientated systems.
Sixth proposition
Does the "superior goods hypothesis" imply that an
ever increasing „funding gap“ must inevitably result or
that systemic changes of the type indicated are
necessarily and inevitably called for?
Certainly - under rigid ceteris paribus assumptions - a
rising share in health spending must necessarily lead
to an increase in the tax-rate in tax-financed systems
or in the contributions-rates in contributory-funded
systems or in the share of private spending. But in the
real world several prior measures of reform can be
taken as part of a pragmatic strategy which would
obviate the necessity of taking such measures:
Step 1:
The first step involves reforms and
incentives: Reforms in the steering mechanisms i.e.
not only reforms in the way we finance or pay doctors,
or finance hospitals, but also in the way we use
competition on the supplier side to increase the cost
effectiveness in the system. These are necessary
reforms to my mind and I can fully conquer with some
of the points raised by the earlier speaker. In other
words, changes in the incentives, changes in the cost
effectiveness are the first steps in order to realise
savings. Only when these steps have been taken we
can legitimately approach the insured and ask for
more money (see step three). We should actually
realise the potential for savings inherent in the system.
Step 2:
The second step involves more integrated
forms of provision, which are not only more humane
from the point of view of the patient (in terms of quality
of services and convenience), but which are also
more cost effective and equitable regarding the
distribution of health care services. In any case we
have to increase the cost effectiveness and the
efficiency, particularly the target efficiency of existing
programmes. We need a better co-ordination and
harmonisation of the financing and benefits sides of
various selective programs. And we really must look at
existing programmes very carefully. We have to
evaluate them, because, I am quite convinced,
essential savings in this area are possible: Instead of
selective individual elements we need "integrated
health policies" or "integrated social policies".
Step 3:
The third step works in changing the
parameters of the system. Only after we have
undertaken the first two steps do we have the
legitimate right to reform the financing and benefits
sides by approaching employees (in contributoryfunded systems) or tax payers (in the tax-funded
systems) in the search of needed funds
By changing the definition of the tax-base (BeveridgeModel); or by changing the rules governing the
compulsory membership in statutory health-insurance
funds, the types of income which would be included in
the base or the cut-off points beyond which the
contribution-rate does not increase and also for
allocating responsibility for contributions (BismarckModel).
In contributory-funded system we can change the
income thresholds for obligatory insurance and for
assessing contributions or we can secondly re-define
universal persons subject to compulsory insurance or
compulsory membership in the system. Thirdly we can
broaden the definition of "revenue" by including further
forms of income. We can limit the insurance of family
members who do not pay contributions or make them
pay a minimum or average contribution. On the
benefit-side (as opposed to t revenue-side) we can
also change and restrict the types of benefits provided.
Or we can define basic and optional benefits even
though that is of some problematical nature. Needsoriented and tax-funded supplements to the
contributory-funded system may be called for; or else,
in those cases where common societal tasks have
been placed onto health-insurance funds, a
refinancing of these tasks out of general tax revenues
is called for. Finally we can - theoretically - increase
the privatisation on the financing side, but that leads to
some of the conclusions, which I have already have
pointed out above.
All of these changes lead to a reform of the
employees’ share in contributory-funded systems. But
these are, at best, short term measures, because
without true structural changes the problem of
financing health care will only be postponed over time.
Therefore structural reforms are more important.
Step 4:
If changes on the employee-side are not
sufficiently effective, changes on the employers’ share
in the funding system may become necessary. E.g.: In
contributory-funded systems, contributions need not
only be based on the firm’s wage-bill but could be
related to the total value-added by the firm (thereby,
energy resources, capital and other factors of
production would be included as well).
Step 5:
If the steps indicated thus far do not
suffice, a much greater degree of integration of
financing and benefits - and in contributory-funded
systems, a greater tax-share - will be required. Such
concepts generally go with notions like „negativeincome tax“ or „demogrants“.
Seventh proposition
Let me refer to Professor Münnich’s very interesting
paper. I am completely in agreement about the effects
of some of those driving factors he mentions, but I
disagree with one quotation - which, maybe I
misunderstood. I quote: ”In my opinion we cannot but
completely restructure our social security systems in
the long run, this general goal leaves much leeway for
its implementation. The new balance between social
solidarity and private responsibility will most certainly
include more private responsibility than Europeans are
used to at the moment”. If Professor Münnich means
that in the long run the individual will have to show
more responsibility for his own health e.g. by changing
his life style than I agree completely. If he means that
we should, in the short run, increase co-payments or
other elements of private financing (that is how in the
political domain this term is generally being used - or
abused perhaps), than I have problems for the
reasons I have already indicated.
I quote as another statement in disregard Professor
Uwe Reinhardt: ”The German health insurance system
is enviable. In the USA we can only dream about
something like that you ought to thank God for having
such a system in Germany.” Now let us not overdo this
praise, we know we have quite few problems, too. But
there must be some discrepancy: If the system is
referred to as a positive example abroad, why should
we revamped completely?
Eighth proposition
I quote Henry Ahrens my former colleague at
Brookings Institution, who pointed out that the
necessity of reforming health care finance will be on
the agenda of every democracy for the foreseeable
future. And I quote him literally to say: ”The capacity of
nations to deal with the resulting financial pressures
will depend on the structure of their health care
financing systems. Those in the best position to
control spending will be nations in which centralised
methods of finance are linked to the overall budget
(United Kingdom for example) or to earmarked taxes
(Germany for example). The nation clearly in the worst
position is the USA with decentralised financing
arrangements under which no payer has effective
leverage over providers". Do not read me wrong: I
believe overall budgets to be an interesting step
towards reforms - which is probably what Henry
Ahrens means. I do not think that sectorial budgeting
is the answer to our problems. It is actually a source of
our problems, because it introduces inefficiency and
competition for income shares between the sectors
(i.e. between general practitioners and specialised
physicians, between physicians and hospitals etc.).
And is sort of forces the dynamically changing reality
into existing patterns.
Ninth proposition
The ninth proposition is about the whole question of
privatisation and future trends in financing health care.
I believe, that recent political changes in the UK, in
France and now in Germany and other countries will
lead to a change in our paradise. What we have
experienced in health care policy in the public debate
these last years was essentially part of the large-scale
debate of a Thatcherite or Reagonite nature in several
fields of social discourse. While I do not have a
scientific basis but I still predict that the pendulum will,
to some extend, swing back to reassert the solidarity
principle as a cost-effective and equitable way of
financing health care. However some elements of this
debate which I was referring to as the neo-liberal
debate will surely persist. Indeed I think there are valid
elements i.e. the emphasis on incentives or the
emphasis on competition on the supplier’s side which I repeat again - could increase cost-effectiveness.
Conclusion
I conclude with Uwe Reinhardt and Henry Ahrens:
Why give up on a superior system which, compared
internationally with other systems, works well both in
terms of cost effectiveness and equity?
By making pragmatic reforms of a type that I indicated,
I believe we can assure that our health care system
will continue to be both more cost effective and
equitable than those alternatives proposed by some
others.
I believe that these kind of socially orientated health
care systems are the best answer to the problems of
the poor and weaker elements in society. In the long
run they are also the best answer for international
competitiveness of a society and the best solution of
the problems of the strong as well.
Forum I
Research
and
Development : What
role can society play
in
creating
a
supportive
R&D
environment ?
Umberto Bertazzoni
and more particularly in the key actions « Health, Food
and Environmental Factors », « Control of Infectious
Diseases » and « The Ageing Population ». These key
actions will be well complemented and supported by
RTD activities of a generic nature, like « Chronic and
degenerative diseases », « Genomes and genetic
diseases », « Neurosciences ». In this context a
significant role will be played by the generic activity on
« Public health and health services research » aiming
at the improvement of the health systems and to the
fighting of drug-related problems.
Although it is difficult and premature to give an
estimate of the future funding of all these activities
under the Fifth FP, it appears that a notable increase
in the support to Health Research is to be foreseen,
given the emphasis and the amplitude of the actions
envisaged in the Fifth FP proposal.
Further support to the biomedical research in the
future FP will be provided by facilitating the access
and the networking of research infrastructures
specially in the fields of biological databases and
collections and of centres for clinical research and
therapeutic trials.
The problem of the training and mobility of young
researchers will be further addressed by offering the
possibility to obtain Marie Curie fellowships of various
kinds to join transnational laboratories and health
undertakings.
Funding of Health Research at European level
When comparing the growth of the Community RTD
from the First Framework Programme (FP) which
covered the years 1984-1987 with a total financement
of 3.75 billion ECU to the Fourth FP (1994-1998) with
a total of 12.3 billion ECU and that of the Biomedical
and Health (BIOMED) Programme which increased
during the same period from 13.3 to 380 million ECU,
it is clear that the relative importance of biomedical
research has been considerably enhanced in the EC
research programme. This is due to many factors and
certainly a key role has been played by the society as
a whole and their representatives (Council of
Ministers, European Parliament, Health research
associations …). This trend has been considerably
reinforced in the EC proposal for the Fifth FP whose
main idea is that of putting research at the service of
the people and where the accent has been placed
from the very beginning on important social objectives,
that of promoting the quality of life and health of the
European population. This is directly reflected in the
different research activities of the thematic programme
« Quality of life and management of living resources »
Participation of SMEs to technology stimulation
measures (exploratory awards, co-operative research)
in the different Health Research actitivities will be also
supported.
A particular effort will be made to foster the coordination of the research activities and projects. This
effort is regarded as an essential but not easy task
because, as S. Feldmann said, everybody wants coordination but nobody wants to be co-ordinated.
Dario Pirovano
The entry into force of the EU medical devices
directives is going to affect heavily the R&D style of
work in the very next future. Finished the times of the
„me too“ devices which, in order to be placed on the
market would require more efforts than studying a new
one. The generalisation of safety and the freedom to
choose the performance for the device will result in an
increased search for better performances. This will no
longer be limited by the compulsory application of
standards. In other terms, the medical devices
directives will move the market battlefield from a sterile
differentiation among products based on conformity to
standards to a real search of the best performances,
thus accelerating the process of substitution of
treatments with drugs with treatments with medical
devices.
Baldur Wagner
This is a European Health Forum. It is therefore fully
justified to concentrate on what the European Society
especially the European Union can do to create a
supportive environment for research and development.
The European Union is an important link between the
national and the global level.
There has always been an interest by the medical and
public health research community in international cooperation. Scientists more than health-administrators
have realised a long time ago, that in order to be
successful they have to have international contacts,
that they have to share their experiences with
colleagues all over the world.
However, in the past and even today scientists in
Germany - and I think this is true for many other
European countries too - have concentrated in cooperation with partners across the Atlantic - the United
States.
This is understandable as the USA plays a leading
role in modern medical and public health research.
However, it is to be very much regretted that at the
same time co-operation within Europe is being
neglected. Very often German scientists meet their
possible European partners at congresses in the
United States. Very often they first learn there
research results of European activities. Very often
European research results are first published in
American publications. I am not against trans-atlantic
or even world-wide co-operation, but being Europeans
we have give Europe the first priority.
Therefore, my first and main message is: Strengthen
co-operation within Europe.
We have to realise that Europe and the United States,
and of course Japan, are not only partners but at the
same time are world-wide competitors on a global
scale, on world-wide markets. We have to realise that
the European internal market is one of the biggest
markets in the world, especially in health, and that it is
justified that European industry is helped by research
in Europe, we must concentrate on this market in
Europe.
Today in medicine and medical-related areas
innovation is essential for economic progress. It is the
driving force for industrial development. The
strengthening of the scientific and technological base
is therefore needed to improve the world-wide
competitiveness of European industry. European
industry depends on European research.
Can the European Union stimulate and improve the
research environment in Europe? My answer is a
clear: yes.
Taking some of the sub-topics for this forum I would
like to give a few examples - which we surely shall
discuss later in more detail - as to what is being done,
what could and should be done in the future:
1. Education
A good education, especially postgraduate education
and further training are very relevant for good
research. The Treaties of Maastricht and Amsterdam
have recognised that the Community can contribute to
the development of better quality education by - to
name a few examples - :
-
encouraging mobility of students and teachers
-
encouraging the academic recognition of diplomas
and periods of study
-
promoting
institutions
-
developing exchanges of information
experiences on common issues.
-
training fellowships, research training networks,
scholarships, summer-schools, conferences.
co-operation
between
scientific
and
2. Funding
Research needs funds. The extent to which a society
supplies adequate funds for research is an indicator
for its ability to face the challenges of the future.
Research investments today will lead to economic
strength in the future.
National funding - especially
resources because of limited
should be complemented by
Frame-work Programme of the
in times of scarce
economic progress EU funds. The fifth
European Community
for research and technological development, which will
soon be decided by the European Parliament and the
Council, will be able to make a big contribution.
Improving the quality of life and health is not only a
major challenge but it is also one of the priority
scientific and technological objectives of this
programme. Its aim is to help to increase the
knowledge and to develop technologies in the field of
life sciences. Progress in this area will help to increase
the competitiveness of the Community's enterprises by
opening up new prospects in areas in which the
Community already has a strong position such as biotechnology and in the fields of health and the
environment.
3. Regulation
New knowledge and technologies deriving from
generic action can be of great benefit of European
health, its industry and the environment. This too is
one of the priorities of the EU research activities.
However, this kind of activity is in need of regulations.
Research development as well as the production rely
very much that these regulations are friendly to
research and development. Over-regulation must be
avoided, as far as possible.
4. Information
The creation of a user-friendly information society is
another big priority for EU activity, not only in
research.
The convergence between information processing,
communication and content is increasingly important
to many industrial and social activities including health.
It will contribute to improve Europe's competitiveness
and quality of life. The advent of the information
societies will open up the possibility of a wide range of
new activities for both individuals and companies of
the community in many fields, including of course
health. As a consequence health is one of the main
areas of future EU activities in the field of informatics.
Summing up
Science, research, industry, health-policy are
interrelated. They depend very much on each other. I
hope that this meeting provides a suitable forum for
improving this relationship in the future
Joachim Weith
Underlying social conditions that advocate change and
demand progress are a prerequisite for the successful
work of research and development sectors throughout
industry.
The health industry in particular depends on the
institutionalisation of such underlying conditions: in
contrast to industries that are organised as a market
economy and whose immanent compulsion towards
gains in productivity and efficiency is well-founded in
the competitive situation of market participants and in
the existential risk of losses (for example, the highly
innovative pharmaceutical industry of the industry for
medical apparatuses), most European health systems
know no such incentives or only a few. Chiefly public
owners of the "health care industry", who see a high
moral obligation in providing health facilities for the
population and shy away from the discussion as to
how much health our economies can afford,
developed a high "deficit and loss tolerance" over the
course of the decades. This, coupled with the
ideological hypothesis that economic efficiency in the
public health service is opposed by humanitarian
objectives, resulted in Europe in the emergence of
only a few incentives to study and test new and
different systems of health care, with a few exceptions
- among them and worth particular mention is
Switzerland with its managed care models.
A further factor for the inflexibility of the health care
sector in its structure and way of functioning lies in the
political power of the institutions and associations of
the groups involved.
In Germany, for example, associations of panel
doctors and the professional representation of the
doctors are heavily resisting every attempt to develop
and test new forms of care, in which service providers
and health insurance schemes reach direct
agreements; in other countries tried-and-tested
models - for example, the Swiss family doctor model
or the American gatekeeper model, in which the
patient must first consult the family doctor before
seeing an in many cases more expensive specialist fail as a result of the understandable protests and
influence of the specialists' associations.
The political-ideological explosiveness of the "social"
topic of the public health system also contributes to
the prevention of innovative and successful research
and development work in the health care sector. Every
new idea, which wants for example to strengthen the
sole responsibility of citizens and patients, is under
suspicion of wanting to undermine the social state;
since the old class antagonism between the
bourgeoisie and the proletariat in the period of postindustrial service companies is no longer suitable for
the marketing purposes of the parties, the public
health system has become the popular playground of
those fighting out a modern class struggle.
All this does not foster the rationality of the discussion
and the inclination through efficient research and
development to elaborate new forms of health care,
which make it possible to also place the increasing
medical possibilities - in high quality and financeable at the disposal of the citizens of Europe in future.
The prerequisites for successful research and
development in the public health system within this
meaning are:
•
•
•
•
•
•
A de-ideologisation of the discussions on quality,
efficiency and affordability of the public health
system
The bringing about of a broad consensus as to
what European countries are willing to pay for their
public health system
The furtherance of model projects and their
evaluation within the range of the "new" forms of
health care
The strengthening of the individual market
participants and a reduction in the role of the
associations
The creation of competitive structures in the public
health system; only these will enforce optimisation
in all sectors in the long term
The withdrawal of the state from its role as the
"organ establishing the way public health systems
function" to become the "controlling organ" of the
results of the public health systems.
Herwig E. Reichl
Summary
After a quick introduction and establishing a contract
(“turn off all cellular phones“), short impulse speeches
were given by those members of the group who had
presented their view in the plenary morning session
(U. Bertazzoni, H.E. Reichl).
This was followed by a period of brain storming,
whereby topics for further discussions were collected
(see Photographic Protocol Pages (PPP) 7 + 8).
Out of a range of interesting topics, three were
selected for further in-depth discussion in small
groups:
R + D needs good PR (public relations) (Logan,
Pasterk, Pirovano, Weith)
Capability-enhancing environments for R + D are
produces by national industrial policies (Christenson,
Molenaar)
Lack of Risk Capital (Reichl, Weiland, Wiedenhofer)
These groups presented their results to the others on
posters (PPP 13; 12 + 15; 14), followed by discussions
which brought further insights.
Some recommendations given by the group were :
radical review of patent law
work on the ethical problem, searching for consensus
on the meaning of “ethics“
no R&D in fields with negative public perception
teaching the next generation the importance of R&D
improve educational systems
increase funding of health research
improve health systems through more research
better co-ordination of health systems and actors at
national and European level
public guarantees for high-risk venture capital
tax incentives for money invested in high-risk areas
risk capital provided from banks and the European
Commission
reduce administrative hurdles
To present their ideas to the plenary session on Friday
afternoon, the group, encouraged and motivated by
Keith Warren-Price, chose to draw a wall painting,
showing the long and difficult way from IDEA to
MARKET ( PPP 16 + 17) :
Lack of risk capital, a key problem from start to finish,
is threatening, as well as distorted information and
poor education. The latter can be overcome by quality
control and knowledge.
Next is the “lake of despair“ : economic regulations
and other administrative swamps, which can be ferried
by single European policies for health, economic
deregulation and thorough research to anticipate
future medical needs.
The Budgets/Cost Containment swamp is bridged by
careful analysis of social and economic consequences
as well as by improvements within the health systems
through more and better research.
Further impeding “rocks“ like the unwillingness to
accept risk and other mentality-based obstacles can
be bypassed by public funding as a safety net for highrisk R&D;
the stumble stone “patenting“ can be removed by
harmonisation (e.g. reducing the number of languages
for a European Patent), and the desert of tax and
economy politics can be smoothened by tax
incentives.
When the final goal, the market, is reached, favourable
national and European industry policies are required,
as well as better co-ordination of European Health
systems, so that our product can win the marketbased competition.
This was presented to the plenary session by Jim
Logan, the principal artist and Herwig Reichl, despite
severe technical problems.
Forum II
Public health and the
single market
Norbert Klusen
“Two recent rulings of the European Court of Justice,
the famous “Kohll and Decker” cases, have evidently
made it clear that in one way or other the
repercussions of the basic European freedoms will
sooner or later touch the national markets for medical
goods and services. The reactions of the national
players involved have up to now been quite different
depending on the national system and its structures.
The spectrum ranges from sheer neglect to a crass
exaggeration of the consequences expected. Perhaps
the most critical approach culminates in the conviction
that henceforth the treasured and valuable element of
subsidiarity will be practically devoid of its contents.
Some people are in fact afraid that a union-wide
harmonisation of
social protection might reduce
national political and economic responsibility and
introduce whatever model of standardised protection
one could think of. These fears are likely to result from
a certain misunderstanding of the principle of
subsidiarity. After all the European Court of Justice
had to judge on the European legal qualities of
medical goods and services not on the national
prerogative to structure and to finance systems of
health insurance. As things are, medical goods and
services are but highly complex goods and services
even if they are sometimes treated differently. The
present
discussion
also
reflects
a
limited
understanding of unsolved economic questions at
national level which are in urgent need of a convincing
solution instead of permanent and yet by and large
fruitless reform. Asked by the organisers of this
meeting to provoke in order to stimulate a debate, I
should like to concentrate on two aspects relevant for
our daily work in the interest of our clientèle.
Europe and European developments are relevant for
us. Our insured expect us to get prepared for a reliable
economic future of statutory health insurance. More
market forces could be used in the interest of the
patient if the statutory health fund were functioning as
a purchasing co-operative.
Our insured – the over 5 million insured of the
Techniker Krankenkasse – belong to a group of our
working population with a traditionally high degree of
professional mobility. It stands to reason that we have
a far above average interest in European matters and
closely follow the steps taken by the European
institutions. We also have a keen interest in the
changing framework of the macro-economic structure
which has an important influence upon our field of
professional activity. The political, juridical and
economical changes affecting our daily work and
economic responsibility are obvious and are closely
monitored. Thus the rulings did not come as a
surprise. They are but a very first step in a series to
follow and at present have only very limited direct
consequences since up to now there are far more
questions than answers, especially for the patients
concerned. The Kohll and Decker debate does ,
however, serve as a mirror for structural contradictions
and shortcomings at national level. It is those, our
society finally will have to tackle if a want-driven health
care system under more or less complete State control
is to be avoided. As a matter of fact , economic
problems call for economic solutions notably guided by
a fundamental and unwavering ethic understanding of
the social implications of our task.
Over-capacities, the lack of competition among
providers of services and a limited or no influence of
the health fund on structure, pricing or quality
assurance endanger the long-term quality of our
system. Already expenses are rising again and
question the value of yet another reform. This is valid
for France and for Germany as well. This is to a
certain extent a common European problem calling for
subtle national answers.
The patient as an incomplete market participant will
not be able to master the complex structures of
medical supply. The patient is in need of efficient cooperative purchasing of goods and services in order to
assure an economic future for the solidarity our social
model so much needs. As a matter of course this is to
be understood as a mutually satisfactory economic
partnership with providers which aims at a general
orientation towards quality. Sheer co-payments
without proven structural effects void solidarity, punish
the sick and only help to channel more funds into a
process lacking economic logic. In many respects we
are in need of new paradigms and strategies instead
of the traditional curing of symptoms. This is a tasks
that can only be accomplished in a framework of
subsidiarity which consequently has to be preserved.
True subsidiarity will also aim at safeguarding the
economic future of quality health care which can only
be available to everybody in an environment of
solidarity since pure market conditions lead to social
exclusion and risk-picking to the detriment of the ill,
the old or the poor. Subsidiarity should, however, not
be interpreted as a tool to fence off the national health
care market from potential competition from other
Member States. Our health insurance systems are
different as are national social preferences , standards
and expectations. Cherishing the illusion that of all
markets just the one for health care can be sealed
against foreign “intruders” is neither very promising nor
desirable. Co-operative purchasing is made easier by
subtle contracting and the keeping up of the benefitsin-kind principle, with cost-reimbursement as an option
for those who prefer it. Any indiscriminate
reimbursement of costs introduced as a standard
pattern of remuneration might even further reduce the
influence on essential parameters of the product or the
service in question. Cross-border contracting - as
discussed by our Dutch colleagues - is thus an
interesting aspect of the ongoing discussion.
Summing up:
The European challenge goes far beyond “Kohll and
Decker”. The Single Currency and its side-effects on
the future structure of employment and transparency
of prices also have to be studied in depth. With a
growing general mobility, our insured will rightly ask for
more eurocompatibility of their health insurer. For this
we shall be prepared. For this we also need the
assistance of national politics , since subsidiarity of
health insurance tomorrow will depend on the
successful integration of the European element into
national considerations. Moreover there is an
important aspect of subsidiarity at national level,
strengthening the health funds instead of expecting
everything from the State. Subsidiarity does thus not
only refer to the relationship of Member States and the
Union but also to functions and tasks at national level.
The Internal Market for medical goods and services
has its chances and risks and thus demands flexibility
of the actors and profound information on all matters
concerned. Given a few structural elements , the
consumers in a high-price-country may actually benefit
in many cases. Incredible and inexplicable pricedifferences between Germany and most neighbouring
countries are there to see for everyone. This refers to
medical devices, to pharmaceuticals and to medical
aids, to name only a few sectors. The matter is twosided: protecting an artificially high price-level in one
country from EU-competitors has little if anything to do
with subsidiarity. Protecting patients from a complete
loss of market transparency , potentially missing
quality standards and thus the risk of double treatment
- abroad and later again at home – can, however, be
useful. In any case, the present situation will not see
many individual “Kohll and Decker” treatments abroad
, if only, due to a lack of language skills. This buys us
time to get preparations under way how the new
options ought to be integrated into our system. Every
single actor will be concerned and thus new forms of
dialogue are likely and important. Our institution is
ready to accept this challenge and is looking forward
to exchange views and experiences with everybody
concerned. The rapid developments at European level
force many national institutions to either be part of the
problem or part of the solution: ours is a clear option
for the latter.”
PARTNERSHIP AND CO-OPERATION BETWEEN
THE
EUROPEAN
(FRONTIER)
REGIONS
ESPECIALLY
FOCUSED
OF
THE
STRENGTHENING OF PATIENTS POSITIONS
A partnership between the regions, society and the
citizens for social, health and community care in the
frontier regions. It’s important for regions to work
together (especially cross border co-operation) to build
partnerships and to make patients on both sides of the
border more stronger.
Although there are many regions in Europe, with
different competences and levels of resources,
working within broad and varied cultural and political
frameworks, they and the citizens all face common
health, social and welfare issues and challenges.
Citizens need a stronger position in the changes in
policy for health-care on both sides of the border to:
value and recognise individual rights and needs of all
citizens regardless of race, age, gender, culture,
language, nationality, disability, religion or sexual
orientation
ensure that all people in receipt of social, welfare and
health services have the right to choose and control
their own services
ensure that there is a choice of such services
empower the service user as a citizen to be involved in
the governance of service provision and planning
Citizens are especially encouraged to:
persuade national and local governments to embrace
this partnership
work in partnership with organisations of and for in
particular:
- long term sick people
- elderly people
- disabled people
- socially disadvantaged people
adopt policies to facilitate and enable individuals,
communities and Non-Governmental Organisations to
take responsibilities in respect of service provision
In order to make these citizens stronger they have to
use their resources to:
work together with pan European organisations to
persuade the European Union and Council of
European
facilitate dialogue, exchange information and ideas
between regions
arrange regions to work together with NGOs and
community groups
respond to the Partnership positively. It is a practical
way of moving towards an “Europe of the regions” and
the people with the emphasis clearly on the people as
citizens- a movement towards the European civil
society.
Corrado Sellaroli
The recent authorisation by the European authorities
to market Viagra could be a good test on the future
possibilities to achieve a real common market for
drugs in the EU, avoiding excessive imbalances
between consumer prices in different countries. Until
now, the industry has followed strictly national price
policies, not always geared on the level of relative
wealth of different countries. Apparently also the WHO
is unwilling to take position on the pricing issue.
In recent years, the share of drugs in total consumer
spending and the share of national income devoted to
health expenses ceased to grow above the average in
many European countries. According to an OECD
report, this trend had no visible effects on the global
health situation in Europe or elsewhere. It could be
interesting to promote a wide research on how the
doctors reacted to the pressure by public agencies
and by insurers in order to moderate over-prescribing
habits.
Expanding travelling habits, social security coverage
abroad and a higher degree of medical knowledge in
the public start to create a peculiar kind of single
market: go or stay abroad for health purposes, a
modern version of the thermal tourism of the beginning
of the century. This trend is also pushed by the
different degree of easiness in obtaining without
prescription some drugs, and by the differences in
reputation of some treatments in specialised clinics or
health structures. Of course the different national
prices of drugs and of medical treatments (just not to
mention the imbalances in fiscal policies) are also
taken into account.
ecourage the regions to share their experiences
between professionals, all the agencies involved and
NGOs
In other words, the single market for health products
and services seems based on the fact that, if an
harmonised supply does not exist yet, there is a
growing trend for bargain-hunting of offers available to
the consumers, with all the risks tied to self medication
through lesser known products or relatively unknown
health practices.
It’s expected and hoped that the NGOs in the regions
and the other partners involved in welfare services will
The Brussels achievements are surely impressive:
mutual recognition of medical degrees, freedom for
involve NGOs and individual service users in planning,
development, delivery and review of services
doctors to work abroad, simplification in obtaining
European drug patents, harmonised evaluation and
approval of drugs by the specialised EU Agency. On
the other hand, it seems unlikely that the average
European consumer could be considered as a
homogenised one, even if the living habits, the causes
of mortality, the income levels and the insurance
systems tend to converge.
But the harmonisation achievements seem to be
mainly of political nature, and not targeted, until now,
to the final aim of having the same drug at the same
price everywhere. Maybe it could be recalled that the
European Commission started 15 years ago a strong
campaign to reduce the national differences in the
prize of the cars, but that very little progress has been
achieved until now.
Philip C. Berman
Summary
SUBSIDIARITY
The following points were made:
It is not clear whether the principle of subsidiarity is
central to the European health agenda, or whether it is
a diversion from that agenda.
Subsidiarity is “Eurospeak” – of little relevance to
health services at local level
Subsidiarity is a shelter for governments and their
vested interests – an excuse to avoid the development
of a real European health agenda
Subsidiarity is not clearly understood.
Different
people use the term in different ways, but perhaps this
confusion is of benefit to the Commission and the
governments of the Member States.
Accepting that health services are a national
responsibility, and even more a local responsibility, the
group recommended that
The term “subsidiarity” should be clarified in its health
context both at national and local levels
There should be recognition at national level that
health services will be affected by the Single European
Market – Kohll/Decker are merely early instances.
Governments must move beyond the subsidiarity
issue, working proactively with the Commission in
developing SEM policies related to health services.
2. SHAPING THE EUROPEAN AGENDA
Health has a very low priority in the overall EU agenda
Member States have very little interest in the EU
health strategy
The EU’s health strategy is insufficiently developed,
within the competence given by the Treaty
There is the suspicion that – at the macro level – the
EU has decided to keep Member States happy by
diverting them to the relatively insignificant public
health programmes, while the real agenda is
concerned with health services and the SEM.
Although the EU’s health strategy is insufficiently
developed, health will continue to be forced onto the
agenda by crises (i.e. BSE, blood) and that quality
issues may emerge as one of these crises.
There was acceptance that the determinants of health
are largely outside health systems, and this clearly has
consequences for the development of the EU health
agenda.
There are a number of barriers to the development of
an effective European health agenda:
There is no effective lobby for a European health
agenda
There are many powerful vested interests seeking
outcomes that may not
have the improvement of
health status as their central purpose.
Health is given a low priority at EU level
There is difficulty in developing a European health
agenda when the outcomes of health care are so
difficult to determine
The group recommended that:
Vested interests need to be identified and their
objectives understood
A clear EU strategy is required which provides real
added value at both national and local level, and which
can be both understood and valued.
Since public health is to a considerable extent
determined outside healthcare by education, housing,
poverty and employment issues, these issues should
be factored into the EU health agenda.
Health will only successfully be developed as an EU
agenda with “bottom-up” support, involving individuals
and experts at a national or local level in developing
the agenda, which is currently too remote.
Quality issues and EU-wide standards should be
included on the agenda
The agenda should concentrate on a limited number of
issues.
3. THE SINGLE
INDIVIDUALS
EUROPEAN
MARKET
AND
The citizen is the forgotten partner of EU health policy,
whose needs, preferences and experience are
ignored. There is no one championing the patient,
except possibly the pharmaceutical industry which has
a distinctive vested interest.
There is a fear that the SEM, in strengthening market
principles, will undermine the principles of solidarity
and equity – perhaps leading to a US-style polarisation
and a two-tier health care system.
Individuals/citizens must be more involved through the
democratic mechanisms of representation, public
communications, surveys, discussions on priorities.
National experts should be more carefully selected
and should be used more extensively for consultation.
The group recommended that:
Clear EU health targets should be formulated on an
intersectoral basis
The EU health policy should be clear and transparent
Providers and consumers, and not only governments,
should be involved in the development of policy
concerning the SEM and health services.
4. THE SINGLE EUROPEAN
HEALTHCARE SYSTEMS
MARKET
AND
While the group did not have time for detailed
discussion on this theme, the following points were
made:
Medical goods and services are merely goods and
services like any other goods and services within the
SEM, and it is therefore unrealistic to expect that they
should be excluded from the SEM. Kohll and Decker
are therefore probably only the beginning of an
evolving story.
There should be acceptance that different standards of
healthcare, and differing contexts, will make any kind
of EU harmonisation impossible.
However, it is desirable that there should be a
convergence of systems: planned together and
applied individually.
Since many of the issues that we are facing are
primarily border issues, perhaps the focus should be
on bi-lateral agreements rather than EU-wide
agreements.
CONCLUDING COMMENTS
It was clear that there had been two parallel
discussions among the group. One involved those
who were already involved in the European debate –
the Eurocrats and those working at a European level,
who were well acquainted with terms such as
“subsidiarity” and Kohll/Decker – and the other
included those who actually deliver care. The latter
group found these debates of almost no relevance to
the real and massive problems that they are facing.
A serious challenge is to ensure that the policies
developed in Brussels have both relevance and
benefits to those at the “front-line” – the patients,
nurses and doctors, and the managers.
Forum III
Challenges and opportunities
for an enlarged European
health sector – the role of the
regions
Gerhard Buchleitner
“The changes in Europe leading to the creation of
employment and a social union cannot bypass the
health system. A growth in employment can only be
expected in the high-tech sector – and in the social
and health sector, which is developing into a market
that raises high hopes for the struggle against mass
unemployment. All EU Member States are currently
going through a process of "geriatrisation". With an
increasing number of elderly people requiring care,
there is a demand for expanding the social and health
system accordingly. In the federal province of
Salzburg alone, the number of persons requiring care
will increase from the present 17,000 to 22,000 by the
year 2000. What constitutes an extreme burden on the
social security systems in all Member States,
translates into an enormous opportunity for the
regional employment situation. During the same
period, 700 additional full-time jobs must be created in
the health-care sector. When financing this task, all
EU Member States face the problem of expensive
health systems which are increasingly difficult to
provide with adequate budgetary funding. They can
learn from one other as to how to cope with this
challenge. All serious approaches to reform lead to
more prevention, more emphasis on health planning,
performance-oriented accounting systems and a more
efficient use of resources, particularly with regard to
large equipment units, staff and medication. Savings
must, however, never be to the detriment of patients.
After all, the focus of all health systems must be on
people.”
Martine Buron
Public health has clearly become an area where
Article 129 of the EU Treaty, which was added in
Maastricht, requires the European Union to take
action. It calls upon the Community to contribute
towards ensuring a high level of protection for human
health, and it encourages Member States to cooperate and promotes co-operation with third countries
and international organisations with competence in the
field of health.
Community activities relate to the prevention of
disease, particularly the main epidemic diseases and
addictions, focusing on research into their causes and
their transmission, as well as on information and
education in health matters. These measures are
stipulated by Council in conformity with the procedure
provided in Article 189B. For the purpose of supporting
the entry into force of the Treaty on European Union,
the Commission - upon request by Council - outlined
the set of actions to be taken in the field of public
health.
The Committee of the Regions was given the
opportunity of commenting on each of the action plans
in the field of public health, for which their advice was
sought. In its comments, the Committee stated that, on
account of the fact that individual health and public
health are both questions that are very close to every
citizen, the subject was of priority interest to the
Committee of the Regions. Moreover, the Committee
underlined that in countries, where the responsibility
for health management was located on a regional
level, it was important to involve the regional
collectives as much as possible in the setting up of
networks, establishing for example regional monitoring
centre, and – if such centres exist - to examine on the
local or regional level, which of these centres could be
integrated into such a network.
Moreover, subsidiarity should be applied in its
broadest form, i.e. responsibility for their respective
tasks with regard to public health should be delegated
to local and regional authorities.
The Committee of the Regions stated that individual
health is defined by endogenous factors, by society
and the environment and pointed out that individual
persons often cannot in all circumstances exercise a
total control over certain factors that influence their
behaviour. For example, persons exposed to poverty
and disease and living in insanitary lodgings don't
have access to – or don't have the financial means –
for better nutrition or physical exercise.
With regard to health promotion, the Committee of the
Regions gave preference to an approach by subject
instead of a multi-topic approach in connection with
promoting health issues. It specified that one should
consider the improvement of health as one of the
important elements that determined the quality of life.
While international co-operation in the field of health
protection is essential (and in this connection the
Committee of the Regions stressed repeatedly that it
was important to co-operate with third countries and
WHO), the Committee of the Regions also stresses
the need to take account of cultural differences when
offering advice or presenting detailed programmes.
The attitude taken in connection with health risks will
often be influenced by these cultural differences.
The Committee thinks moreover that when striving to
promote the co-ordination of policies and programmes
in Member States, one should pay sufficient attention
to regional issues, as well as to the contribution that
regional and local authorities can make, given the fact
that co-operation on a national, regional and local level
is important in order to make sure that the health level
is raised throughout Europe.
When engaging in specific activities for the prevention
of disease and the promotion of health, as well as
structural and strategic projects for health promotion, it
is important to recognise that individual national or
regional authorities cannot alone assume the
responsibility for health promotion, and that it is also
important that all participants take part in the struggle.
By the same token, the inter-sectorial dimension of
health promotion should be fully recognised when
setting up networks.
Daniel Mart
“The European unification process has accumulated
so much critical mass that it can not be stopped
anymore. To achieve this, a multitude of gradual steps
have been undertaken and the people of the different
European nations had time to warm to the idea of
integration and to feel more and more as Europeans.
The next big step, the introduction of the Euro, will be
another milestone in this development bringing our
nations closer together, not only economically, but
also emotionally.
Through all these years the political leaders have
always excluded health-care and social security from
their considerations. It will probably be easier to create
a European Army than to create a pan-European
health-care system. Rather than even touching this
difficult subject, our politicians have excluded it from
the agendas altogether.
In April 98 the judges of the European Court of Justice
have reminded the public and the politicians that the
treaty of Rome stipulates free circulation of people,
goods and services in the European Union by
rendering the controversial Kohll and Decker
judgements. By these judgements they clearly state
that the treaty includes medical goods and services.
The interpretation of these judgements made by
certain countries, trying to limit their impact to these
specific cases or to claim national sovereignty in this
matter are nothing else but poorly managed damage
control.
As a consequence, reactions in Europe to this legal
milestone encompassed everything from shock to
ignorance. But even those politicians who want to
ignore the consequences have conceded that the
Kohll and Decker judgements will be seen in the future
as the one triggering step towards integration of our
social security systems.
Luxembourg is surrounded by Germany, France and
Belgium and the regional micro-economy that has
developed here through the last two decades is
turning this region actually into a laboratory for
European integration. Citizens are working in one
country and living in another one, small enterprises
are used to cross-border contracts and consumers
have been crossing borders for the last 20 years,
progressively considering these borders as an
obstacle until they finally came down with the
Schengen agreement. Under these circumstances it is
not astonishing that the first attack on the
"nationalistic" confinement of our social security
systems has come from Luxembourg citizens.
There are commonalties in the European health-care
systems, albeit negative ones. There is no ideal
system and they all have financing problems, whether
they are based on the "Bismarck" contribution systems
shared between employers and employees or whether
they are tax-based. The financing is closely linked with
economic activity and strangely enough the Euro
harmonisation process with it's downfalls such as high
unemployment, has made the situation even worse as
funding available for health-care has diminished.
Reducing workloads to battle unemployment, with
initiatives such as the French 35hour working week, is
increasing the strain on the health sector, which is one
of the most work-intensive in our society. The recent
European directive on working hours has put so much
pressure on certain hospitals and other sectors in
health-care that some countries are frantically looking
for exceptions or legal loopholes to avoid bringing their
systems down through the impossibility of
implementing the directive.
Opening systems such as the Luxembourg one, which
are all more or less budgeted on national levels, to the
open market actually transfers the power of financial
control from the state (mostly through the willing or unwilling medical profession) to the citizen. It is our belief
that this transfer of power to the citizen is a political
will and expressed through the European treaties.
The consequences of this are that closely monitored
and budgeted systems are going to implode under
open-market pressure and will develop by their own
purely economic principles. The health sector is
extremely work intensive and has known growth rates
of close to the 10% range per annum. This is actually
one the most dynamic sectors in our economies with a
fantastic reservoir for employment and is being kept
under an artificial restraint until now.
To achieve this sudden unprepared and destabilising
transition from controlled systems to market economy,
health-care harmonisation has to be achieved on
several levels. Definitions of medical goods and
services through the different nomenclatures have to
be made in an identical way throughout Europe. A
market-orientated and non-subsidised price has to be
put on all these "goods" to make them comparable
and exchangeable.
A European definition of what is to be included in socalled "basic" healthcare has to be made to avoid the
sacrifice of decades of social progress and the
American excesses of purely market-based healthcare run by profit-orientated commercial outfits. Socalled comfort medicine and not strictly medical
accessories should be freely insurable through a
market that has to open to private insurers.
We cannot engage into a pan-European health-care
system without considering at least these few common
principles.
As always there are years and years of political
dissension, down talking and bargaining ahead of us
but the irreversible first step has been taken. After
introducing free migration of doctors in the European
Union the integration process has come to a standstill
for too long in our sector and again the non-imposed
self-evolving dynamics of regions within Europe has
been the motor for change in the interest of the
responsible European citizen.”
Wolfgang Routil
High level health care without health policy in the
EU
“For decades, the systems of social security including
health insurance, which have evolved in the individual
Member States, were no matter of concern to the
European Union. All the more surprising must have
been the decisions of the European Court of Justice in
the cases Decker and Kohll, although, in fact, it was
clear to anyone informed about Community law, that
the European Court of Justice is not able to interpret
the freedom to provide services in another way. In
deciding the causes Decker and Kohll, the European
Court of Justice made clear, that the health insurance
of an EU national, having received medical services in
another EU Member State, is obliged to reimburse at
least those costs, which would have accrued for the
treatment in the home country. Is the provision of
health care since then no more a regional matter, but
a duty to be dealt with exclusively at Community level?
Do the cases Decker/Kohll constitute the end of the
principle of subsidiarity, which has been considered
respected in particular in the field of social security.
In my view - which may probably contrast with the
opinion generally held by German commentators - the
answers to these questions must be clearly no. In my
opinion, too much importance is being attached to the
decisions in the cases Decker/Kohll. For more than 40
years now, since the introduction of the present social
insurance laws in Austria, we have been already
putting into practice the general principles relating to
Decker/Kohll, which in fact has been long time before
our accession to the European Union. Patients
undergoing medical treatment abroad are entitled to
claim reimbursement of the approximate amount of
costs, which would have accrued in Austria for the
provision of equivalent medical services. Those 40
years of experience with this arrangement have
shown, that in the medical field, cross-border services
are barely made use of. There are two reasons
explaining this phenomenon. The main reason is, that
patients requiring primary health care services in
general do consult a doctor near their place of
residence. This is not only true for the general
practitioner, but also for the provision of specialised
services, provided either as out-patient services by the
specialist, or as in-patient services in hospitals.
People requiring medical attention have obviously the
desire to seek medical treatment as close as possible
to their home. In addition, it seems logical, that
patients do only take difficulties of receiving crossborder medical services upon themselves, if this
implies also important economic and professional
advantages. The fact is, that the demand for medical
services by Austrians abroad in the course of the last
years has been practically limited to the field of
prosthetic dental services, which Austrians presumed
to be cheaper in the neighbouring Eastern European
countries.
For this reason I am firmly convinced, that after the
Decker/Kohll era too, the principle of subsidiarity will
continue to be valid for primary medical and standard
care. This reflects to a large extent the actual situation
in Europe. Primary health care will be organised at
regional level, regardless of whether the health care
system is nationalised as this is the case with the
British Health Authorities or with the Italian Sanitary
Units, or whether there are social insurance systems,
like the „kassenärztliche Vereinigungen“ in Germany
(associations of doctors affiliated to the social
insurance system, organised at state level), or whether
health care is provided by institutions run
predominantly by regional health insurance funds.
Although the cases Decker/Kohll should not be
overvalued, the EU should nevertheless consider the
organisation of health care services as one of its
important duties:
it would in fact make sense to co-ordinate and to fund
expensive high-level-medicine at supra-regional
Community level. Apart from the fact, that patients
requiring highly specialised medical services are ready
to take travelling distances upon themselves, it would
be advantageous from the medical and the economic
point of view to reduce the provision of high-level
medical services to a limited number of specialised
health care centres. These few centres would
guarantee a high number of consultations, necessary
in order to achieve high medical standard, and the
high costs relating to their construction and operation
would in addition be justified from the economic point
of view. For this reason, the EU regulation on social
law 1408/71 has rightly been providing for nearly 30
years now, that patients, who are not in the position to
obtain adequate medical care in their home country,
are entitled to use medical services provided in
another EU Member State, after authorisation by their
social insurance institution. What is missing, however,
is a Community instrument for the co-ordination and
common funding of such highly specialised centres.
The national economies of the Member States have
growing difficulties in funding and providing state of
the art medical services free of costs for patients.
Modern medicine has come to a point, that it is able to
offer more than the society is willing to afford itself
from the economic point of view. Limiting of health
care services shall never be shifted onto the individual
doctor, as this would not only contradict the doctor’s
comprehension of his profession, but would also be a
disrespect towards the particular confidence, which
the patient has in his doctor. For this reason, it is high
time, that a common “golden standard“ for a possibly
high number of diagnostic and therapeutical
procedures will be elaborated in a common Europe,
which should guarantee, that the national health care
systems, within their social security structure, provide
a uniform standard of medical care within the
European Union. In considering an economic use of
the resources available to the social security systems,
which are, after all, predominantly facing excessive
demand, this standard should set not only minimum,
but also maximum limits. Services situated above this
commonly defined standard, should not be offered by
the social security systems, services of this kind
should be available on a private basis. In my opinion, it
would make sense to institute a kind of “European
Consensus University for Medical Associations“,
where it would be incumbent on the professional
medical associations to elaborate standards of
medical practice for the individual European doctor.
Primary health care should continue to be provided at
regional level, however, the variety of different health
care systems within the present EU Member States
seem to suggest the creation of a platform instituted
by the EU, where information may be exchanged
between the specific regional health care structures.
In my view, the health policy of the EU, provided at
present by Art.129 of the EC Treaty, can largely be
considered an alibi. The promotion of certain health
programmes, which in addition are funded with
comparably small resources, is not suitable for
complying with the decisive requirements of a co-
ordinating European health policy. What is missing in
Europe and what cannot be realised at regional level,
is the co-ordination and funding of expensive highlevel medicine and the development of common
standards for medical practice,- in a time, where the
societies within Europe are no longer able and willing
to afford themselves medical services, which from the
professional and technical point of view are feasible.
Taking into consideration, that nearly one half of EU
funds are being used for agriculture, the small portion
provided for the health sector seems even more
disconcerting. Europe-wide, health care expenses
total to 500 billion ECU, being therefore three times as
high as the expenses in the field of agriculture. This
ratio suggests, that the EU reduces the physical wellbeing to the stomach.“
Tapani Piha
The group started from the notion based on the
subsidiarity principle that regions and local authorities
are responsible for production of healthcare and health
promotion services for their populations. Their
responsibility includes many other services, too, such
as social protection, education, youth and elderly.
Consequently, local actors have considerable
experience in health matters and how they are
organised. The regions cannot be excluded from the
European discussions on health policy.
The starting point opened several strands of debate:
- the impact of freer cross-border healthcare market
in the European Union;
- health effects of tourism; and
- the evolution of the subsidiarity principle.
Jacques Delors said that we need a Europe of
regions. The definition of a region differs from country
to country and seemed to escape the group’s efforts.
Some regions have political competence, others don’t.
A region can be defined in economic terms, but also
by cultural and language characteristics. Regions must
serve a purpose. Could we actually think in terms of
health regions? They might not be congruent with the
present political Euro regions. Probably new
transnational regions will emerge because they make
economic sense in an integrating Europe.
Regions and healthcare
The Kohll and Decker cases were considered to be a
landmark in the development of a real European
healthcare policy. From a citizen’s point of view, the
European Court of Justice had no alternative for the
verdict. Common sense tells us that costs which would
be reimbursed for in one’s own country should be
reimbursed for treatment received in another country.
This is nothing new for Austria who has already for 40
years reimbursed cross-border services. However, the
group was reminded that in the real life not many
patients use this opportunity as they naturally seek a
doctor who is located as near as possible. The cultural
and language barriers are also formidable in many
areas of Europe.
The speakers were thrilled about the new
opportunities the freer healthcare market offers for
regions and their healthcare policy planners. For
example, regions could benefit from obtaining highly
specialised services from nearby regions, not
necessarily in the home country. But the vision went
much further: the portability of nursing insurance
benefits from one country to another, Europe-wide
hospital chains, setting up treatment centres in
attractive locations. Hip replacements in Majorca were
quoted as an example that shows the benefits for the
patient and the insurance scheme. The Kohll and
Decker ruling will no doubt promote competition in the
European healthcare market.
The enthusiasm for the freer healthcare market was
clear but the group was reminded that the national
authorities have been rather reserved to this idea.
Several countries in Europe do not have insurancebased health systems. The tax-based social security
schemes seem to be much less influenced by the
Kohll and Decker case. The implications for tax-based
systems are less obvious although not completely
analysed yet.
The enthusiasm must also be tempered by keeping in
mind other facts. In Germany there are both federal
and regional sickness funds. The national funds have
been more successful as competition has favoured
bigger units. This is clearly a threat to regions.
The development in the healthcare leads to a question
which services regions need to include in their social
protection schemes. Several speakers estimated that
regions need to establish a basic package, consisting
of the most important healthcare services, and let the
comfort and luxury services to be financed outside of
the public system. While some speakers warned
loudly against two-tier system, others saw them as an
unavoidable future. The European Union has also a
role in making sure that inequalities with its area are
reduced rather than increased.
Another question is how the quality of services can be
guaranteed. The possibilities include quality standards
for healthcare agreed at European level. The
resistance of the medical profession towards quality
management is slowly giving way to its acceptance.
Luxembourg is now emerging as a unified economic
area, not confined to its national borders. While there
was an agreement on cross-border medical services
already in
1890, doctors in Luxembourg are now more
systematically networking with their cross-border
colleagues and drawing up quality standards.
Luxembourg is a real European laboratory in this field.
The costs of the healthcare will in many cases be
borne by regions. While the costs are huge the
positive side of the equation is that healthcare is a
very labour-intensive industry. In the federal province
of Salzburg, the ageing of the population will imply 700
new jobs by the year 2000. What constitutes an
extreme burden on the social security scheme
translates into an enormous opportunity for regional
employment. However, the financing remains a major
problem. Taxation cannot be used in most cases.
Therefore, all savings potentials must be used in full.
The regions should learn from each other. For
example, networking of insurance systems is badly
needed and still broadly lacking. The new information
technologies were identified as a means of bringing
even the most remote regions into the front-line of the
development.
The group identified emergency services and health
promotion campaigns as natural and immediate fields
for co-operation between regions. Prevention of
smoking, for example, is a task for families and
communes but effective campaigns must be supported
by broader action at regional, national and
international levels.
Let me tell you a story about a need of emergency
services: Some time ago there was a severe car
accident in Germany near the Luxembourg border.
Five people were severely injured. The rescue
helicopter had to be called from Mainz which is 150
km away while the 2 Luxembourg rescue helicopters
were waiting only 30 km away.
Tourism and Regions
Tourism can play an important role in health. In
addition to health benefits to clients, spas and similar
health oriented services are economically important for
many regions. But the beneficial effects of tourism go
much beyond the proper health tourism. Tourism in
general will have positive effects on health although
they have not been studied much. Surveys show that
the majority of tourists claim to have done something
for their health. As tourism is one of the leading
industries in the world it could be a mighty partner for
health promotion. The tourism industry has in many
countries recognised its responsibility by offering for
holiday-makers
delicious
and
healthy
food,
opportunities for physical activity, social interaction
and facilities free from tobacco smoke.
Subsidiarity
Subsidiarity is a contemporary concept. It didn’t look
the same 10 years ago, and it wouldn’t look the same
in 10 years time. One speaker emphasised that the
principle should be interpreted in a much wider way
than until now. The principle should be used to
empower communes and regions within national
states. Subsidiarity should apply to all levels of
administration.
Conclusions
The important role of health promotion and disease
prevention was underlined. Health promotion is not
only cost-effective but also increases the quality of life
and is an answer to the wishes of citizens. Therefore,
the group called the Health Forum Gastein to focus
more on health than on disease.
The group glanced in its discussions at a possible
future, with perhaps virtual regions emerging that
serve above all the interests of patients. The group
called for a strong support to a social Europe, and
welcomed further discussions in the context of the
European Health Forum Gastein.
Forum IV
Meeting
the
challenge
of
a
changing economic
environment: How to
finance
the
European
health
systems in the next
millenium
Jens Bostrup
The question, I will put to you today, is a rather
fundamental one: Why put (more) money in the health
sector and / or make more efficient use of the
resources?
The answer seems obvious - to make people
healthier. But statistically there is very little evidence of
such a link, if any at all. Life expectancy is commonly
used as a yardstick for the popular health, but you will
find no relation at all with the level of expenditure on
health.
From a more cynical point of view you can argue, that
the actual health isn't really important - what counts is
to make people feel well and healthy. By the end of
the day, the responsibility for allocating resources to
the health sector lies with the politicians and the
politicians prime concern is of course to be re-elected.
The important thing in this regard is not whether the
electorate actually is in good health or not - the crucial
factor is that the public feel good and feel well taken
care of.
Putting money in the health sector does not make
people feel any better. If the statistics from Eurostat is
to be trusted, the reverse - the less you spent on
health, the more healthy people feel - is closer to the
truth.
At the overhead you will see the 'old' EU-countries,
organised after how much they spend on health.
France has by far the most expensive health system,
spending 9.6 pct. of GDP in the sector. However - the
number of people who feel 'very good' is well below
EU average. The figure isn't here, but the number of
people who feel 'very bad' is above EU-average. The
Dutch feels a little better, but still below average. It
appears that only the UK gets value for money. 37 pct
of the British is feeling 'very good' - almost twice the
French and the Dutch figure.
But you will have to look at the bottom of the table to
find the most satisfied citizens. Greece and Denmark
are number one and two in the bottom, when it comes
to spending. But in the 'well being contest' they come
first and second - with astonishing 53 and 48 pct
feeling in very good health.
It is tempting to conclude that the less you spend on
health care, the better people feel. The tendency line
would support it. But as you can see the picture is not
at all clear, and it is certainly not a recipe for political
action. You need not look any further than Portugal for
proof. They are in the bottom when it comes to
spending - and when it comes to well being.
Here the countries are ordered by perceived health with Denmark in top, followed by Greece, Ireland and
the UK. The other figure is the average life expectancy
for men and women compared to EU average.
It appears that the Greeks feel healthy - simply
because they are healthy. Even though they spend
least, they live longer than most Europeans.
The same simple explanation does certainly not apply
to the others. The UK health is below average, the
Irish even more, and the top scoring Danes actually
has the lowest life expectancy in the European Union
apart from the Portuguese.
Denmark, the UK and Ireland have something else in
common: They are all financed by the state through
general taxes.
The system I know best is the Danish, which - if you
ever tried anything else - really is a lousy one, not only
from a statistical point of view. There are almost no
private operators or true competition. Almost all
services are free, there is no special health insurance
or contribution - the costs simply disappear in general
taxes. It appears that the health services come, if not
from heaven, then from somewhere near. Most Danes
don't or won't believe that health services are better in
other countries. They believe in their state.
It is perhaps significant that none of the continental
systems is doing well in the 'feel good contest'. My
personal experiences with the systems in Belgium and
France are that they provide much better services for
the patients.
But they do that by treating the patients as capable
and critical consumers. They give you a pretty good
idea about what kind of money they put in to the
system. They make it possible to choose between
different providers - and often the patients can even
decide what level of services they are prepared to pay
for.
And here comes the trouble. As opposed to humble
and grateful subjects, consumers are never satisfied.
They want more and better.
It is not for me to draw lessons. My job - as a journalist
- is to ask the cynical and provocative questions. My
question goes to those, who will advocate even more
and even stronger market forces in the health sector:
Why? What good does it do? It may be more efficient
from a rational point of view. But if it makes people feel
more like consumers, making them feel less grateful,
more sick, more demanding - is it still worth the while?
If it at least prolongs life, the answer is of course yes.
What Eurostat tells us, is that neither more money nor
more competition does anything to prolong life and do
not improve the quality of life, i.e. increase the feeling
of well being. To explain that paradox, you will have to
bring in a number of other factors, ranging from work
patterns over environmental problems to cultural and
psychological issues.
Given the crucial importance of these factors - does it
make any sense to discuss the technicalities of
financing isolated from the social and cultural aspects
of health - and of the health sector? And given the
distinctly national or regional nature of those factors does it make any sense to look for European
solutions?
Bernard Merkel
“The question of how to finance health systems in the
future is often considered in terms of finding the best
way to respond to the problem of endlessly rising
health costs.
Clearly there are problems in financing health services
at the moment, and it may be that demand for services
will always outstrip suply. But it may be misleading to
assume that costs will inevitably continue to rise
rapidly, and still more so that there will inevitably be
problems in financing health costs in the future. Indeed
the OECD data for 1997 seem to show that health
expenditure is now stabilising in European countries
as a percentage of GDP. We need therefore to look
very carefully at factors which will affect the size of any
potential problem in financing European health
systems before jumping to conclusions. We have to
look for instance at what might be the likely impact of
the ageing population and the increasing use of new
technology. The answers to these questions are not
straightforward.
In this context the European Commission has been
supporting various analyses in an attempt to obtain a
better overview of the likely developments in the
European Union. Considerable work is underway
looking at the impact of demographic change, in
particular the ageing population, on health care costs.
Another study is looking at the economic impact of
prevention and promotion measures on costs to see
whether prevention is actually cheaper than cure.
A second issue related to assessing costs and
making decisions on financing is the question of what
do we get for the money. In other words, what are the
outcomes of health systems in terms of health gain?
how cost–effective are current health interventions,
whether in the fields of prevention, diagnosis or
therapy? and what new technologies and other
developments can we see on the horizon that could
improve cost-effectiveness?
In light of this the Commission is supporting work
looking at how different kinds of health interventions
can be evaluated and are being evaluated in practice.
In addition we are attempting to promote the use of
technology assessment and are funding studies which
aim to define ‘best practice’ in health care and to find
ways of spreading it.
In addition, in the new policy that the Commission is
now developing a major emphasis will be placed on
improving information on health and health systems in
the European Union. These will cover, for example,
trends in costs and financing, cost containment
measures, the use of market mechanisms and system
reforms. The aim will be to set up systems that
provide comprehensive and comparable information
that can be used as a basis for policy.
A third and final point that will affect health financing is
the development of the European single market. There
are already provisions regulating the reimbursement of
health care costs in certain circumstances. The recent
European Court judgements in the Kohll and Decker
cases appear to widen
the scope of what is
reimbursable –though the exact effects still have to be
determined.
But this raises two general issues of what inter-country
co-operation in health services is currently taking
place,
and how far it could be extended with
consequent savings, increased efficiency in the use of
resources and improvements in services.
The European Community does not run health
services, nor is it directly involved in funding them.
But it is playing a role in health policy, and in view of
the importance of developing even more efficient and
effective health services, that role is likely to grow.”
Werner Reimelt
Health care is above all a political task a question of
what is to be provided and who is to pay the costs. At
the same time, however, it is also an economic
challenge, namely how we organise the fulfilment of
our desires in the most efficient way and with a
minimum of cutbacks. And finally, health care is a
medical challenge with the goal of maximising
efficiency in the given conditions. It ensues that the
financing of the health systems of the future involves 3
main groups of activities:
a) fund raising
b) transfer of funds, and
c) the utilisation of finds.
ad raising of funds:
In recent years, the solidarity principle has been
abandoned in favour of a risk that can be calculated
and insured on the insurance market. Most countries
aim at striking a new balance between state funding
and free market organisation. This development will
and has to continue. In the interest of a more
understandable system, contribution oriented fund
raising should be given priority over tax oriented fund
raising.
Apart from hybrid types of the obligation to insure and
compulsory insurance, in almost all countries there are
additional insurances which go beyond the basic
protection afforded by compulsory insurances and
offer a more comprehensive insurance cover.
ad transfer of funds:
The transfer phase is the most important sphere in the
health care system. It constitutes a system of
incentives acting upon the provider. Each provider is
doubly conditioned by this system, firstly the provider
will identify and offer tile most attractive health care
service for its own purposes, and secondly the
provider will attempt to always retain sufficient
capacity to satisfy demand for tile economically most
interesting services or, alternatively, extend its
capacity to provide these services. Here, then, we find
market anomaly or information symmetry.
This will increasingly lead to innovations in the area of
costs and revenue Management - such as the
Managed Care approach or the fund holding concept
of the National Health Service in the United Kingdom.
By inserting a "gate-keeper", the demand is not solely
formulated by the provider, but a competent
representative of the intermediary will decide the
utilisation of an emergency hospital.
ad utilisation of funds:
In most countries, the health care system focuses on
the
hospital. This leads to expensive treatment variants
such as inpatient treatment being given preference in
terms of price, which prevents a shift to the more
productive and more cost efficient outpatient area.
Therefore, it must be an economic mission to
maximise the number of treatments in the hospitals'
outpatient wards or by doctors with their own practice,
until there a balance between the productivity and
input prices between the two procedures is
established. An attempt to solve this problem would
be, for instance, to introduce several general
practitioner systems, also at the public hospital level.
Ray Robinson
“I have been asked to be provocative in my opening
statement. As such, I want to suggest to you that one
of the fundamental assumptions underlying this forum
is misguided. That is, I want to argue that the
universal search for methods of aggregate cost control
in the finance of health care - while understandable
from a Treasury, macro-economic perspective - is a
mistaken priority from a health economist‘s
perspective.
Rather than focusing on aggregate
expenditure we should be focusing on allocative
efficiency in the use of resources and equity in the
distribution of these resources.
Health care is often criticised for taking up an
increasing and unmanageable share of a country‘s
GDP. To that charge, i have several responses. First,
as William Baumol has pointed out, as a labourintensive service industry we should expect the
relative price of health care to rise through time.
Second, it is impossible to say what the optimal level
of health care spending should be on the basis of
existing data on costs and benefits. US expenditure
levels are often held up as an object lesson in what to
avoid; however, if well informed users want to spend
14 per cent or more of the GDP on health care, so be
it.
Third, I do not accept the prevailing view that rising
health care expenditures are unaffordable for
governments. This is more of a political judgement
than an economic one. And, in any case, people who
subscribe to this view do not argue that private top-up
expenditure is unaffordable.
Finally, objections to rising expenditures are often
based on the belief that additional expenditure on
health does not generate sufficient benefits to justify
its costs, because of distortions in the market process
introduced by suppliers‘ vested interests for increased
incomes (i.e. doctors, hospitals and pharmaceutical
companies) and ill-informed patients demanding
treatments of dubious effectiveness. But this last
concern is really about allocative efficiency, not overall
expenditure.
Given the role that governments of all countries are
going to continue to play in the funding of health care,
far more attention needs to be paid to the costeffectiveness of different types of expenditure. On one
level, this will require greater investment in R&D to
establish the cost-effectiveness of new technologies.
On another level, it will require substantial investment
in information systems to enable the dissemination of
data on cost and clinical effectiveness. Both of these
activities should be European wide.
On the organisational level, arrangements for funding
health care that combine clinical and financial decision
making, together with a gate-keeping function at the
important primary-secondary care interface, are an
important pre-requisite for a more efficient use of
resources.
Various manged or integrated care
approaches that are being developed around the world
offer a promising way forward in this connection.
Finally, I believe that the quest for reduced public
expenditures, and a possible greater reliance on
private expenditure through cost sharing, will pose a
real danger to the principles of equity or social
solidarity embodied in most European health care
systems. It is important to ensure that these are not
eroded on the basis of specious arguments about
economic necessity.”
Wolfgang Schmeinck
Health care coverage in Europe is essentially the
concern of the individual states. The systems differ in
organisation, financing and delivery of health care
based on a more or less wide range of philosophies of
need, medical standards and quality of care. The
overall finance system of a country can be based on
contributions to insurance companies (social or private
insurance) or the health care is paid out of taxes.
Despite the differences in providing health care,
several factors have combined to exert upward
pressure on health care expenditure in all European
countries. The ageing of the population, with an
increase in chronic diseases and disability, has
created new pressures o health services. The pace of
technology development has quickened over the past
decade, generating new diagnostic techniques and
treatments,
sometimes
replacing
and
often
supplementing existing treatments. The expectations
of patients regarding the range of treatments and
quality of services available have also increased in
most European countries.
On the other hand, unemployment has grown in many
European countries in the last years with the effect,
that the revenues of the sickness funds have
decreased. As the resources available for paying
health care have become more constrained and the
pressure on health expenditure have increased,
national decision makers have to develop strategies to
deal with resource scarcity. If present attitudes
towards raising and spending funds do not change,
then the foreseeable future threatens either a rise in
expenditures and a corresponding increase in
contribution rates or a distinct increase in rationing.
To avoid rationing of medical services as a major
instrument to deal with the problem of financing health
care, it is necessary to discuss different options of
balancing revenues and expenditures. But the
normative message of the motto „rationalisation before
rationing“ is still applicable and can be extended by
the postulate „rationalisation before the utilisation of
new funding sources“. Thus, the utilisation of the
existing rationalisation potential remains a permanent
task of health policy.
Many criteria are available for evaluating the efficiency
of health insurance and its funding. These include:
fiscal effectiveness (effects on revenues)
employment effects and effects on the costs of labour
risk sharing and compatibility with social policy
principles
legal consistency and
political feasibility.
The persistence of social health insurance deficits
despite rationalisation measures would leave only the
following alternatives open: the increase in
contribution rates, increased revenue generation
through changes in the structure of revenue sources, a
more restrictive definition of the benefits catalogue, the
transfer of funding responsibility to other payers (e.g.
the public hand or other social insurance institutions)
or the transfer of funding responsibility to private
households.
When weighting the evaluation criteria mentioned
above, in Germany the prime considerations are the
positive effects on the cost of the factor „labor“ and the
anticipated effects on employment, especially since
the erosion of assessable income has a stronger effect
on the financial situation of the social health insurance
in 1997 - i.e. in the short run - than on the volume of
services and expenditures. The following alternatives
are in discussion at the moment:
Changes in income threshold for determining the
obligation to have health insurance and for the
assessment of health insurance contributions,
broader definition of the revenue base, which means
expanding the revenue base to include at least half of
the income of pensioners that is nit presently used as
a basis for assessing contribution (e.g. company
pensions, capital income), limiting the free coinsurance of family members limiting the employer´s
contribution rate or paying the employer´s contribution
to workers
removing benefits from the benefits catalogue which
are not directly related to sickness and its
consequences (to be transferred to others payers, e.g.
by tax) and
increasing patient co-payment.
Although widely practised throughout Europe, taxfunded health care is not the focus of serious debate
in Germany at present, for the good reason that it has
the following flaws in terms of the allocation of
resources:
Abandoning the principle of equivalence erases for the
citizen (who no longer has the status of being insured),
any perception of the relationship between the
financing of the health care system and the utilisation
of funds.
Tax-funded health care leaves little room for personal
preference. General elections, in which public health
care features as but one of many sub-systems within
the range of governmental tasks, provide scant
opportunity for the parties involved to influence
decisions on medical care, or to shape the process of
innovation.
Günter Danner
Facing a widening gap between expenses and funding
is considered to be likely. It has been stated by the
participants that a few principal decision regarding this
development will have to be made by those who bear
the political responsibility. A comprehensive approach
to health care costs is said to be currently missing as
is a convincing approach of how to measure
effectiveness and outcome. Missing parameters for
the socio-economic output of the health care sector
are macro-economically problematic. Short term
reduction of costs has hitherto largely replaced a
comprehensive approach to this financially and
ethically momentous market. The widespread search
for new sources of additional funding has up to now
not lead to substantial progress. Thus the subsidiary
questions of how to gather funds, e.g. whether by way
of taxation or contributions is said to be of minor
importance since the general tools of how to come to
grips with the expenses will have to be defined before.
Differences between various EU systems thus seem to
play a less significant role. On the other hand , given
the rather problematic experiences with want in above
all tax-financed and State controlled structures, a
certain preference for a social insurance model has
been shown by the majority of participants. It has
been said at an early stage that the effectiveness of
the system ought to be more important than a mere
discussion of costs. The social momentum of the
health care sector as a growth industry has been
referred to in terms of macro-economic relevance of
health sector related expenses for the economy and
the labour-market.
The element of demography has been discussed in
detail ,revealing concerns of some and lesser worries
by others who are of the opinion that not merely
growing age is responsible for higher expenditure in
this sector. The latter have referred to recent studies
showing that the peak of expenditure in many cases of
illness occurs during the final year prior to death. In
case of a younger person this includes missing
contributions or taxes due to a premature loss of life.
The pivotal question of how at best to come to grips
with a provider-driven health care market has been
raised frequently by both statutory and private insurers
as well as by scientists. A focus on real human needs
and on an improved role of the patient as the weakest
part has been considered necessary. The implications
of the Interior Market, its freedoms and obligations
have been discussed. It has been made clear that
accessible structures of health care open to EU
citizens and residents are obligatory since otherwise
the co-ordination according to the Regulation 1408/71
(EEC) cannot be possible. Promising developments
are seen by an increased competition among
providers and by incentives to all those players willing
to improve the general situation and not just there own
individual micro-economic situation. Evidence based
medicine (EBM) has been referred to as the future
standard , together with an accent on primary care and
e.g. disease management. The element of subsidiarity
regarding the future role of the EU has been touched
frequently. It has been made clear that in accordance
with statements from the Commission and the
mainstream of the Draft Treaty of Amsterdam,
subsidiarity is not seriously questioned. This all the
more since the recent rulings by the European Court
of Justice (ECJ) have only defined basic European
freedoms to be valid for the health care sector as well.
These rulings have not , contrary to certain national
conjectures in some Member States, notably
Germany, infringed on the national prerogative
regarding the structuring of the health insurance
system. They do have on the other hand made it clear,
that the billion ECU market “health care” does not
make
an
exception concerning its market
characteristics. Subsidiarity may, on the other hand,
be in a far greater danger due a an uncontrolled loss
of quality regarding health care. Any downgrading
competition even among sovereign Member States
may, however, sooner or later lead to a demand for
basic EU standards, thereby introducing supranational
structural responsibility through different channels.
The role of statutory and private health insurers has
been discussed, largely with regard to the only two
countries where such systems co-exist in an interlinked fashion: Germany and the Netherlands. The
demand to deliver “basic” care by the social insurers
and “additional” benefits by the private sector has
been touched. The difficulties of how to define a
ethically just and economically sound partition have
been realised by many. This all the more since highcost medicine is usually related to severe illness
requiring expensive treatment which has to be
accessible for everybody and consequently will never
leave the responsibility of the statutory insurer.
According to the understanding of the participants, the
following list reflects the list of priorities with the
exception of the EU implications which have been
considered a general condition mirroring effects of the
Internal Market and its forces more than an instrument
of the health care sector:
Measuring
outcome
and
evidence
based
medicine
Coming to grips with a provider-driven market
by suitable incentives to all
Focus on human needs
How to improve effectiveness
Taxes or contributions
Social balance in finance
Demographic crisis
Gate-keeping and targeting
Benefit
competition
in
non-solidarity
based
sectors only
EU-implications
understood
as
a
general
condition for future developments
Short term savings in one area entailing rising
expenditure elsewhere
The first three of the above points have been
considered to be of particular concern for the analysis
of present shortcomings of the existing health care
markets and have consequently been looked at in
detail. Potential benefits as well as pitfalls have been
looked at in trying to arrive at solutions and
compromises relevant as recommendations to political
actors:
Regarding point one on the above list a new system of
how to agree on targets between providers and
insurers and patients is recommended. This new order
may serve to help the patient in a confusing market, to
stress the rights of the patients regarding the
providers’ predominance or the reluctance of the
insurers to take their service obligations seriously. It is
this potentially relevant conflict of interests among the
three actors involved which might lead the political
decision makers to over-caution. An improved
communicative approach on regional, national and EU
level together with a constant flow of relevant
information, a better data base at all levels and more
individual responsibility have been defined as major
factors
regarding
this
aspect.
Conventional
remuneration not having progressed much regarding
the outcome for the patient, it has been understood
that in the future more than today already a better
targeting of the funds available is in the interest of all
actors, allowing the patient to be treated with a higher
regard to effectiveness, the insurer to benefit from
better cost-effectiveness thereby achieving more with
the same amount or less and the provider to avoid
rationing as a form of ultimate cost-containment.
Regarding point two on the list, the “Focus on human
needs”, the gatekeeper as the personal adviser has
been recommended, though not without a word of
warning concerning possible difficulties arising from a
too rigid limitation of the choices of the patient. Thus
the element of voluntary decision by the insured has
been favoured over attempts to but curtail the choice
of doctors, a way which might neglect the close
individual relationship between doctors and their
patients. Ethics have been attached with high social
values regarding the important question of a social
culture valid for the entire EU. Increasing the quality of
life has been considered an important issue. On the
contrary, attempts to but evaluate socio-medical
endeavours through the eyes of an accountant has
been considered inadequate. A form of “managed
death in dignity” has been claimed for those in need of
it with a strong element of humanity to avoid ethically
unwelcome calculations reducing man to matter and
sole cost factors.
The third point, “Coming to grips with a providerdriven market by incentives to all players” represents a
crucial issue to most of the participants. The future
role of the carriers of statutory health insurance as
purchasing collectives for the incomplete market
participant “patient” has been favoured by a strong
majority. The absence of market elements on today’s
health care scene has been attributed by and large to
neglect of
political concern, strong lobbying of
provider-groups and a lack of understanding of the
incomplete nature of the health care market in its
present shape. It has been made clear, however, that
the role of the good provider of medical services will
not only be strengthened but also directed toward new
social responsibility. Assuming it to be true that up to
now in many cases the poor treatment has been
financially more attractive than the good one, a future
improvement of quality can also be expected. With
more and a socially feasible degree of competition on
the health care market, this could help to improve the
situation. The element of restricted competition,
already relevant in certain countries, may further help
to improve results. Selective incentives are but one
way of such a model but seem to facilitate the
realisation of this process. The prevention of
exploitation of a system by a minority of participants
concerned mostly with micro-economic gains, has
been defined as a key issue. Any political attempt to
pour more funds into a system lacking even simple
elements of steering through competition among
providers has only made things worse and will
ultimately question solidarity. It has been mentioned
that structural responsibility and financial one should
be brought closer together, preferably in one hand.
Any nationally existing administrative monopolies may
therefore be re-defined in order to make the entire
system more flexible. This should preferably not been
done without concern for those involved in any of
these institutions. New strategies have therefore to be
formulated by any such institution in order to include
new challenges as well as the Single Market, the Euro
and other key-elements of a changing world.
Incentives and instruments to facilitate the
transformation may have to be defined at national
level. It should, however, be clear, that henceforth in a
world of a common economy and a single currency
market decision must not overlook the EU
implications. Though today still in an early phase, even
the medical market for goods and services will see a
growing momentum of European issues relevant for
every actor involved.
Questions of morbidity, disease management and
other intelligent forms of how to pay for cascades of
treatment instead of just reimbursing fees for
uncoordinated individual services at the discretion of
the provider will dominate the future discussion. New
forms of cross-segment dialogue may help to come to
flexible solutions instead of having political decisions
watered down by the omnipresent influence of
individual economic lobbying. Linear reductions and
budgets have in the past shown remarkable effects for
limited periods of time but have by and large not
solved the basic problem of an ever rising
consumption of health related goods and services. It
has been stressed, that even if political “force” may be
indispensable at certain times, a new order of this
highly complex market will need a broad consensus in
order to last. It has been clear to a large number of
participants that this can only be achieved by a better
understanding and the readiness to be open to a
different line of arguments. The main actors, patients,
insured, doctors, hospitals, insurers of any kind
without much difference regarding their status, the
pharmaceutical industry and others share a common
interest that adequate forms of treatment should be
accessible to everybody. Without a new way to more
effectiveness, the political suppression of expenses
will further increase, affecting not only the quality of
care but also the micro-economic perspectives of the
other actors involved. True progress does therefore
require innovation and should be given a higher rank
on the list of political priorities throughout the EU in
order to stimulate decision-makers to come up with
new and well targeted solutions.
Forum V
The role of the
European
Union:
Legal
and
institutional
framework of the
Union’s policy on
health
Georgios Gouvras
In its various communications and statements
concerning health systems and policy, the
Commission has repeatedly commented on the
multitude, complexity, and relative importance of
factors affecting human health, and acknowledged that
conditions, systems, and practices in the Member
States are very diverse. At the same time it has
recognised that Member States face very much the
same problems, and that the Community could greatly
contribute to creating the conditions for improvements
needed to improve health status, reduce costs and
expenditure, and make health systems better
performing.
It should be stressed, in this context, that each
Member State’s health system is different as it reflects
a unique pattern of historical and cultural
development. Nevertheless, the Member States saw
from early times the need and opportunity to work
together in large parts of health and health-related
sectors ; this was reflected in the founding Treaties
and also in their successive revisions. At the same
time, there was increasing realisation and
acknowledgement of the fact that, as it is the case with
all endeavours, opportunity will be accompanied by
risks ; in this case the risk of being unable to express,
in a text such as the Treaty, clearly and limitatively
what the Community ought to be doing in the area of
health . What is more, it is impossible to express in the
Treaty what and when a particular topic should be
treated as a priority, what specific type of intervention
would be ideal as circumstances change, and what
level of prescription and resources will be ascribed to
Community activities in this area. It was only natural
that such considerations, and fears from the inverse
delegation of powers (from the periphery, the Member
States that is, to the centre represented by the
Community) that took place, gave rise to strong
support for over-riding principles such as subsidiarity,
proportionality, and added value , which evolved from
implicit to explicit status in the Treaty, and became
causes celèbres in political debate and rule-making in
recent years .
Interestingly, growing awareness of the inherent
limitations of centralised systems , such as the
Community’s, to be sensitive and responsive to the
needs of those who have ceded decision-making
power to them , was matched by an increasing wish
to benefit from the best conditions and situations
which prevailed only in a few particular places in the
space created by the centralised system and over
which that system, over-ridingly, held sway. For
those enjoying (or believing of enjoying) the best
conditions, their preservation became paramount and
this led , in some cases, to outright opposition to the
process of centralisation or even partial transfer of
competence. This is as true for the Community as it is
for individual Member States, their regions or counties,
and even for smaller territorial administrations. In
other words, the apparent paradox of people ceding
decision- making power (or sovereignty) to the centre
because it is in their interest to do so (expecting to see
applicable to them the best standards that have been
put into practice anywhere in the system, and hoping
to benefit from the establishment of an all-embracing
level-playing field ) , and at the same time being
reluctant to live with the consequences of the transfer
of power, is not a novel phenomenon peculiar to the
Community, but occurred from times immemorial to
many societies.
In the European Community, the legitimate aspirations
of its citizens to enjoy the best achievable health
status and
benefit from the best practices and
services anywhere they live , work or travel to for
whatever purpose, have to be matched by the everpresent confidence and knowledge that decisionmaking is optimally organised and no power transfer is
taking place which is not in their interest and cannot
be influenced by their participation.
They must
possess or have access on demand to information on
how to benefit from systems and services that exist or
are put in place on their behalf, and be able to get firsthand experience of progress towards the best
standards. And what is valid for the citizen is a fortiori
valid for all those who by profession, vocation or
election are there to serve in or create these systems
and services.
Is the European Community succeeding in contributing
to the realisation of these aspirations ?
The first thing to be said in trying to construct a reply is
that the Community has no unfettered discretion to
seek to find the optimum level of its contribution in
terms of mandate, instruments and resources. The
mandate, not unambiguous for the reasons cited
above, is laid down in the Treaty, and is the
embodiment of the judgement of the contracting
parties (the Member States) concerning what they
think can best be achieved by a transfer of powers at
the level of the Community. It may be argued, and it
has been argued by many, that what is laid down and
the way it is laid down are not optimal , and this
causes, rightly or wrongly, controversies, false
expectations, and, after a period of implementation,
disappointment and criticism. Whether the mandate
itself reflects the aspirations of the citizens of the
Community is a wider issue involving the nature of the
democratic process and cannot be dealt with here .
What about the implementation of the mandate itself ?
To begin with this is a matter of interpretation most of
which is of a legal character, but also involving
political , administrative and financial aspects. To the
question « are we as a Community, given the
mandate, doing the right things, and if so, how good
are we at doing them ? » there are conflicting answers
but little hard data to support them .
The
implementation of Treaty provisions is subject to
consultations,
proposals,
negotiations
and
compromises, most of them imperfect, but all
necessary. In the field of health, matters became
complicated from the outset because no specific legal
basis existed at the beginning, and health-related
measures with far-reaching consequences for the
citizen were introduced on the basis of other
objectives : free circulation of people, free circulation
of services, their establishment and conditions of
competition, public procurement, pharmaceuticals, the
safety and wholesomeness of food, dangerous
substances, free circulation and establishment of
health professionals, medical devices, health and
safety at work, environmental health, and research,
especially medical and biological research. A
substantial body of regulation was developed, which
clearly had a significant impact on the health systems
of the Member States, as well as on the health status
of the EC citizens. This impact is the object of Forum
II, but,
needless to say, constitutes the
main
component of the Community contribution to health
status and health systems.
What then of the public health mandate proper ?
Shortly after the coming into force of the Maastricht
Treaty, the European Commission issued a
communication on the framework for Community
action in the field of public health. In this document,
the Commission set out a strategy to attain the
objectives on health protection laid down in the
Articles 3 and 129. This strategy consisted of keeping
under review the health status in the EC, in particular
as regards mortality and morbidity and the influence of
health determinants ; in devising and adapting criteria
for undertaking Community action; in identifying the
legal, administrative and financial means at the
disposal of the Community for achieving the objectives
of the Treaty ; in selecting priority areas by the
application of the set criteria ; and in proposing
recommendations, to be issued by the Council of
Ministers, and incentive measures, to be agreed by
the European Parliament and the Council, the codeciders of legislation in the EC. These incentive
measures, on the basis of Article 129, consisted of 5year programmes of action, and of decisions enabling
the setting up of structures, such as networks.
This strategy appeared to have struck the right
balance between the desires of the Member States,
and received support from the other Institutions and
the vast majority of other stakeholders.
In pursuing this strategy, the Commission has adhered
to the principles of subsidiarity (taking measures only
where it was better for the Community, rather than
individual Member States, to do so) and proportionality
(measures should not be excessive with respect to the
result they aim to achieve). It also set the ambitious,
but realistic, target of trying to obtain for the whole of
the EC what has been acknowledged to be the best
result in a given area that has been achieved in the
Member States of the EC.
In the space of less than five years from the coming
into force of the EC Treaty, the Commission,
implementing the aforementioned strategy, brought
forward proposals and secured the adoption of five
public health programmes of action (on cancer, AIDS
and other communicable diseases, health promotion,
drug dependence, and health monitoring). It also
proposed three other programmes (on rare diseases,
pollution-related diseases and injuries), and secured
the adoption of a decision to create a network for the
epidemiological
surveillance
and
control
of
communicable diseases . The latter is a most
important enabling measure which provides for an
early warning mechanism, consultation and coordination procedures for counter-measures, and a
framework for agreeing detailed rules on the
surveillance and sharing of information on
communicable diseases by the authorities of the
Member States.
The Commission also presented in the same period
two reports on the state of health in the European
Community (the second on the health of women), and
two reports on the integration of health requirements in
EC policies and on the practical implementation of
various public health programmes and actions . It
published communications on tobacco and smoking,
on drug dependence in the EC and a plan for tackling
the problems in this area, and on health education in
schools. A strategy on blood safety and selfsufficiency was devised to underpin the EC legislation
on blood-derived medicinal products, a Council
recommendation on the suitability of blood donors and
the testing of their donations was adopted, and two
reports were issued on progress towards Community
self-sufficiency. The Commission presented also a
strategy for pharmaceuticals in which the public
health aspects were particularly stressed, and
supported activities to increase understanding and
assist in policy development on the choices facing the
Member States concerning expenditure on health and
their ramifications on increased access to and
continuity of services across the internal borders of the
EC.
In the context of the action on BSE and CJD, besides
contributions to the research, scientific advice, and
market-oriented efforts, three
documents were
presented on the epidemiology and surveillance of
transmissible spongiform encephalopathies in the
wake of the BSE crisis. A proposal for the limitation of
exposure of the general public to electromagnetic
fields was put forward, reflecting the growing concerns
over non-ionising radiation . And appropriate
mechanisms were put in place to ensure that a “health
watch” was kept over instruments in other policies that
could have an impact on health . Finally, and perhaps
most importantly, work was initiated to find ways to
contribute in a practical manner to the everyday health
problems of the European citizens as they move about
in the EC.
Despite the vast amount of the work undertaken ,
however, it was always going to be important to keep
the strategy under review and to assess the
results and the alternatives. How do we know that
these actions reflect the proper role of the Community
? And that we would thus obtain the best possible
results ? These key questions have not ceased taxing
the Commission. They are at heart of much soulsearching in the Community institutions, the Member
States, and many other interested parties. The
Commission has tried to address them in its recent
communication on the development of public health
policy in the European Community with a view of
launching a wide-ranging debate before the expected
coming into force of the Amsterdam Treaty.
To begin with, the communication considered that
experience gained from the implementation of the
current set of public health programmes has not been
particularly encouraging : the programmes, while
pursuing worthwhile objectives, have turned out
unfortunately to be rather inflexible and cumbersome.
At the same time, there has been a gradual shift away
from the old specifications for Community programmes
of action and towards new blueprints reflecting much
stronger the need of administrations, and through
them the health professionals, institutions and
organisations, for accurate and rapidly-transmitted
information . For these reasons, the communication
advocated the concentration of efforts on actions that
support the creation and development of lasting and
all-embracing structures providing reliable data to
health administrators at various levels, capacities for
analysis and support for the development of effective
and coherent health policies, and finally devising and
testing of intervention strategies and methodologies.
Taking into account the possibilities offered by the
Treaty and the need to provide the Member States
with unique , and the greatest possible, support, the
communication presented three strands on which a
future Community public health policy could be based.
A first strand would cover the creation of a health
information system to inform not only Community
policies, but also those of Member States. National
health systems in the European Union differ widely,
but as mentioned earlier, Member States all face
similar problems, including public pressure and
concern about health. A new information system
should therefore cover both the area of health status
and health determinants and questions relating to how
health systems are responding to the challenges they
face. The Community is in a unique position to set up
such a system which would link together the relevant
national authorities in the collection, analysis and
dissemination of information.
A second strand would be the development of a
capability to react rapidly to threats to health. This
would build upon the Community network on
communicable diseases which will be underway
shortly. It could then be extended to cover noncommunicable diseases where a rapid response is
often necessary or desirable. It should cover for
example environmental hazards and large-scale
accidents.
Finally, the third strand would consist of measures to
promote better health and disease prevention by
tackling health determinants. This would build on the
experience of our existing public health programmes,
such as those on cancer, AIDS, drug demand
reduction, and health promotion, and on major
initiatives, such as on tobacco. But it would go further.
It would be able to accommodate other important
health problems, such as mental disorders and cardiovascular diseases, as well as new issues as they
arose in the Community.
It is hoped that the debate on this communication, and
the wider role of the Community in assisting the health
systems of the Member States, would generate the
consensus and the ideas which would permit the
Community to make a telling contribution to the health
of its citizens.
Michael Hübel
The Development of Public Health Policy
in the European Community
“The Commission set out a framework for action in the
field of public health in November 1993. This
described the strategy to be pursued and measures to
be put forward by the Commission to give effect to
Article 129 of the EC Treaty.
Eight public health programmes have been proposed
in the context of this framework. Five are in the course
of implementation (on cancer, AIDS and other
communicable diseases, health promotion, drug
dependence, and health monitoring) and the others
(on rare diseases, injury prevention and pollutionrelated diseases) are being considered by the
European Parliament and the Council under the codecision procedure.
There is now a need to consider how far the existing
framework remains satisfactory and is able to respond
to a number of important developments, such as
emerging health threats and increasing pressures on
health systems, as well as the enlargement of the
Community and the new public health provisions in the
Treaty of Amsterdam. Moreover, such a review is
particularly urgent as most of the existing programmes
will be coming to an end in or about the year 2000 and
proposals will have to be put forward in the near
future.
The Commission’s recent communication on the
development of public health policy first considers a
number of developments in health status and health
systems in the Community, as well as principles and
pre-requisites of public health action at Community
level. These considerations lead to the conclusion
that, although the principles and underlying philosophy
of the 1993 communication on the framework for
action in the field of public health remain valid,
priorities, structures and methods are all in need of
fundamental review and reformulation.
Finally, the communication outlines a possible new
Community public health policy, based upon three
strands of action:
-
Improving information for the development of
public health,
Reacting rapidly to threats to health,
Tackling health determinants through health
promotion and disease prevention.
Issues related to enlargement, and to the integration of
health requirements in Community policies, would be
dealt with by all three strands.
The Commission intends to come forward with
concrete proposals on the new policy once the Treaty
of Amsterdam has been ratified. In the meantime it is
hoped that the ideas presented in this communication
will stimulate a broad debate on the future Community
public health policy.”
Günther Liebeswar
The Treaty of Amsterdam is the next step in
development of the European Community's Founding
Treaties which began with the Single European Act in
1986 and the Treaty on the European Union in 1993
(Maastricht). The purpose of the intergovernmental
conference which preceded the Treaty of Maastricht
was not to delegate major additional authorities to
community institutions but to fill gaps, remedy
deficiencies, and further improve existing instruments.
So far the legal framework for community activities in
the area of public health was defined by the provisions
of Article 129 in connection with Article 30 of the EEC
Treaty. I would describe the provisions mentioned
above as "soft law", since even the possibility of
recommendations by the Council cannot lead to any
legally binding measures.
As far as the new health article (Art. 152 EEC Treaty)
is concerned, the Treaty of Amsterdam does,
however, lead to a certain enlargement of Community
powers, in particular through the
authorisation to
introduce veterinary and crop protection measures as
well as to set high quality and safety standards for
organs and substances of human origin, blood and
blood derivatives. Thus, recommendations recently
made on the selection of blood and plasma donors
and on the screening of blood and plasma donations
after the new treaty has entered into force could be
translated into legally binding standards – of course,
only after a corresponding proposal by the
Commission.
The mandate to observe health policy constraints for
the purpose of maintaining a high health protection
level in defining and implementing community health
policies and measures, the so-called integration
clause, was incorporated into paragraph 1 of Article
152 of the EEC Treaty to underline the importance of
this issue. Moreover, the activity of the community to
complement policies of the member states is defined
in paragraph one of the article. The aim of this activity
is to improve public health, prevent human diseases,
and control the risks to human health. The activities of
the community include the fight against widespread
serious diseases; the aim is to promote the study of
the causes, transmission, and prevention of these
diseases as well as health information and education.
The community is also to complement the measures of
Member States to control health damage in connection
with drug use, including information and prevention
measures.
Paragraph 2 obliges member states to co-ordinate
their corresponding policies and programmes in cooperation with the Commission.
an effort to adjust their national practices, they reject
any harmonisation of their legal systems.
Paragraph 3, which aims at supporting co-operation
with third countries and international organisations
responsible for public health, remains unchanged.
Particularly in connection with the accession
negotiations with Eastern European countries and the
strategy of their adjustment to community law, this
mandate to the community institutions, above all to the
Commission, must be given special attention.
Sophie Petzell
Paragraph 4 concretises the measures that are to be
adopted in view of the targets defined in paragraph 1
of the article. The decision-making procedure remains
unchanged. (co-decision procedure following hearings
of the Economic and Social Committee and the
Committee of the Regions).
Letter a contains measures for the definition of high
quality and safety standards for organs and
substances of human origin, and for blood and blood
derivatives; these measures do not prevent the
maintenance and introduction of stricter protection
measures by the Member States. Letter b includes
measures diverging from article 37 of the EEC Treaty
in the areas of veterinary health and crop protection
which directly aim at the protection of public health.
Defining support measures aiming to protect and
improve human health but which do not intend to
harmonise legal and administrative regulations of the
Member States shall continue to be possible. The
areas in which projects received support so far will be
evaluated for the coming Health Framework and
adjusted to future challenges.
Furthermore, the Council can continue to issue
proposals upon proposal by the Commission on the
targets set in this article with a qualified majority
voting.
Paragraph 5 explicitly stipulates the maintenance of
full responsibility by the Member States for the
organisation of health systems and medical care in
Community activities in the sector of public health, that
is, the Community has no authorisation whatsoever to
act in these areas. In its communication dated April
1998, however, the Commission expressed prudent
considerations, e.g. to address issues of quality
assurance in this context on its own. The ministerial
conference under Austrian presidency, however, made
clear that although the Member States welcome an
exchange of information and opinion on this issue in
“The legal and institutional framework on health cooperation within the European Union is vast.
Successive Treaty changes have broadened cooperation in health protection within the Community.
The Amsterdam Treaty takes an extra step forwards
not only in the Treaty text itself, but also by integrating
the Social Protocol in the Treaty. On top of this the
Treaty asks for integration, or mainstreaming, of health
questions in all Community decisions.
This has not only produced proposed health
programmes and a stream of directives from
Commissioner Flynn´s area of employment and social
affairs. The policy areas of consumer protection,
transport, fisheries, agriculture, R&D, education,
environment, telecommunications, humanitarian, aid,
drugs fighting, to mention a few, have produced
proposals with a legal base in the Treaties concerning
citizens health and welfare.
And still, quoting Commissioner Flynn, – from two
different speeches, I admit:” the Member States have
jealously retained their competence in the field of
health, ceding to the Community only a limited role in
the field of health protection and the promotion of cooperation between the members of the EU. It is clear
that the provision and financing of health care is a
matter for the Member States. However, ensuring that
the continuing development of the European Union
supports the health protection of our citizens is and
must remain a responsibility shared by between
Member States and the Union.”
It has taken decisions by the Court of Justice based on
rules for the Internal Market, not at all specifically
intended for areas of health protection, to chip out
pieces of this jealously guarded wall. I am thinking of
the many judgements in favour of parallel import of
drugs, and of the recent judgements by the Court
giving the EU citizens the right to seek health care in
any Member State of his or her choice. This is to be
paid by the insured person’s social security institution
in his home state – without prior authorisation from this
social security institution.
Both, in my opinion favour the citizens.
The parallel import of drugs is a thorny, complicated
and sensitive question. But as far as I can see a fairly
simple one – that is from a pure competition policy
point of view. Complicated national regulations on
drugs and social security systems in each Member
State have resulted in price levels on pharmaceutical
products differing very much from country to country.
There is no free and open competition on the market.
It seems in general that countries with strong own
pharmaceutical industries tend to have high prices.
Classical low price countries are France, Spain,
Portugal Greece and Italy. This gives traders incentive
to seek supplies of pharmaceutical products in the low
price countries and place them on the market in high
price countries at a much lower price than the same
products marketed directly by pharmaceutical
companies in this country.
The pharmaceutical industry does not exactly love
this. The Court of Justice in Luxembourg has looked
into several cases where the industry in different ways
has tried to hamper or circumvent the parallel trade.
Most of these cases have come to the Court in
Luxembourg from national courts asking for
interpretation of the rules on free movement of goods.
Cases where the Commission has attacked the
hindering of parallel trade as violation of the antitrust
rules of the Treaty also exist.
This far the Court rulings have favoured free trade
rules and the parallel trade has been kept open
providing high price countries with lower priced
products, to the benefit of the consumers and
admittedly to the detriment of profits for the
pharmaceutical companies.
We will, by the way, soon see the free trade rules
tested again in the Court. German Bayer AG has
brought a case to the Court after having been fined
three million ECU by the Commission for having
restricted deliveries of their big-seller drug Adalat
through their daughter companies in Spain and
France. Notably to stop re-exportation of the drug in
question.
The Court recently used other general articles in the
Treaty – again to the benefit of patients in the Union
and this time to the anger of several Member States.
One minister of health was even heard muttering that
the Treaty might have to be changed to stop the
consequences of the Court’s decision.
Two Luxembourg citizens had gone abroad to seek
health care. One to buy prescribed glasses in Belgium
the other to have his daughter treated by a German
orthodontist. Both were refused reimbursement from
their social security institutions. Both took their cases
to court.
The EC Court in Luxembourg was asked if it is really
possible for a country to force a person to ask for
authorisation by the person’s social security institution
before looking for help in another state. Is this
compatible with Articles 59 and 60 in the Treaty? The
two articles concern free provision of services within
the Community to citizens from other Member States.
The court answered that such national rules actually
do deter insured persons from approaching providers
of medical services established in another Member
State. Such rules are barriers to freedom to provide
services in accordance with articles 59 and 60.
Moreover doctors and dentists have, through several
community directives, been granted the right of
establishment and freedom to provide services all
through the Union. Thus doctors and dentists
established in another state must have the same
guarantees as those established on national territory.
According to the judgement it would seem that Article
56 of the Treaty allows Member States to restrict the
freedom to provide medical and hospital services. But
only if maintenance of medical services in a nation is
essential for public health or even the survival of the
population could be at jeopardy. The Court said
however that there were no risks of the kind in the two
cases and indicated that these risks are far of, also in
other cases.
What then does this ruling mean? Well, as I see, it
means a far greater freedom for the citizens to seek
help and care wherever they wish without prior
consent from the institutions in the home country and
with a guarantee that the expenses will be paid
according to tariffs at home. I do not believe that this
possibility will be limited to well off patients with good
international contacts. I think that many citizens will
have chance of option when it comes to the Medicare
he or she wants. I also think it is healthy to expose the
national systems to competition this way.
Michael Hübel
Recommends that the Community should take
tangible steps to develop the legal
basis and
implementation structures to ensure ‘a high level of
human health protection in the definition and
implementation of all Community policies‘, in particular
those
policies
that
could
influence
determinants, including inequalities in health.
health
Within the health information strand, work on good
practice in prevention, treatment, care and
rehabilitation must be developed as a priority. For
example, one important area should be the creation of
a structure which collects, analyses and disseminates
information on the processes, outcomes and costs of
interventions in prevention, treatment, care and
rehabilitation. This will need to be done with the
collaboration
of
national
and
international
organisations and agencies. It will collect guidelines on
actual practice for a variety of conditions. This will
enable Member States and health authorities to
implement appropriate policies. This information
addresses the resource allocation concerns of
Member States and health authorities. It will also
provide information to our citizens on good practice.
Forum VI
Health systems in Central and
Eastern Europe and particular
health risks
Marianne Fotaki
HEALTH CARE RISKS IN THE REFORMS’
PROCESS IN THE FEDERATION OF RUSSIA
Background of reforms
In the late 1980s, the perennial problems of Soviet
health care system such as antiquated and
deteriorating facilities, insufficient supplies and
outmoded equipment as well as low incentives for
health care workers and public dissatisfaction with
quality of services were for the first time openly
discussed. It was then recognised that universal and
free of charge provided health care was not only
under-funded but also mis-managed.
In the light of difficult economic situation of the
beginning of 1990s and growing inability of the state to
act as the sole payer for health care provision the
system of compulsory health care insurance was
introduced. This reform was mainly prompted by the
necessity to search for alternative sources of finance
but was also aimed at empowering the citizen through
providing them with opportunity to choose their
insurers. Despite this breakthrough approach, overall
a few things have improved in health system of the
Russian Federation while some health care indicators
seem to have deteriorated.
The reasons for this could be sought primarily in
unequal capability that different regions and
enterprises possess to establish or participate properly
in insurance funds, as the availability of resources to
be deployed for this purpose is conditioned upon
macro-economic factors such as employment and
sustainable economic growth. Second, the lack of
experience in managing and contracting for services is
widespread, as is the lack of information about costing
and quality control mechanisms. Third, the marketoriented reforms presuppose the existence of a
properly informed consumer who makes rational
choices. The asymmetry of information between the
user and provider, which is significant for public goods
such as health care always poses a serious problem.
In the case of Russia where no attempt to familiarise
the public but also the involved actors with new
concepts was ever undertaken, the limited success of
the reforms in this field was to be expected.
Therefore there is a number of priority issues for
Russian government to address at present:
The single most important problem is how to devise an
appropriate public-private mix to fund health care
system. The health insurance scheme introduced in
Russia is not yet uniformly implemented throughout
the country and it can not serve as a sufficient source
of revenues. This is in part because the number of well
developed insurance companies operating in Russia is
not great as yet but also because local budgets do not
pay their due contributions to the territorial medical
insurance funds.
There is a need to initiate the debate on priority setting
in order to define the appropriate level and type of
services to be provided through public funds. This is a
precondition if the best allocation of scarce resources
is to be achieved and the accruing benefits
maximised.
Health care in Russia is still delivered in app. 60% via
hospital/specialist care and only app. 30% via primary
health care. This is the opposite of proportions that
apply across European Union countries, and goes
against the recommendations of the World Health
Organisation. It is also fundamentally inefficient, as
primary health care based on a family doctor service
acting as a gate-keeper and preventing unnecessary
referrals constitutes a much more cost-effective way of
delivering the bulk of care.
The progress of reforms is often dependent upon the
existence of enthusiasts who lack the necessary
relevant experience and also the indispensable tools
and methodologies to proceed successfully with the
implementation of reforms.
These issues could best be dealt with through the
implementation of an adequate financing system with
in-built cost-containment mechanisms, strengthening
of Primary Health Care and rationalisation of the use
of hospital sector. Also health care promotion activities
are of great importance if viewed as a medium to long
term policy. This is why they should form the agenda
pertaining to health care reforms.
Russia. However, the absence of fully functioning
compulsory health insurance funds on the one hand
and continuing severe under-funding of the sector on
the other (health care expenditure in Russian
Federation amount to 3-4% of its GDP as opposed to
average of app. 10% for OECD countries), has
exacerbated yet further the inadequate and
inappropriate provision of even the most essential
services.
Public- private mix
It lies within the interest of donor initiated efforts to
contribute to the realisation of some of these
objectives. One way to achieve this aim is through
making available the relevant expertise that already
exists and provision of appropriate and tailored
Technical Assistance projects. A number of problems
in the field of health care financing and delivery which
Russian system faces at present, were and still are
extensively discussed in many industrialised countries.
Different schemes, aimed at search for higher
efficiency while maintaining an acceptable level of
quality of care are being tried throughout Europe. This
rich stock of knowledge should be transferred and
shared in a ready usable and acceptable form with the
beneficiaries in the regions as well as federal
authorities.
In practice no system relies solely on one single
source of finance. Development of the optimal mix
between public and private sources for Russia at
present, presupposes an exploration of the
acceptability and viability of alternative sources of
finance should they be introduced (e.g. ear-marked
taxes on cigarettes and alcohol although it is
recognised that this may not be immediately possible).
There is also a need for evaluation of willingness and
ability to pay and for what type of service both by
individuals and the government in addition to the
development of acceptable mechanisms for priority
setting in health care. The temptation to restructure
the system towards models of private insurance where
the type and level of care depends on the insurance
premium paid, which was already expressed by some
Russian policy makers, should be strongly resisted.
Health
care
consumption
possesses
the
characteristics of a public good, no health care system
can rely solely or chiefly on private provision of
services without resulting in stark inequalities and
ultimate inefficiency.
Financing
Care Delivery
The entitlement of all citizens to free access to health
care is proclaimed in the Constitution of the Russian
Federation. Everyone is entitled to free care under a
programme, which specifies the package of basic
services. Employers pay 3.6% payroll on behalf of
their employees to mandatory insurance funds, which
in turn allocate money to the competing insurance
companies. The latter make payments to providers’
organisations for the volume of services rendered.
Those not in work have their contribution paid by their
local government from local budget revenues. This
system of funding based on principles of solidarity and
competition proposes an innovative approach to health
care financing and if fully implemented, it would make
a major contribution to restructuring of health care in
The absence of economic incentives and the use of
obsolete planning methods not based on modern
concepts of needs’ assessment has resulted in the
development of the health sector through the increase
of the number of inappropriately qualified physicians
and the expansion of bed capacity. The polyclinics
were and still are staffed with a large number of
rudimentary trained and underpaid specialists whose
qualifications, experience, and range of responsibilities
would not be recognised as of a specialist level
according to the EU standards. Russia has twice as
many physicians calculated on a per capita basis and
13.8 hospital beds per 1000 of inhabitants against 9.2
average for OECD countries. This is however not
reflected in the quality of services provided which is by
Rationale for the donor initiated assistance
general acclaim poor and unequal. The system of
evidence based standard setting as well as auditing
and monitoring of quality of services provided is either
non-existent or where in place it is usually based on
the "norms" which bear little or no relevance to
efficiency or clinical effectiveness considerations.
Also the necessary shift towards provision of bulk of
services through Primary Health Care networks with
an ultimate goal of reversing the current pattern of
delivery has not yet been observed. This could be
accomplished through development and upgrading of
the capacities of primary care settings, but also
through competitive incentives given to providers in
form of an appropriate remuneration system. The
importance of Primary Health Care is based on its
preventive character and family orientation, which in
the long term constitutes possibly the most efficient
policy. On the other hand its integrated, wide ranging
and cost effective characteristics underlie and stress
even further its acute relevance for Russia and should
be therefore be given a definite priority in the reforms’
agenda.
Arun Nanda
Introduction
The 1990s have seen all countries of central and
eastern Europe (CCEE), including the 10 candidate
countries for accession to the EU, go through
enormous social, political and economic change. In
general, the transitional crisis and its health-related
consequences were deeper in those candidate
countries which were a part of the former Soviet Union
i.e. the Baltic States, as compared to the remaining
candidate countries of CCEE. This, as well as
differences in historical, cultural and economic
development, makes variation in some health
indicators quite significant amongst the CCEE and as
compared to the EU countries.
Demographic and socioeconomic background
Socio-political changes caused a sharp decrease in
birth rate which, together with the rise in mortality,
have in some countries, resulted in a dramatic decline
in natural population growth. From 1990 it became
negative in the majority of the candidate countries
reaching levels well below the lowest in the EU. Data
for most recent years show signs of improvement in
some countries, for example the Baltic States.
In parallel with the decline in birth rate and mostly
because of that, the proportion of elderly people in the
candidate countries was increasing relatively faster
than in EU countries but is still well below the EU
average.
The candidate countries display a wide range of
transitional patterns in relation to their economy.
Unemployment rose rapidly, reaching figures above
10% and GDP per capita declined. Since 1995, there
are signs of recovery although the GDP per capita in
all the candidate countries is well below the lowest in
the EU countries.
Health status
Life expectancy as an overall indicator of health status
shows that around 1970 all the candidate countries
were in the range between the EU maximum and
minimum. However, by the mid 1990's they were all
outside this range, some being considerably below the
EU minimum. The average difference between EU and
the candidate countries was about 2-3 years in 1970,
while by the mid 1990s the gap had increased to 6-7
years. However, whereas trends in the Czech
Republic, Poland and Slovenia show improvement
during the transition period, most other countries show
a decline. Trends in the Baltic States, which are very
similar to trends observed in the other countries of the
former USSR, suggest that the increase is in a large
part associated with alcohol related mortality.
Infant mortality in the candidate countries declined but
more slowly than in the EU. Presently, infant mortality
is close to the EU average only in the Czech Republic
and Slovenia. In all the remaining candidate countries,
it is above the worst level in the EU, with rates for
Romania being particularly high.
Maternal mortality in most of the candidate countries is
rather close to, although somewhat above the levels of
EU countries, except for Romania and some Baltic
States. High maternal mortality is associated with high
abortion rate as abortion is still a frequently used
family planning method in some CCEE.
Cardiovascular diseases (CVD) are the leading
causes of mortality responsible for about half of deaths
in any industrialised country. Differences in CVD
mortality are the main cause of the gaps in total
mortality or life expectancy between the EU and the
candidate countries. Premature CVD mortality in all
candidate countries (except Slovenia) is well above
the highest level of the EU. The Baltic States have
specific trends, the reasons for which are more as
those mentioned above in the case of life-expectancy.
Cancer is the second leading cause of mortality in
most industrialised countries. Around 1970, overall
cancer mortality (and also lung cancer mortality) in the
candidate countries was close to or below the EU
average. Since then, due to diverging trends,
premature cancer mortality is now, in most of the
candidate countries (particularly in Hungary), well
above the EU average. In some candidate countries
there has been a decline in cancer mortality since the
early 1990s. nineties.
External causes of injury and poisoning (accidents,
suicide, homicide) are the third leading cause of
mortality and also (with CVD) contribute to the
mortality gap between the EU and the CCEE. Again,
the trends observed in the Baltic States are quite
specific and similar to those in other former USSR
countries. Although presently mortality from these
causes is on a decline, it is still about 3 times higher
than the EU average. A similar situation exists in the
case of suicide. In addition to the Baltic States, high
suicide rates are observed in Hungary and Slovenia,
while in the remaining candidate countries, rates are
relatively close to the EU average. In relative terms,
the gap between the EU and some of the candidate
countries is particularly wide in the case of homicide.
The difference between the highest level in Estonia
and the EU average is almost 20-fold.
In the CCEE, the programmes for surveillance,
prevention and control of infectious diseases,
particularly immunisation programmes, were well
developed before the transition period and were
comparable with most EU countries. Disruption of
these programmes in some countries, in combination
with other factors – particularly with the deterioration of
socio-economic living conditions during the transition
period – have contributed to the worsening of the
situation with respect to incidence and mortality from
certain infectious diseases. Some of the candidate
countries, particularly the Baltic States, Bulgaria and
Romania, are not yet self-sufficient in the vaccines
they need.
Tuberculosis incidence is increasing in about half of
the candidate countries – particularly in Romania and
the Baltic States and the prevalence of tuberculosis
strains resistant to drugs is also high. The remaining
countries are in the range of the minimum and
maximum in the EU. The largest diphtheria epidemic
in Europe since World War II occurred in the countries
of the former USSR, including the Baltic States. In
general it peaked in 1994-1995 and has since then
decreased sharply. The incidence of measles in all of
the candidate countries is well below the EU average.
There has been an epidemic increase in the incidence
of syphilis since 1992-1993 in the Baltic States and
Bulgaria. In Romania it has already been high since
1988. It is very likely that the incidence of other
sexually transmitted diseases have also increased.
The incidence of AIDS is at a very low level compared
to the EU, except for Romania where most AIDS
cases were reported among children in health settings
and orphanages. The level for Romania is still well
below the EU average.
Risk Factors
Lifestyles related risk factors play an important role in
determining the overall health status of the population,
particularly in the development of non-communicable
diseases. Part of the present health gap between the
EU and the candidate countries is caused by
differences in the historical and present exposure of
the population to such risk factors as smoking,
excessive alcohol consumption, drugs, sedentary
lifestyle, unbalanced nutrition and others.
Most recent estimates of prevalence of daily smoking
among adults are generally higher in the candidate
countries.
Statistics on alcohol consumption (In general the data
on alcohol consumption is based on sales data)
particularly in some of the candidate countries are not
sufficiently reliable to allow accurate comparisons. In
some of these countries where estimates of
unregistered alcohol consumption are available, the
actual consumption is much higher than shown by
official statistics and exceeds relatively high levels in
EU countries. Along with the total average amount of
consumed alcohol, the health damaging effect also
depend on the specific drinking patterns. In some of
the candidate countries (e.g. the Baltic States) the
consumption of excessive amounts of highly
concentrated alcohol beverages in one sitting is quite
common. This often causes intoxication or risk-taking
behaviour.
There is evidence that illicit drug use is increasing
rapidly, particularly among young people in most of the
candidate countries. Although comparable statistics
are not commonly available.
Health care resources and consumption
Like in the EU, the candidate countries are
undertaking reforms of their health care systems. In
many of the candidate countries the emphasis is on
decentralisation, reform of health insurance, and a
more adequate use of health resources. Comparisons
based on statistics on health care need to be treated
with a degree of caution since there are known
differences in organisation structure, national
definitions and data collection practices.
The number of hospital beds and the hospitalisation
rates continue to decline in most of the candidate
countries, particularly in those with previously high
levels. In the mid 1990s most of the candidate
countries are within the EU maximum and minimum
range for both these indicators.
The average length of stay in hospitals continues to
decline in practically all countries. It is relatively high in
the Baltic States, Bulgaria and the Czech Republic but
in other candidate countries the average length of stay
is close to or below the EU average.
The number of physicians employed in the health
sector has declined only in the Baltic States and
presently nearly all the candidate countries are in the
same range as the EU countries.
Total health expenditure in relative terms (as a
percentage of GDP) is the lowest in Romania, Poland,
Latvia, Lithuania and Bulgaria. In the remaining
candidate countries it is within the same range as the
EU countries. However, in absolute terms (i.e. $ per
capita) health expenditures in the candidate countries
are generally much lower than in the EU countries.
Background
Central and Eastern European countries (CEEC) face
important challenges in their transition processes. The
change to democracy and free market economy led to
increased threats to health by accentuating social
inequalities, widening the income differences, and
causing a higher dependency ratio. The aged and
poorly maintained health systems are struggling with
old management structures, fewer resources spent on
health and threats from the resurgence of
communicable diseases and ill health stemming from
high alcohol and tobacco consumption and
environmental problems. Nearly all CEE countries
faced a decrease in life expectancy and an increase in
infant mortality. Although most of them have now
reversed these trends, they are still far from EU
averages.
The health system reforms undertaken by all the CEE
countries address these challenges while trying, as did
many EU Member States in their reforms, to make the
health system more efficient and effective. The
presentation will first look at the common ‘European
Value system’ and how it has influenced the reforms in
the CEEC and then investigate the challenges of their
implementation.
Challenges and opportunities of EU Accession for
the CEEC
The need for significant improvement in the health
systems of the CEEC has been stressed in the
‘Agenda 2000 Commissions Opinion on the
Application
of
Membership’.
The
‘Acquis
Communautaires’ need not only to be integrated in the
legal framework, but structures and devices need to
be put in place to enforce them.
Even though EC competence with regards to health is
limited, there are many health related issues in the
legal dispositions, e.g. the four freedoms of
movement. The health systems in the CEEC need to
be prepared to fully co-operate in the European Social
Security Convergence and other health related
activities at the Community level.
While the ‘accession excuse’ can help to better sell
painful reforms to the general public, accession
creates also a very high expectation among the
population. We will study how the collaboration with
the EU, the EC and Member States could be beneficial
to the Health system reform processes.
Challenges for the EU Member States
Officials and professionals in the health field from the
Member states look with some reserve towards the
enlargement, especially on issues related to the four
freedoms of movement. We will examine some of the
aspects: how will CEE health services respond to
emergencies? Will CEE citizens be happy enough with
their system or try to use the systems of Member
States? Will the CEEC's financing mechanism be able
to cover the expenses? Will health and safety at work
be assured? Are CEE health professionals well
qualified? Are goods safe and of quality? How healthy
will be the accessing population ?
Possible Actions to respond to these challenges
Finally we will review possible actions to respond to
these challenges for the different parties involved: the
CEEC themselves, the EC, and the Member States.
We will see that in the long run the health of Europe
can only gain from the enlargement, even though it
might be a long and difficult process.
Witold Zatonski
The Health Miracle in the Vistula Basin
In Poland, after 30 years of permanent increase of
premature mortality (age 20-65 years) in males and
stabilisation in females, since 1991 there has been an
unexpected and dramatic decrease in adults mortality.
(Similar phenomena has been observed in the Czech
Republic and Slovakia but not in Hungary).
Premature mortality among Polish people from causes
other than infectious diseases is shaped primarily by
so-called 'man-made' diseases – those resulting
directly or indirectly from human activity or lifestyle.
Between 1965 and 1991, a strange phenomenon of
increasing rates of premature death was observed in
Polish men. As a result, the probability that a 15-yearold boy living in Poland would, at the death rates of
the early 1990s, reach the age of 60 is not only lower
than in Western Europe, but is also lower than in Latin
America or even India (Murray, Lopez, 1994). Poland
has entered the 1990s in a catastrophic state of adult
health (Zatonski, 1995).
The main causes of the increasing death rate,
especially in the middle-aged Polish population, seem
to involve the Polish lifestyle. There are more than 10
million smokers in Poland, with an annual cigarette
consumption of almost 100 billion cigarettes, and
Polish men have been the world's greatest consumers
of tobacco for more than 20 years. Three to four
million Poles drink distilled alcohol daily, or almost
daily, often to state of intoxication. The Polish diet has
long been characterised by a high intake of animal fat
and a low intake of fruit and vegetables, especially
during the winter and spring. Behaviour on the roads
(by both pedestrians and drivers) and in the workplace
does not meet West European norms of safety.
Physical activity is still largely undiscovered as a
method for maintaining good health and self-esteem.
Medical care in Poland is of a standard proportional to
the socio-economic development of the country, and
the improvement after the second World War was
commensurate with its possibilities. The number of
doctors, the level of their education and the numbers
of available beds in health care facilities have all
increased substantially, and access to modern
medicine is improving. Thus, the numbers of doctors
and hospital beds per 1000 people in Poland are at
the same level (or higher) as in many countries of
western Europe (Feachem, 1994). The results of the
work of the health services are also measurable,
resulting in falling rates for infant, child and maternal
mortality, fewer deaths before the age of 40, improved
infectious diseases control and widespread child
immunisation (Zatoñski, 1994; Zatoñski and others,
1996a).
Since 1991, however, after the sudden socioeconomic changes of the late 1980s, there has been a
dramatic drop in mortality rates in adults. The main
contribution to this change was a sharp decrease in
CVD mortality, with a rate of decline unprecedented in
any developed country in the world (W.A.Zatonski,
A.J. McMichael, J.W. Powles “Ecological study of
reasons for sharp decline in mortality from ischaemic
heart disease in Poland since 1991”, BMJ Volume
316, 4 April 1998). The decrease in premature
mortality in middle age and constant post-war
decrease in infant mortality (which accelerate after
1993) led to an increase in life expectancy between
1991-1996 of 2 years in males and 1.5 years in
females (Central Statistical Office 1997). In 1996 life
expectancy reached its highest value ever (Central
Statistical Office 1997). These positive health
developments are also noted in other CEE countries
(the Czech Republic, Slovakia) (Bobak and others,
1997), but not in Hungary.
The strategy of improving public health status in
Poland and other CEE countries has to be based upon
evidence and science, and has to take cost / benefit
ratio into the consideration.
Fernando Esteves
Summary
In Forum VI, there was a very participated and sincere
discussion about Health Systems in Central and
Eastern Europe (CEE).
Based on the discussion, we could conclude that after
the end of communism, all CEE countries had to make
choices concerning health systems. The change to
democracy and free market economy imposed a new
way of facing health care systems. And the reforms
were undertaken.
The idea of the reform process was to create more
efficient and effective health systems.
Several modifications were made at different levels: At
an administrative level, at a political level, at an
economical level and at a medical level. The opinion of
the participants on Forum VI is that despite some good
results in particular areas, the reforms didn’t have the
desirable success.
No real public health is implemented in most of the
CEE countries. According to the participants of this
Forum, there is a lack of various important things:
There is a lack of communication and regulation;
There is a lack of qualified human resources in
decision making, management and monitoring;
Economically, things aren’t better:
The lack of available data to make better assessments
concerning costs of health care services and costs per
disease makes that there isn’t a clear idea of how the
invested money is spent;
The introduction of health care insurance raised some
problems, like the selection of people in low risk. The
question is: is this desirable on a health care system?
Politically, CEE countries also face some problems:
In the majority of them, medical services are free. Are
the CEE countries people prepared to pay in the future
a service that they usually don’t pay?
Other question is the role of state. The participants
agree that the national states have a central role in the
definition of health policy.
In Forum VI, all these matters were discussed and one
of the most important conclusions was that the
European Union (EU) has an important role to play in
the increasing of quality of Health related issues in
CEE countries.
The participants agree that there is now a strong
demand for the European Union’s action. The CEE
countries expect to join the European Union and the
participants concluded that their accession would be
good for everybody. There are more aspects that join
us than those which separate us.
In the opinion of the participants, the desirable cooperation between CEE countries and European
Union countries should have as background the
following ideas:
1 – At first place, each of the CEE countries has to be
analysed and the decisions have to be made
respecting each one’s culture and reality. Different
countries require different health options;
2 – The people’s mentality has to be modified. On
every reform, each change is not well accepted.
People feel that they are losing something, forgetting
that they are earning something too.
3 – The quality of the CEE countries health systems
has to be ensured;
4 – It would be desirable that the health policy became
a priority for CEE countries. Until now that didn’t
happen;
5 – The bilateral and multilateral co-operation between
European Union countries and CEE countries should
occur in areas like the monitoring of reforms, the
training of new management concepts, the transfer of
know how in the insurance field, the development of
primary care or the improvement of preventive
medicine.
6 – It would be desirable to compromise the population
on the reforms, mainly trough NGO institutions:
7 – Finally, we have to be patient. It is impossible to
have results in two or three years. Every health reform
is slow.
According to the participants on the Forum VI,
Solidarity and Co-operation are the central words for
Europe’s health of the next century. Solidarity between
European Union countries; solidarity between CEE
countries and, finally, co-operation between European
Union and CEE countries. This is the best way to build
a healthier Europe for present and future generations.
Mikko Vienonen
The organisers of the Bad Gastein Forum on Better
Future for Healthcare Systems in Europe deserve to
be complimented for including the views of patients,
citizens and consumers of health services to be heard
on this important platform. I hesitate to put on the hat
of patients, as one may question the mandate of a
WHO representative to speak on behalf of them.
Nevertheless, working for the World Health
Organisation as an international civil servant, I have
been responsible for a European programme focusing
on patients' rights and citizens' empowerment within
the health care systems and established an expert
network to enhance the dialogue between
patients/citizens, administrators, professionals and
politicians around these issues. Based on this
experience I will try to elaborate on some of the
essential questions
that patients and their
organisations feel strongly about when the future of
health care systems is discussed.
To start, I would first in a soft and friendly tone need to
criticise the name of the Bad Gastein Forum. Should
we be mainly concerned that the future is good for
health care systems or shouldn’t we instead aim for a
better future for the people (consumers and patients)
who are using the systems in order to promote their
health, prevent diseases, cure illnesses and
rehabilitate handicaps incurred after an illness?
Should we not aim for health gain for the population?
Although health care sector is the biggest single
employer in Europe and although the health industry
is a huge business, it still must remain just a means for
a goal. Using the consumer's voice one can argue
with good reason that we are the ultimate employers
and payers of this huge apparatus, but so far as our
funds are often channelled through third party payers,
our views and opinions have been taken too much for
granted. Even the whole health sector vocabulary
throughout the vast spectrum of European languages
reflects this subordinate position whereby the patients
are expected to be patient when it comes to waiting for
treatments, lower our voice when there is no choice,
be subjects to orders, prescriptions and referrals
without easy access to the documents which are
written about ourselves, and not to question the
decisions that ultimately have to do with our own
bodies and souls.
Ladies and Gentlemen, be prepared that the times are
changing. Patients are in the process of taking their
places at the steering wheel. There are many among
health professionals who are afraid and hesitant about
this movement and trying to turn back the pendulum of
time, but it will not be successful. The genie is out of
the bottle and refuses to go back. It is much wiser to
accept the challenge and become involved in this
new and more mature type of relationship, which I
believe at the end will also come to benefit the health
sector as a whole.
In 1994, 34 European countries together with the
World Health Organisation and the Council of Europe
organised in Amsterdam a consultation on patients'
rights. The Amsterdam Declaration on the promotion
of patients rights has ever since played a decisive role
as a guideline and check-list for countries and their
patient/consumer organisations. It is of paramount
importance that at a high political level countries have
committed to protect everyone's right to:
respect as a human being,
self-determination,
physical and mental integrity,
respect of privacy,
moral and cultural values, religious and philosophical
convictions; and
such protection of health as is afforded by appropriate
measures for disease prevention and health care.
Although the aforementioned human rights and values
are essential for consumers and patients, from the
practical point of view it may be even more important
that it has been explicitly stated that:
the patients must have right to information of
health care systems in general and about their
own health status in particular,
the informed consent of the patients is a
prerequisite for any medical intervention,
all information about a patient's health status,
diagnosis and treatment must be kept
confidential, and that
everyone has the right to receive health care as is
appropriate to his or her health needs equitably
without discrimination and according to the
financial and other resources in a given society.
It is often overlooked by the providers of services and
third party payers that the patients should have a
collective right to some form of representation at each
level of the health care system in matters pertaining to
the planning and evaluation of services, including the
range, quality and functioning of the care provided.
The right to choose a care provider is also commonly
neglected or made difficult within our health care
systems.
How then can the consumers' and patients rights be
put into practice? Some countries such as France,
Ireland and the United Kingdom have formulated and
adopted Patients' Charters at high political and
administrative level to which individuals and/or patient
and consumer organisations can appeal when they
feel that their rights have been violated. Another
method is the promulgation of specific patients' rights
legislation (see Figure 1, Annex 21). The first country
to choose this way was Finland in 1993. Since then
the Netherlands, Lithuania, Israel, Iceland and
Denmark have followed the same route. It is still a bit
too early to evaluate the outcome of such legislation
from the patients' point of view, but it seems that
citizens have been empowered and become more
conscious of their rights. On the other hand, the
providers of services have also become more
observant of the rights of their patients and in a more
goal oriented and conscious way tried to take them
into consideration. It must be emphasised here that
very seldom a true conflict of interest exist between
the providers and consumers of care, but the
characteristics and circumstances where health care
services are rendered and the authoritative and
hierarchical traditions of medicine make the violations
against patients rights to happen unintentionally.
Consumers and patients want to regain their position
as masters of their own body and life. In the health
sector this is perhaps more difficult than in other
sectors of society, as the consumer is usually not in
the position to make informed choices without the
advise of a health professional. Additionally, health
insurance and other third party payer mechanisms
have removed or substantially reduced the cost as a
factor that would make the patient into a cost
conscious consumer. On the contrary the "moral
hazards" of trying to get all the benefits out of the
system is a constant
threat. This forces the
administrators and the auditors of these publicly
funded systems to manoeuvre at the edge of
confidentiality and privacy. Finally, the medical and
pharmaceutical industry can manipulate the public
opinion by creating a demand for new expensive
technologies and drugs. It is not always that evident
that these demands are based on true needs and that
the new therapies would necessarily be more effective
than the older cheaper ones.
As Figure 2 (see Annex 22)is suggesting, we need to
move from ethics of ignorance to true consumer's
empowerment through self management of health and
through more conscious access to care. Patient and
consumer organisations have a tremendous challenge
in putting this new vision into practice. Many of them
have started to take a self-critical view towards the
more traditional attitude whereby they have acted as
advocates and loudspeakers for specialist physicians'
opinions and desires.
Are we - the patients and consumers, the providers of
care (physicians, nurses, hospitals, etc.), third party
payers (social health insurance funds and companies,
municipal, regional and state health authorities), and
the health industry - prepared to confess that we all
have our legitimate points of views and vested
interests. The consumers and patients no longer
accept that any of the other groups assume the
authoritative liberty to speak and use the legitimate
voice of the health care consumer. Health care is one
of the most essential elements of any society and their
functioning (either good or bad) influences deeply
individual lives. We want that health policy and health
issues in general are openly debated and difficult
questions are not swept under the carpet. Priority
setting and even rationing are here to stay even
among the most affluent societies and they can be
discussed with us, but do not try to patronise or
swindle - it will no longer work.
References:
WHO Regional Office for Europe (Scherfigsvej 8, 2100
Copenhagen, Denmark): A Declaration on the
Promotion of Patients' Rights in Europe, 1994.
Leenen H. et al. (WHO Regional Office for Europe):
The rights of patients in Europe. Kluwer Law
International. The Netherlands 1993.
WHO Regional Office for Europe: The promotion of
the rights of patients in Europe. Proceedings of a
WHO consultation. Kluwer Law International. The
Netherlands 1995.
The point of view of industry
Walter Clement
0) Preliminary Remarks:
Science is not objective as such. However, if a
university scholar presents the "Vision of Industry", he
can of course only give an "interpretation", but never a
lobbyist statement. Here in Austria it might even be
easier, since scientific political advice is often given
within the framework of social partnership. In this
context different ideological positions are scientifically
interpreted (The Advisory Council for Economic and
Social Affairs is sometimes also called the "climatic
chamber").
Now that I have defined my position I would like to
briefly comment on the general topic of the "Future of
Health Systems".
Obviously two different aspects are addressed:
a) the future
b) health systems
ad a) If you look at the aspect ”future", the impression
arose during the last two days and a half that future
health systems are a reflection of the existing ones for
the most part, at best the extrapolation thereof.
Alternative scenarios have not been drawn up. Thus
the speakers have (unconsciously?) kept up with an
Austrian tradition, the evolutionary development
("Austrian Economics" according to Hayek). However,
in the face of demographic development, of
decreasing morbidity in young age and increasing
morbidity in old age, of the introduction of expensive
technical developments in the health sector and
eventually of the dynamics of health expenditure, it
would be useful, at least as a mental exercise, to
ponder about possible and profound health reforms.
ad b) My reaction toward the term health systems is
less positive. From the economic systems theory
position health systems are catastrophic. Patch-up,
quilt, patchwork would be harmless designations.
More adequate would be wild jungle of contradictory
provisions, overlapping mechanisms and inert, but
flourishing institutions.
But what dimension does the added proportion
have?
Financial indicators (see Annex 17: "Financial
Indicators")
only show a weak correlation with the states'
prosperity, if at all.
1) Categories of Health Systems
The categorisation and classification of health systems
maintains many jobs at WHO, OECD, EU and many
research institutions (see Annex 13).
Against this background, the question could arise
whether such a lack of transparency and such variety
might hamper the consumer-patients, who eventually
pay the bill? Obviously not, according to the outcome
of an opinion poll (see Annex 14):
A systematic correlation between centralised public,
decentralised public, public/private combinations and
consumer satisfaction can be rarely recognised. At
least it is clear that problematic health systems are
strongly criticised by critical citizens. Similar
assessments are valid for the reform need of the
respective health system (see Annex 15).
It seems as if public opinion is relatively unreliable – or
at least what is reflected in the [Euro]Barometer,
because totally different systems are appreciated!
However, this fact was known to Macchiavelli as early
as the 16th century and he wrote "Il principe", in which
he granted the Sovereign the power to provide for law
and order.
In the age of Enlightenment, in which we are still living
at the end of this millennium, one rather could stick to
the principles of a rational state order/ health care
order.
Today these are called benchmarks.
-
How good are such benchmarks for orientation?
What do such indicators tell us?
2) Benchmark Indicators for Health Systems
If one has a defeatist attitude, one could read into the
various international indicator systems a certain
indifference.
Outcome indicators (see Annex 16: "Health
Outcome Indicators")
reflect eating habits, economic situation, working
conditions, hygienic conditions, education, etc. as
well as the benefits provided by the health system.
Efficiency and effectiveness indicators (see Annex
18: "Efficiency Indicators")
Finally the considerable variation between
outcome indicators and expenditure for health
proves the restricted influence of financial means
for health alone. (What the man in the street, too,
can express - without knowing much about
econometrics: "Money isn't everything".)
The analytical myopia gives - at least from the point of
view of Austrian Economics – reasons for rejoicing:
”It should not be possible for social systems to be
synthesised out of the analytical test-tube in the
way of "constructivism".
Formulated in demagogic terms:
- Presumably the majority of Scandinavians feel
more at home in national welfare homes.
- The French expect their individuality to be tamed
by a centralist system (which is replaced by
another one every couple of years).
- The Germans are completing social market
economy by the most elaborate bureaucratic
regulations to achieve perfection.
- Austrians are champions in muddling through.
Again - and this time in more scientific terms - health
systems, too, are a conglomerate of analytical
embedding and ideological positioning.
”Standards and targets (according to OECD)”:
Adequacy and equity in access to care
Income protection
Macro-economic efficiency
Micro-economic efficiency
Freedom of choice for consumers
Appropriate autonomy for providers
4) Between Ideology and Rationality: Guidelines
for Reform
How can and how should this dialectical process of
construction and evolution, of positivist rationality and
ideology, of harmonisation and autonomy take place in
practical terms? Given the challenges on the one hand
(demography, Maastricht criteria, economic crises)
and the ”cold star of shortage” (economics) on the
other hand, future health systems will certainly not
follow the leitmotif of ”Anything goes”.
Guidelines are to be developed and complied with, not
only for evolutionary health care reform but all the
more for structural reforms.
In due respect for ideological wishful thinking, such
guidelines for reform have to take account of some
basic economic and functional facts. In so far
economists can not be called nice guys, because they
have to confront the ”human needs” with economic
limits. The "economy of the land of milk and honey" is
a contradiction in terms.
I would just like to remind you of the following:
1) The demand for health care benefits is a chain that
has been interrupted several times:
De facto patients are incapacitated to a farreaching extent. Their demand is interpreted by
agents. These are doctors, hospitals, health
authorities. Both the quality and the cost for health
care benefits are not transparent for the patient.
The economic principle (of what I want preferences - and what I can afford - budget –) is
no longer valid. Consequently inefficiency is
unavoidable:
First Principle ###:
”Health systems under pressure primarily have to
make the demand chain more transparent
(transparency of cost and benefits)”.
2) The legitimisation for massive public intervention is
justified by the attitude that health is partly a
private, partly a public, in any case however a
commendable possession. The state sells this idea
using popular catch words such as right to health,
elimination of exclusion, community of solidarity,
etc.
In fact no state can give a guarantee for health,
neither a guarantee for a job. Its possibilities
depend on tax and contribution performances.
Thus:
3) Health systems are penetrated by party politics,
bureaucracies, solidarity groups, "parafisci" and
”the odd man out in the market”! In such systems
efficiency of allocations and transactions is highly
improbable. Thus:
Third principle ###:
”Health systems under pressure have to establish
in each of their sub-systems ”incentives” to
increase the efficiency."
4) Health is an important area of human capital. Thus
health expenditures are regarded as investment
into this human capital. These are necessary for
higher economic growth in overall economic terms
and for higher income in individual terms. Thus:
Fourth principle ###:
”Health systems under pressure should consider
the long-term aspects - beyond just one
parliamentary term.”
5) The ”Visions” of Industry
I have the impression that the ”Visions of Industry”
take account to a certain extent of such
fundamental principles in the explicit propositions.
In principle the following is valid:
Future health systems can therefore be no
technocratic blueprints. The process of political
opinion forming thus includes fundamental
positions and guidelines for the design of
processes.
On the basis of the analysis of publications that are
close to industry and a quick poll of the employer
associations in Europe carried out by myself, reform
propositions for the health sector from the point of
view of industry can be summarised and allocated to
the following areas:
- Innovation
- Competition
- Financing
- Information.
Second principle ###:
”Health systems under pressure truly have to
make transparent their financing to the citizens as
taxpayers and may not pretend they are free of
charge."
Important Areas for Reform Measures in the Health
Sector
(based in particular on the BIAC Statement/June
1998, BDA/May 1998, EFPIA, Employer Association
Finland, PhRMA)
1. Incentives for innovation
Funding of investments into innovative
products (medical biotechnology, medical
technology in the wake of modern therapeutic
processes) e.g. via economic policy framework
conditions, patent protection, tax legislation.
Reduction of regulation barriers versus swift
market entry (time competition!)
This leads to:
Improved quality (effectiveness)
treatment
Increase of efficiency
Increase of cost control
of
the
2. Promotion of competition in the public and/ or
private
sector
(”Competition
promotes
Performance”)
Promotion of the freedom of choice, promotion
of contractual freedom
Health insurance funds should negotiate their
own contractual conditions with different
service providers
Increase of market efficiency via competition
between doctors, more freedom of choice for
the patients, authorisation also of smaller
solidarity groups.
Increase of competition in the in-patient sector
(private and public) with the aim to increase
productivity and to improve therapies
Hospital management instead of administration
Monitoring and evaluation of medical therapies
(evidence based medicine)
Gradual approximation of politically regulated
prices to market prices (transparency of
transfer payments, reimbursements)
3. Reform of health care funding
transparency of costs and cost consciousness
Consideration of the interdependency of costs
in different segments of the health system
More responsibility of the individual by copayment
Establishment of funds in analogy to private
pension insurance
Limitation of benefits provided by health
insurance to health risks which the individual
cannot bear himself (protection against basic
risks)
Separation of extraneous insurance benefits
such as maternity benefits
4. Enforcement
of
medical
information
technologies
Establishment of networks for medical
information and medical technologies (towards
Best Practice), patient advisory councils
Information and further training of responsible
patients (e.g. via Internet)
Improvement of the combination of in- and outpatient care, e.g. by telemedicine
6.) Concluding Remarks
The above reflections have led to the conclusion that
we are still far away from a ”Perestroika of the Health
Systems”. Obviously the pressure or better the lacking
ability to finance the systems is not yet strong enough
that more fundamental considerations about a new
design of the health systems (similar to the
considerations about pensions schemes) would be
required. Obviously it is still too early to consider
financial policy concepts which theoretically assume
the
total
"degeneration"
and
the
following
establishment (”zero base budgeting”) of a system.
Thus in general the strategy of ”piecemeal
engineering” is being followed. In this context the
Health Forum Gastein certainly is an important
milestone!
Health policy in Austria
Wolfgang Routil
Basically, health policy is governed by simple and
convincing principles. All of us would agree with
the following statement in the WHO Ljubljana
Charter:
"A health care system should be:
driven by values of human dignity, equity, solidarity,
and professional ethics,
and targeted at protecting and promoting health"4
The intensive discussions of the last two days, as well
as the turbulent reform debates in all European
countries, show that although there is a consensus
over principles, disagreement prevails over how these
should be interpreted and implemented.
4
The Ljubljana Charter on Reforming Health Care), June 19,
1996
This debate is dominated by both economic and
social-ideological paradigms of highly controversial
nature.
Percentage of population over 65
In today's member states of the European Union, the
percentage of those over 65 in the population amounts
to 15.5 percent as compared to 10.4 percent in the
year 1960 (see Annex 19)5.
These sober figures do not sound dramatic. Their
significance becomes evident, however, if we realise
that this difference in the two percentages
corresponds to more than 22 million people over 65,
that is, the population of Belgium, Denmark, and
Finland combined.
The challenges that this change in population structure
brings for health care providers, physicians, hospitals,
and all other professional groups are enormous. At the
same time, the challenges for those financing the
health system are also growing.
This addresses the main problem of modern industrial
societies, just as it was diagnosed by Germany's
federal association of panel doctors (Kassenärztliche
Bundesvereinigung) in 1994:
"Medicine can obviously perform much more than
economies are prepared to pay for."6
The general social security act (Allgemeine Sozialversicherungsgesetz - ASVG) defines what the
Austrian economy is prepared to pay:
"Health care must be sufficient and expedient, but
must not exceed the required standard. The treatment
provided must as best as possible re-establish,
stabilise, or improve the health, the ability to work, and
the ability to take care of one's vital personal needs."7
This pragmatic approach unavoidably raises urgent
questions.
What is sufficient, what is expedient? Were we to
discuss this issue on the basis of a practical example,
we would produce quite different answers, depending
on our professional perspective, our personal ethics,
and of course on how we are personally involved.
This inevitably leads to the second question: Who
decides what is expedient and sufficient but does not
exceed the required standard?
5
The patient concerned? The treating physician?
Experts in the financing institutions, health
economists, or politicians?
The fact is that in some European countries a
appallingly open debate is taking place about the
possibility of denying some services to people of a
certain age because the statistical probability of a
successful treatment seems too small.
I believe that in order to establish equal opportunities
for everyone in a united Europe, we have the
obligation to reach a transnational consensus – e.g.
through the creation of a "European Consensus
Institute for Medical Associations" that guarantees
minimum medical standards for the protection of
citizens and sets an upper limit for the benefit of
national economies.
In such a framework it should be possible to discuss
the actual performance of Social Securities and their
willingness to provide certain services in a nonagitated and objective debate, free of national narrowmindedness.
If you have followed health policy developments in,
say, Germany and Austria in the last three years, you
will be aware that the possible financial collapse of the
social security systems has been debated upon in
both countries with almost identical intensity.
What surprises me is the fact that politicians and
social security institutions are voicing almost identical
doomsday prophecies – reported by the media –
despite clearly diverging key data on the financial state
of health systems.
Health expenditure in 1996 in % of GDP
In Germany, health expenditure amounts to 10.5
percent of GDP, in Austria the figure is 8 percent. (see
Annex 20).
The health sector accounts for 10.6 percent of
Austria's public expenditure, while in Germany the
figure exceeds 15 percent. Per capita expenditure in
Germany amounts to 2,233 US $, in Austria 1,703 US
$.8
In Austria, there are 2.8 physicians and 9.2 hospital
beds for every 1,000 inhabitants, in Germany 3.4
physicians and 9.6 hospital beds.
At the same time, the per-capita GDP rate of Austria is
higher than that of Germany9.
6
Public health expenditure in % of total expenditure in
1996
7
8 OECD Health Data 1998
Labour Force Statistics, OECD, Paris 1997
Principles for further development of the health care system
in the Federal Republic of Germany from the point of view of
panel physicians. Resolution by the assembly of
representatives of the federal association of panel physicians
dated May 9, 1994
Allgemeines Sozialversicherungsgesetz (ASVG), general
social
security
act
§
133,
Par. 2
9 National Accounts, Main Economic Indicators, OECD, Paris
1998
These figures in illustration X (see Annex A, illustration
X) show that public health expenditure in Austria, one
of the world's richest countries, corresponds to the
European average.
In this respect I am very thankful to the president of
the European Health Forum Gastein, Primarius Dr.
Günther Leiner. Before the meeting took place he
pointed out that the social and public health services in
Europe should not be considered primarily as cost
factors but as a promising sector for new jobs –
approximately ten percent of the EU's labour force is
employed in this sector. Agriculture offers jobs to only
five percent of the labour force – and the figure is
gradually decreasing. As a comparison: this year,
Common Agricultural Policy will swallow more than 43
billion Euro10, almost half of the entire EU budget,
whereas the percentage attributable to the social and
health sector is below ten percent.
The intensity of the debate over costs can also be
attributed to the high political dynamics inherent to the
Austrian social security system. This results from the
fact that this system possesses a thoroughly political
self-administration structure. A structure expressed by
a practice in which top representatives of the social
security system also hold key functions in major,
explicitly political institutions.
Incompatibility regulations that in the meantime apply
to politics hardly affect the social security sector.
Even the recently presented Austrian structural study,
and in particular the reactions of politicians to it, show
that there is little hope of systematic reforms.
The principle of integrated political function, alongside
a full-time management job seems unassailable.
The description by Professor Lucius Burckhardt11,
sociologist and president of the Deutscher Werkbund,
initially coined for designers, is even more
characteristic of politicians. They…
"are conservative. They invent object improvements
without changing the ancient decisions of principle
upon which these objects are based"
The structure of this compulsory insurance system,
actually organised as a corporate state, is truly
ancient, since it was developed in the first half of this
century.
There is no real reason for a political management
level within the organisation. The social security
system is subject to political supervision – represented
by the ministry in charge, the Federal Government,
and finally, the Parliament. The standards set by
10 European Commission: Preliminary Draft General Budget
of the European Communities for the Financial Year 1999 –
Overview [SEC(98) 800-EN]
11 Exhibition catalogue „Error Design“, Krems, September
1998
health, social, and political guidelines and their control
are guaranteed.
Depoliticising the social health insurance system
would be a first step towards professionalisation. It
would also help eliminate the ideological element and
the tension from technical discussions such as those
regarding access to certain health services, the
implementation of care programmes, and last but not
least, the discussion of costs.
In order to avoid any misunderstandings: The political
primacy of the state is indisputable – I argue, however,
that the state can assume this function more
efficiently, directly, and transparently if the social
security organisation itself does not represent a power
factor, which can ultimately complicate actual
government control.
In her presentation of the study mentioned above, Mrs.
Eleonore Hostasch, Minister of Social Affairs,
addressed an even more sensitive issue. She
demands a productive competition between social
insurance institutions.
This competition can be authentic only if the individual
social insurance companies are compelled to woo the
customer. There can be no competition, however, in a
compulsory insurance system that imposes a specific
insurance company onto citizens.
The only possible solution to this problem is to give
individuals the freedom to choose the insurance
company they want by establishing a system of
obligatory insurance to replace the existing system of
obligatory insurance company.
The organisations necessary for this step – that is, the
existing social health insurance institutions – are
already available.
A system based on the free choice of health insurance
would be more compatible with the free choice of
physician, psychologist, chemist, and other service
providers that represents a central value in the
Austrian health system.
The introduction a 20% deductible for patients who
choose their own physician is de facto a sensitive
restriction of this freedom, and the frequent attempt to
impose upon patients the choice of medical care
institutions owned by health insurance companies, in
particular of outpatient clinics, thus discriminating
other providers, reveals the same trend.
This undermining of free choice is highly questionable
not only from a medical and moral point of view. The
trend toward a quasi-state health service also
constitutes an economic and social problem.
The freedom of citizens to choose among several
social health insurance providers would better
correspond to the EU principle of freedom of services.
In a nutshell:
Reaching a consensus on the limits of basic medical
services accessible to all citizens – both upstream and
downstream – is a European task. It must be
guaranteed by a European health policy to which only
few approaches exist so far, aiming to protect the
individual and the interest of national economies.
The persistence of compulsory insurance monopolies
contradicts central EU principles. It does not
correspond to the actual needs of the insured either
because they are forced into dependence.
Defining a social framework and monitoring
compliance is the task of politics. By partially
delegating this role to the self-administration of social
insurance institutions, the state curtails its own
authority.
Citizens have the right to codetermine the shape of
this health system. A high degree of transparency and
direct influence by the elected democratic state
institutions are necessary in order to permit this type of
codetermination.
It is therefore necessary to increase the role of politics
in the Union's health sector. I would like to conclude
my exposition with a quotation from Virchov dated
1859: "If medicine really wants to fulfil its grand task, it
must enhance its influence on political and social life.
Medicine, therefore, is a social science after all and
politics is nothing more than medicine on a large
scale."
Pádraig Flynn
Ladies and gentlemen:
I am delighted to have the opportunity to be with you
today and to contribute, at the close of this discussion,
to the building of a better future for health systems in
Europe.
The role of health systems
Health is now an issue at the forefront of citizens’
minds. People are concerned about their health, and
about the efficiency and effectiveness of the structures
put into place to ensure that their health is protected.
Indeed, one of the defining tasks of modern developed
societies is to enable citizens to live in good health; to
protect them as far as possible from diseases and
health risks; and to provide the best treatment and
care services when these are needed.
It is in the light of this that the Maastricht Treaty
introduced a key objective for the European
Community ‘to contribute to a high level of health
protection’. This is the basic goal behind all
Community policies and initiatives on health.
In the Community and its Member States, we have
made great progress towards achieving this goal.
People in the Community are, generally speaking,
healthier and living longer than ever before.
The quality of our health systems plays a fundamental
role in securing this high level of health protection. Of
course, protecting and improving health does not stop
there. It is about creating and securing the living
conditions conducive to health and healthy lifestyles,
for example through high standards of hygiene, safe,
good quality foodstuffs and the lowest possible levels
of environmental pollution. Long-term unemployment,
poverty and social exclusion can also threaten
people’s health.
The problem with health systems in Europe is that
many people have come to think of them solely in
terms of cost. Rightly, this has surfaced strongly at
this conference.
In fact, the issues are much wider. 20th century
Western European health systems are an important
asset of our societies. They form part of the distinctive
European social model which sees solidarity not as in
opposition to economic success but rather as a
condition for it.
A key illustration of this is the emphasis that we place
on access to health care and health services. Our
health systems are open to all citizens. We have
introduced a range of health insurance schemes which
make sure that access to health care is virtually
universal. This distinguishes the Western European
model from approaches elsewhere, and it is something
of which we should be proud.
In the future, the issue of ensuring universal access to
health services will take on a new dimension. People
will be moving ever more freely between Member
States and between different health systems. This will
require the EU to keep careful track of the extent of
cross-border co-operation and to look closely at
existing systems and rules of reimbursement, for these
were put in place 25 years ago when the situation was
very different.
Health systems also play a major role in the economy.
On average, the health sector accounts for some 7-8%
of GDP in the EU, and the resources it consumes
provide an important boost for the most innovative
areas of the economy – pharmaceuticals,
biotechnology, information technology and scientific
and medical research in general.
in the population set to increase over the next ten
years, this must be taken into account.
It is instructive to compare health systems in the US
and Europe. The US spends more on health than we
do – 14% of GDP compared to this 7-8% that we
spend. But the impact on public health is less
impressive in the US than in the EU. We spend less
yet have a better distribution of health services and a
better result in terms of the health of our whole
population.
Part of this whole phenomenon has a particularly
European dimension.
Increasingly, people are
spending long periods of time abroad after retirement.
Are services in place in the popular locations to deal
with demand for treating illnesses and for long-term
care? Are the systems of reimbursement of costs
between countries adequate? Can we be sure that the
quality of services on offer meets at least minimum
standards?
In the EU as in the US, of course, the health sector is
a huge provider of employment. In 1996, more than
10% of people in work were employed in the health
sector. Health services are one of the fastest growing
sectors in our economies as far as job creation is
concerned.
The tendency to see the health sector purely in
financial terms misses the important point that our
health systems are an important asset that binds
together our economic and social fabric. But the
attention given to cost is understandable, given that
our health systems face significant financial problems.
Those problems are part of the reason why this Forum
is being held and they are important. Many of the
speakers at this Forum have talked about them in
detail.
The challenge to our health systems
Rather, in these closing remarks, I would like to outline
the broader challenges that I see as facing health
systems in the EU.
1. Demographic change
The effects of an ageing European population and
decreasing birth rates are already a test of our
policies.
Some of this is to be assessed in cost terms. Results
from national studies of the link between ageing and
health and care costs shows that the average costs for
treating and caring for people of 80 and over are 2-3
times higher than for people of 60-79. With life
expectancy for men and women rising to or close to
this threshold and with the numbers of people over 80
But the impact of demography is not only to be seen
purely in cost terms. It is forcing a change in the
structure and priorities of our services and the basis
on which we allocate resources.
2. Medical advances and new technology
We are seeing a huge expansion of the use of new
technologies. New treatments are developing and
medical progress advancing at an unprecedented rate.
This means that health systems have the capacity to
meet needs better than ever before.
But many new therapies and technologies, while
potentially being of immense value, have not been
properly evaluated in terms of their cost-effectiveness
compared to existing therapies. In recent weeks, there
has been a very good example of the problems that
can arise when a new ‘wonderdrug’ becomes
available.
Questions of priority arise. Where should the line be
drawn between drugs which are considered to be
clinically necessary to treat serious illness and
disease, and those which are designed primarily to
tackle problems related to personal behaviour and
lifestyle? Similarly, where do we draw the line between
the individual’s responsibility for his or her health and
coverage by health insurance systems?
3. Information: the empowered consumer
The third challenge I want to highlight is the spread of
information on health and wellbeing. An important
consequence of this has been to de-mystify medicine
and this has helped empower consumers/patients. It
has given them the confidence to play a more active
role in making decisions related to their health.
But at the same time, it has made the work of health
professionals more difficult.
They no longer
automatically benefit from the traditional high level of
trust. Nowadays, doctors have to explain and justify
their actions. This is something that will have to be
much more part of how we train our health
professionals in the future.
Patients are consumers who press loudly for their
rights as they perceive them. They want the optimum
in care and treatment and will not settle for less, for
rationing or waiting lists. However, they are still
insisting that, despite rising costs, they are provided
with the full range of services.
One of our recent Eurobarometer surveys illustrates
the point well. When asked whether their government
should only provide limited essential services for
serious diseases, a great majority disagreed. They
wanted a comprehensive package. Similarly, when
asked about total government spending on health
care, only 5% thought less should be spent, and
nearly half thought more should be spent. This makes
decisions on rationing and spending cuts even more
difficult than before.
useful light on the costs of health services in different
parts of the Union. It will be yet another source of
information for the consumer/patient. Citizens and
health managers alike will be able to make detailed
comparisons of prices of goods and services,
resources allocated and outputs of systems.
Differences between countries in the price of goods,
such as pharmaceuticals, are already causing concern
and are the subject of EU discussion. Price and its
relation to quality of service will in future become even
more obvious to consumers and providers alike.
The introduction of the Euro is also likely to see crossborder movements of patients and purchasing of
services from and in other countries increasing in
scale.
In these circumstances, surely it makes sense to think
about what role the Community could play in analysing
developments and helping countries manage
problems that might arise.
5. Enlargement of the EU
The EU has a role in helping governments address
these challenges by providing good, comparable
information and high quality analysis, by establishing
best practice and disseminating it, and by developing
supportive European legislation.
EMU is an immediate challenge. Somewhat further
down the road will come the potential impact of
enlargement of the Union towards Central and Eastern
Europe.
There is also a legal requirement for health protection
needs to form a constituent part of the Community’s
other policies.
This conference has looked at how enlargement of the
EU will affect EU policies and activities in the health
field.
This is the case, for example, for pharmaceuticals and
medical devices, where rules have been set regarding
registration and quality standards.
What is clear is that the applicant countries will need
to adjust their social systems to fit the high standards
of the European social model. This includes a high
level of health protection, as I made clear at the
beginning of my remarks. But this is a development
which I believe that they will welcome and which, in
many respects, they are reasonably well-placed to
respond, as long as Member States and the EU offer
help and support.
It is also true for public procurement, where EU law
ensures that there is no discrimination against
tenderers from other Member States.
EU food law is concerned with ensuring a safe food
supply. Our research programmes give an important
impetus in areas as diverse as biotechnology,
epidemiology, nutritional research and biomedicine.
4. EMU and health
EMU and the single currency present a number of
challenges for our health systems, even if they are not
well understood. The Euro is well on its way and will
draw at least 11 national economies much closer
together. But more than this, the Euro will throw
Earlier this year, we published a Commission
Communication setting out how a new EU public
health policy might address these challenges. We will
be putting forward proposals for legislation to
implement the new policy shortly after the Treaty of
Amsterdam comes into force.
Essentially, the role of the EU in the health field is to
help Member States to find solutions to the problems
and challenges that they all face. In this respect, it is
very similar to our role in the reform of European
social protection systems.
Our plan is to focus on three main strands of activity:
Gathering information and carrying out analyses to
help develop policies related to health at EU level;
Setting up an effective rapid response mechanism to
ensure that information about potential health hazards
is exchanged quickly and that there is the capacity to
respond adequately and rapidly.
Using health promotion and disease prevention
initiatives to tackle the major social and environmental
factors which affect health status.
Ladies and gentlemen, this Forum has been a
remarkably useful and important event.
It has helped to take forward the health policy agenda
in Europe and to crystallise our thinking. We are
seeing major new developments in health and health
systems in Europe. We have to respond boldly and
courageously to the challenges that we face. Today I
have described what I believe these are.
The European Union, working in close co-operation
with Member States and the public health community,
is poised to play its part in meeting them.
Thank you.
Concluding remarks
Frank E. Münnich
Mr. Chairman, Ladies and Gentlemen,
Naturally it is impossible in a brief set of concluding
remarks to give time and attention to all the highly
specific, intelligent and competent details presented at
a conference such as this. Nor is it possible to
individually address the numerous contributions. It is
not even possible to selectively give attention to
specific presentations without running the risk of
according too much weight to subjective interests.
That which has been said here is too extensive and
too important.
Instead, I would like to briefly illuminate seven topics
which, in my view, enjoyed attention during the entire
conference - from the first opening remarks to the
final words of Commissioner Flynn. Each of these
topics received a little more emphasis from some, a
little less from others.
The first topic concerns research and innovation: the
further development of medicine, the healthcare
system itself and the underlying fields of science. The
present state of research financed and pursued by the
European Union as well as the further development of
this research were the subjects of thorough
discussion. It was noted that Europe has enjoyed a
significant improvement in the innovative climate
during the course of the last decade. This fills us with
the hope that this will continue in the same positive
direction. Within this context, gene technology which has been critically assessed in several of the
member states for some time now - was frequently
addressed. One has the impression, an impression
emphatically strengthened by this conference, that the
societal developments at both the national and
European levels currently display such great
momentum in this direction that no specific
programmatic demands must be formulated here to
effect a fundamental change in this trend. In the realm
of research and innovation, tremendous momentum is
at work on European soil as well.
A second fundamental topic is public health. At this
conference, we have seen and learned just how
energetically public health programs have been
implemented at the European and national levels.
One can rightly say that this train is travelling on a
sound track. At the European level, a large share of
what had been programmatically planned has already
been accomplished. Nevertheless, there is a strong
desire to further intensify activities in this area. It
seems to me that serious deficits continue to exist at
the national level. Here there is still considerable need
for action in the fields of research and teaching as well
as in the concrete implementation of programs. I
believe that this understanding is an important result of
our discussions here. It is a telling conclusion which
points us to the future.
A third topic concerns the role of patients and how
they perceive themselves. On the one hand, this
involves the rights to which patients are entitled - or
should be entitled. On the other hand, it concerns
quite generally the part patients can play - and
should play - in our healthcare systems and in the
formulation of healthcare policy. In an act of selfcriticism, I should perhaps note that we did not grant
these issues the full attention they deserved in our
discussions - a situation we so often experience.
And therefore many issues within this context, like
terminal medicine for example, were not even raised.
Patients are, however, the actual focal point of
healthcare systems. They are the raison d’être of
healthcare systems.
They constitute the reason
healthcare systems exist. Healthcare systems do not
exist for the benefit of the social health insurance
funds, healthcare service providers, or for us the
experts. One can see this strange revaluation of the
roles of objective and means in other fields.
Economists and politicians active in economic policy
tend all too often to forget that the economy exists in
order to satisfy human needs and desires, and not the
other way around. Human needs and desires do not
exist to help the business world turn a profit. The goal
within the healthcare sector is to cultivate patient
empowerment, to help the patients achieve an
accurate understanding of their role in the healthcare
system. In doing so, we cannot concentrate our
efforts solely on working with special patient self-help
groups which indeed exist, and which demonstrate
varying degrees of political influence depending on the
prevalence of ”their” illness. In the Federal Republic of
Germany for example, all prominent self-help groups
are presided over by a ”First Lady.” I believe that the
problem is much more fundamental. And we have
detected deficits here. There is still much to do at both
the European and national levels. I can well imagine
that this complex of questions is in need of much more
discussion - discussion which includes the patients
themselves and where we, the experts, appear in a
different capacity wearing our second hats, namely as
patients ourselves. This warrants a forum all its own.
A fourth area is quality assurance. The further
development, application and implementation of the
instruments of quality assurance together constitute an
important task which lies before us.
This is
indispensable on account of the patients - in the
interest of consumer protection. But it is also in the
professional interest of physicians. An undisputed
goal of every physician is to achieve a better
assessment of diagnostic and therapeutic methods
and techniques so as to be able to select the most
appropriate ones for each specific case. A much
stronger indication-oriented handling of medicine and
further development of the instruments helpful in this
process are necessary. To illustrate this, I need only
to name a few catchwords like cost benefit analysis,
evidence-based medicine, and the development of
guidelines for therapy. Such measures are not only of
service to patient protection. It should be clear to us
that quality assurance is of great economic importance
with regard to the needs and difficulties of financing
our healthcare systems. If we do not translate the
principles of quality assurance into action now for
ethical reasons, one day we will be forced to do so for
economic reasons.
Quality assurance is an extremely important area. A
considerable amount of work must still be done at the
level of the European Union as well as at the national
level. The Union could take up the question of what is
actually happening within the individual member states
and whether these developments are coherent or
contradictory. In the spirit of Commissioner Flynn’s
remarks, the member states should ask themselves
what they can learn from each other. Independent
activities like the creation of minimum standards for
cost benefit analyses are also meaningful. I am of the
opinion that quality assurance would serve as an
exciting topic for a later event of this sort which could
deal with the entire range of ethical, technical,
economic and medical questions connected to this
issue.
The (external) expansion of the European Union
eastward represents a fifth area. The participants
here expressed the unanimous opinion that enough
words have been exchanged and that we now need to
see actions. In other words, the activities of the
European Union and its member states should do
without further analysis and devote themselves to the
implementation of the acquis communautaire or to
those structural measures which make possible a
phase-in of these countries into the European Union
with the least possible friction. This would also be in
the interest of the current member states.
A sixth topic is the financing of the social systems
which safeguard health. Heaven knows this topic has
been vigorously examined and discussed, at least on
an abstract, theoretical level. As I first began to
devote myself to the economics of healthcare 25 years
ago, financing was already a central point of
discussion. In my eyes, it is not an exaggeration to
say that advances in our knowledge of this subject
have progressed at the speed of a snail. We are still
at the same point where we always were. It is still a
matter of choice between the alternatives - if one
formulates it as you did a little while ago at the press
conference, Commissioner - Bismarck and Beverage,
or as one could also put it, market and state and the
steering of a middle course - the characteristic of the
German social health insurance. I read somewhere
that the representatives of the social insurances
together with their proponents were the last truly
conservative forces in our European societies. That
may very well be the case, and it may help to explain
why we have such difficulty with far-reaching reform. I
believe this is one of the reasons for the existence of a
transnational defensive front against deeper European
harmonisation.
Financing is thus a second point where we have seen
enough analysis. It is now a matter of political
decisions which will be difficult to make because the
fundamental ideological positions involved are too
contradictory. And we do not want to overlook the fact
that this concerns the vested interests of national
organisations with immense social significance and
enormous bureaucracies. We all know that such
institutions are born to eternal life and that their
adaptation to changing circumstances is extremely
difficult. If one was to make a recommendation to this
field, it would be that we should move on to concrete
measures suitable for each individual situation.
Within this context, there is a seventh topic around
which we creep - to borrow from an old German
saying - ”like a cat creeps around a bowel of hot
porridge” whenever it comes up in discussion. This is
the question of the European Union’s competence in
the area of social insurance. The comments I just
made about conservatism apply here. At stake are
immense questions about international distribution
policy which make every change a difficult process. It
is certainly correct to say that social politicians in
Europe constitute a far-reaching cartel dedicating to
maintaining the status quo, and it is difficult to
recognise any dynamic forces among them.
Especially in regard to how the discussions here have
developed, we can see that this represents an
important field for future activity. More reflection is
necessary. There is a need for new conceptual ideas.
It is easy to say: ”the principle of subsidiarity gives
unto the regions what they are due, and gives unto the
EU what it is due.” But that is not a satisfactory
solution for the incompatibility of economic union and
the division which exists among the member states
with respect to social policy. This is therefore an
extremely significant, interesting and intellectually
challenging area of responsibility: the inner expansion
of the European Union through the creation of a social
Europe.
One can hardly expect that the impetus to stimulate
this debate will come from the political sphere. This
namely concerns questions of redistribution which
politicians like to avoid having to solve. It concerns
the question of whether we are prepared to implement
further redistribution in the European Union for social
reasons. In my opinion, this is the key question. And I
believe that this issue is not dealt with because
agricultural policy is blocking the question of
distribution in Europe. That is my personal political
opinion. It is not a statement from the academic
community. An objective, academic analysis cannot,
however, ignore the political realities. It is therefore
time for the experts to take up this question. The
Commission would have difficulty doing this. It would
immediately be reproached for wanting to grab further
authority for itself. And one cannot expect such an
initiative from the member states. The thousands of
civil servants sitting behind doors labelled ”social
security” in the ministries in Bonn and the capital cities
of the other European states naturally do not want to
find themselves unemployed tomorrow. For these
reasons, the nature of the task at hand demands a
supranational initiative which brings together experts
from different countries. This is a task which calls for
a truly international approach and which could be the
subject of a conference such as this.
This European Health Forum Gastein - which is
nearing its end - was an experiment. For such an
experiment, it is appropriate to choose a broad
framework, to address many different problems and to
draw experts from a wide variety of different fields. An
unavoidable consequence of such a wide framework is
the fact that many questions discussed cannot be
dealt with in the depth that some participants might
have wished. Nonetheless, I am of the opinion that
this experiment is worth continuing. A great many
experts from all European countries had the possibility
to exchange ideas here. They had the possibility to
make new acquaintances. They had the possibility to
become familiar with new points of view. From the
comments I have heard, I would like to conclude: the
European Health Forum Gastein should be continued.
Indeed, there are enough topics suitable for treatment,
also for a treatment which is much stronger in its
focus.
For this reason - usurping the right of the directors I would like to express thanks: a thank you to the
initiators, a thank you to the organisers, and a thank
you to the sponsors of the event. Naturally, the
sponsors remain anonymous, even when everyone
knows who they are. Without sponsors, such an event
could never take place. They are, mathematically
speaking, a necessary condition. I would also like to
thank the interpreters who, in view of the widely
varying rhetorical temperaments of the speakers, did a
fantastic job. I would like to thank Dr. Leienbach and
his
team
from
the
Gesellschaft
für
Versicherungswissenschaft
und
-gestaltung
in
Cologne, and I would like to thank Mr. Köstinger and
his team here for the superb programmatic preparation
and handling of this event. And finally, on behalf of all
the participants of the forum, I would like to warmheartedly thank the initiators Commissioner Flynn and
Dr. Leiner that this conference took place.
European
Health
Forum
Gastein:
SUMMARY
and
OUTLOOK
Lothar Feige
The first European Health Forum Gastein took place in
Bad Hofgastein from 30 September to 2 October 1998.
The forum was intended to help put the health policy of
the approaching 21st century on a broad basis
supported by consensus and to draw up a framework for
Health 2000. The perspective was to develop "a better
future for health systems in Europe. It was intended to
discuss the medium and long-term areas of main
emphasis of the Community, the countries and the
regions in order to co-ordinate their own health policies
and to further develop a common European health
policy.
It
was
intended
to
elaborate
the
interdependencies between the major issues of health,
limited financial resources, employment and ethics. In
this respect the interaction was to be included between
research and development and society as well as the
demographic trends, the effect of the Common Market
and the enlargement towards Eastern Europe and the
forming of international health network even beyond the
borders of the European Union. It was intended to
exchange experience about the national and regional
health policy activities and perspectives.
The Forum met the high expectations. However, one is
not to assume that it was possible to submit
comprehensive results or to develop perspectives. In
fact more questions were raised than answers given. But
this as such is a very important result. European health
policy stands at the very beginning of its development.
There are still the solo efforts which dominate the stage.
And there are still many opportunities and possibilities of
the extended European health sector that are not yet
sufficiently used. This is understandable since the health
systems of the European Member States are organised
differently. The freedom of movement of the European
market and the approaching enlargement towards
Eastern Europe will make the situation more complicated
to a considerable extent. The discussions during the
Forum made it clear the countries in Europe have
extremely differing health systems. Some are funded
from taxes, others from contributions. The possibility to
take private insurance for health also differs very much.
Apart from the appropriate basic protection options have
been developed to establish private systems for the
provision of health benefits. It is possible that different
developments will take different directions. In this many
discussion participants saw the risk of a division of the
health market up to the vision of a two-class medicine.
The European Union is called upon to prevent that
serious differences will occur between different social
groups and different regions regarding health care
provisions. It seems to be necessary in the first place
that the European regions will be learning from each
other. It has been called for to establish a network of the
different insurance schemes. This could be possible
given the existing information technology. Emergency
medicine and health prevention campaigns have been
identified as suitable areas for co-operation between the
regions. In view of health promotion is was noted that it
did not only have cost-reducing effects but that it also
improves the population's quality of life. For this reason it
has been demanded to place the focus of European
health policy rather on health maintenance and health
promotion rather than on the treatment of diseases.
In reference to the development of a common European
policy it was deemed necessary not to lose the social
dimension of Europe out of sight. In so far it is required
to discuss the core issues of a social health system
against the background of the development of the
Internal Market and the enlargement towards Eastern
Europe. The manifold interests present complex social
challenges in this respect. Therefore it is necessary for
the useful planning of resources that the flow of
information will be increased and improved between the
players in the health sector and that more information
about problematic areas in the individual States is
available. It is deemed absolutely necessary not only to
examine the planning and activities of the individual
Member States regarding their European compatibility in
the health sector, but also of those countries that are
seeking membership. The participants of the discussion
regretted that the co-ordination of a European health
policy and the responsibility of the European Union for
health policy matters had not yet been designed in a
sufficient way. Furthermore, there are different points of
view. On the one hand there are those who are the
Eurocrats and who are driving forward the European
debate, however at a very theoretic level. On the other
hand, there are those who work in the health care sector
and have practical daily experience. The latter group
regretted the strong discrepancy, in their opinion,
between the theoretic starting point and the practical
implementation. Those ones responsible for the health
policy in Europe should not lose contact to practical
work. Those ones concerned should be made
participants of the process.
It was natural that the discussion which focused on the
development of health policy in Europe also included the
economic background. The funding of the health
systems in Europe will be one of the most important
problems in the next few years. The gap between the
health policy requirements and its financing is constantly
growing. Thus the question arises whether the only aim
is to limit health expenditure, i.e. to rationalise or even
ration for example health benefits, or whether it is the
task of those responsible in the health sector to take up
the everlasting search for new sources of funding. Yet
the question has to be answered which health system
can be regarded as particularly effective.
The discussion whether health systems should be
financed from contributions or taxes and up to what
degree health provisions that are private-economy
oriented, should be allowed, has only started and makes
it therefore difficult to harmonise the European health
systems. The search for new sources of funding is not
easy due to the general economic situation in the
Member States. European policy emphasises on
employment promotion measures which call for the
reduction of the financial burden of employees and
employers. While for economic reasons the reduction of
health expenditure is required, the developments in the
fields
of
medicine,
medical
technology
and
pharmacology and the general demographic trends
make it apparently necessary to increase the
expenditure of the health system. The rationing of
medical services is to be absolutely avoided. On the
other hand it was demanded to use all possibilities of
rationalisation in the view of costs. This does not mean
that it would have negative effects on the quality of
services. Inefficiencies of the health systems should be
revealed. The possibilities of quality assurance in the
health sector for example were discussed, quoting in
particular "evidence-based medicine" and "guideline
medicine".
The health care market is dominated by service
providers. For this reason it was demanded to develop
incentives which promote the social responsibility of
health service providers. Moreover, the consumers of
health services should be particularly protected. This
would be possible by additional information, via
counselling, but also by participation in the decisionmaking process about the availability of health services.
Against the background of a common market the coordination between suppliers and consumers of health
services seems to be necessary in any case. The
dimension of benefits and the amount of health
expenditure require a broad consensus. Patients, the
insured, medical doctors, hospitals, health insurers, the
pharmaceutical industry and health policy makers and
officials should take part in forming this consensus.
This list could easily be continued, but it clearly shows
how difficult the forming of a consensus will be.
Especially for this reason the European Union is called
upon to create new forums for debate which will promote
and channel the discussions. It has to make available a
legal and institutional framework for the development of
a European health policy. The competence of the
European Union has to be clearly formulated for the
health sector.
This will become more difficult the quicker the integration
of the Central and Eastern European candidate
countries will be approached. When these countries will
be integrated it will become clear how manifold and
serious the respective problems are in the health sector.
The health systems in the candidate countries are
developing against the background of a still
malfunctioning
administration,
administrative
incompetence, severe ecological damage and a very
little developed health awareness of the population. In
this respect it can be noted that there is considerable
need to catch up compared to the current Member
States of the European Union, even if the respective
levels of health services provisions are different. It can
be foreseen that the financial input will be considerable
to harmonise the performance of the health systems.
However, the financial resources of the Union are scarce
and will only allow to gradually bring the candidate
countries closer to a common European health policy.
Where subsidiary action is required, common thinking
and action seems to be necessary.
Hence the discussion of the specific health policy
problems
in
the
candidate
countries
was
uncompromising. With the economic situation gradually
improving in the candidate countries, the difference in
the levels of health provision is still considerable in
comparison to the Member States of the European
Union. This lead to the demand of the candidate
countries for non-material and financial support by the
European Union. This support has to be adapted to the
individual candidate countries. According to general
opinion it seems to be necessary to systematically
analyse the situation in the individual countries and to
provide appropriate support to the economic realities
and the cultural differences. Reforms have to be
introduced and their implementation has to be
accompanied. It was found that this is only possible with
the support of the management of the health systems.
Thus solidarity and co-operation have become major
demands in European health policy.
When summarising the Gastein Forum, it has to be
taken account of that the organisers have given the
forum a broad variety of topics. An abundance of
problems was discussed at an interdisciplinary level and
the search for solutions was taken up. It was accepted
that problem solutions could only briefly be mentioned.
Those who are looking for concrete and practical results
will therefore be disappointed. However, this was not the
aim of the first Forum. The aim was to open up a field of
discussion in order to develop a better future for health
systems in Europe. According to the majority of the
participants the envisaged continuation of the event
should focus on more limited areas. An idea of how this
could look like and which issues should be addressed
clearly materialised. This is the merit of the first Gastein
Forum.
Co-ordinated health promotion measures should be
continued at the national and the European level. Not
only does the promotion of health require particular
attention, but also the treatment of diseases. It was
regarded helpful that considerable progress was made in
research and development. It was found that the
European Union had a innovate climate. Technical
development and pharmaceutical possibilities are at a
very high level. This development favours the role of the
health service providers and for this reason it was
generally demanded that the role of the patient in the
health system should be reinforced across Europe. To
ensure this, experts see a considerable need for
discussion. Future events might focus on quality
assurance in the health sector. The following keywords
determine the trend: evidence-based medicine, cost
benefit analyses, guideline medicine.
Although questions of financing and growth of
expenditure have dominated the discussion about health
systems for years, the need for further discussion and
co-ordination remains. The question, too, remains open
which role the European Union could assume within the
development of the European health systems. How
should the competencies be distributed in a growing
Europe? The participants agreed that health policy will
play an important role in shaping the social dimension of
Europe.
In conclusion it can be said that a pan-European health
system has only commenced to develop. The activities
which have been started and the first steps of integration
should be consequently continued according to the
participants.
A health system that has grown together will enable all
citizens of Europe to have equal access to high-level
and efficient medical services. However, it will only be
possible for the European health systems to grow
together if some further requirements are met. In this
respect the European Commission is being called upon.
The following issues were quoted:
Europe must provide a legal and institutional
framework
for
future
health
policies.
(Differences in the provision of medical
services for social groups or different regions
must be diminished; health policy projects
must be co-ordinated at the EU level.)
The European health market requires
transparency;
debureaucratisation
is
necessary.
(The services of different European health
systems are generally available for legal
reasons. For reasons of competition these
have to be presented and made accessible to
Europe's citizens.)
The health market is provider-oriented;
patients (consumer) have to be empowered in
the
sense
of
consumer
protection.
(Ways are to be found to include consumers
into the decision-making process about the
shaping of the health systems, the content and
the dimension of the range of health services.)
The thread of rationing in the health sector
calls for comprehensive measures of quality
assurance.
(Due to the limited financial means all health
offers and health policy measures have to be
examined, e.g. via cost-benefit analyses or
cost-efficiency analyses to make a rational
decision possible.)
The integration of the Central and Eastern
European candidate countries has to be
encouraged by European health policy.
(The integration policy is to be shaped in the
sense of a harmonisation policy. The
necessary financial means are to be provided
for by the EU.)
The first "European Health Forum Gastein" has
described developments, raised questions, drawn up
problem solutions and thus raised the interest to
continue this interdisciplinary work.
The initiators and organisers have reacted to the
manifold ideas and propositions following the event. The
preparations for the Second Forum in Bad Hofgastein
have been commenced. The general topic is "Health and
Social Protection". The organisers will correspond to the
feedback of the participants and the experience made
during the first event and circumcise the catalogue of
topics without focusing too much on individual concrete
questions.
The organisers will take account of the participants' wish
to discuss the problems of access to public health
systems, issues of general health promotion and the
contribution in particular of new research areas such as
biotechnology to the development of health systems. In
line with the aim of the conference these questions will
be discussed in the wider framework of the European
integration and the development of a common market.
Thus the organisers of the European Health Forum
Gastein are firmly pursuing their successful course.
European Health Forum Gastein
Bad Hofgastein/ Austria
30 September to 2 October 1998
Creating a Better Future for
Health Systems in Europe
European Health Policy at the Turn of the Millennium:
at the Cross-roads?
Global Development, National Responsibility and Regional Challenge
in a Changing Europe
International Networks
with support of:
European Commission, DG V
Austrian Ministry of Labour, Health and Social Affairs
Austrian Ministry of Science and Transport
Government of the State of Salzburg
Organiser
Scientific Co-ordination:
Gesellschaft für Versicherungswissenschaft und -gestaltung
Wednesday,
30 September 1998,
Kursaal hall
15:30 - 16:15
16:15 – 17:15
18:30 – 20:15
Opening Ceremony
Günther
Leiner,
President
of
the
International
Forum
Gastein
Eleonora Hostasch, Minister for Labour, Health and Social Affaires, Austria
William Hunter, European Commission, DGV, Director of Public Health and
Safety at Work
European Health Care at the Turn of the Millennium: At the Cross-roads?
1.
Frank E. Münnich, Consultant
2.
Edward R. Roberts, former Chairman of the Board E. Merck; Member of
the Board Pharmaceutical Partners for Better Healthcare
Dinner Sessions
Hotel Palace Gastein
Ulrich Frick, University of Regensburg, Germany: An integrated, computer-based
dynamic system for Health Planning in Salzburg, Austria
Hotel zum Stern
Wolfgang Routil, Styrian Medical Association, Harmonisation of postgraduate
medical training and continuing medical education (C.M.E.) within the European
Union
Hotel St.Georg
Arun Nanda, World Health Organisation, WHO report 97: Life expectancy in
Europe declines first time since World War II
Hotel Kärnten
Engelbert Theurl, University Innsbruck, Economic aspects of self-medication in
Austria
Grand Park Hotel
William Hunter, European Commission, GD V, The development of Public Health
policy in the European Community
20:30
Reception by the Landeshauptmann of Land Salzburg, Franz Schausberger
Thursday,
1 October 1998
Kursaal hall
08:30 - 9:00
Visions of the future from the perspective of the World Health Organisation
Mikko Vienonen, WHO, Regional Adviser for Health Services Management
9:00 – 9:45
Visions of the future
The European Union's contribution to health, Maastricht, Amsterdam and
beyond
Industry:
Cornelia Yzer, Verband Forschender Arzneimittelhersteller (VFA)
Service Providers/Insurance: Jan Bultman, Ziekenfonds Raad of the Netherlands
Politics:
William Hunter, European Commission, Directorate-General V,
Director
9:45 – 10:00
Coffee break
10:00 - 10:45
Research and development
What role can society play in creating a supportive environment for R&D?
Industry:
Politics:
11:00 - 11:30
Herwig E. Reichl, Hämosan GmbH
Bruno Hansen, Director of Directorate EC- RTD Actions,
Directorate-General XII of European Commission
Development of the health sector
Industry:
Science:
Robert Jones, Glaxo Wellcome, Greenford
Walter Holland, London School of Economics LSE Health
11:30 - 13:00
Lunch break: Hotel Palace Gastein, Hotel Norica, Grand Park Hotel
13:00 - 14:00
Challenges and opportunities for an enlarged European health sector
Industry:
Science:
Politics:
14:00 - 14:45
Paul Brons, Member of the Board Akzo Nobel
Jef van Langendonck, European Social Security Institute Leuven
Christoph Fuchs, Economic and Social Committee of the European
Communities
Árpád Gógl, Health Minister of Hungary
Finance - How to meet the economic challenge of financing the European
health systems
Industry:
Science:
Politics:
15:00 - 15:30
Jürg Ambühl, MSD Sharp & Dohme GmbH
Martin Pfaff, University of Augsburg
Guiseppe Torchio, President of Commission 5 of the Committee of
the Regions
Impulse Speeches in the Forums
Forums I, II and IV work with interactive communication methods
They are divided into sub-working groups : Each of them has approx. 15-20
participants, 1 facilitating support and 4 to 6 experts
Forums III, V and VI are panel forums
They work in 3 groups, with 1 chairperson, 1 rapporteur and 2 to 5 speakers to
present topics of specific interests within the forums
15:30 – 16:00
Coffee break
16:00 - 18:30
The
6
parallel
sessions
start
working
on
the
following
topics
Forum I, Hotel Palace Gastein (interactive ideas and opinion future search
forum)
Research and Development: What role can society play in creating a
supportive R&D environment?
Chair:
Joachim Weith, Shared Medical Systems SMS
Rapporteur:
Herwig Ernst Reichl, General Manager, Hämosan, Austria
Speakers:
Baldur Wagner, Secretary of State, German Ministry
Umberto Bertazzoni, Directorate-General XII, European
Commission
Dario Pirovano, Free-lance journalist, Italy
Forum II, Haus Hofgastein (interactive ideas and opinion future search forum)
Public health and the single market
Chair:
Hans Stein, German Ministry of Health
Rapporteur:
Philip C. Berman, European Healthcare Management
Association Ireland
Speakers:
Corrado Sellaroli, ANSA Rome, Italy
Norbert Klusen, Chairman of the Board TK Health Insurance
Lambert van Nistelrooij, Committee of the Regions
Philip C. Berman, European Healthcare Management
Association Ireland
Forum III, Congress Centre A (Panel)
Challenges and opportunities for an enlarged European health sector - the
role of the regions
Chair:
Franz Terwey, Speaker European Social Insurance Partners
Brussels
Rapporteur:
Tapani Piha
Speakers:
Daniel Mart, President of the Chamber of Doctors of
Luxembourg
Wolfgang Routil, President of the Styrian Medical Association
Gerhard Buchleitner, Land Salzburg
Martine Buron, Committee of the Regions
Forum IV, Hofgasteiner Saal (interactive ideas and opinion future search forum)
Meeting the challenge of a changing economic environment: How to
finance the European health systems in the next millennium
Chair:
Christoph Uleer, Private Health Care,
Germany
Rapporteur:
Günter Danner, Deputy Director European Representation of
German Social Insurance
Speakers:
Ray Robinson, London School of Economics LSE Health
Bernard Merkel, Directorate-General V, European
Commission
Wolfgang Schmeinck, National Association of Company
Sickness Funds
Werner Reimelt, Chairman of the Section Health Insurance,
Austrian Insurance Association
Jens Bostrup, journalist „Politiken“, Denmark
Forum V, Kursaal hall (Panel)
The role of the European Union: Legal and institutional framework of the
Union's policy on health
Chair:
Walter Holland, London School of Economics LSE Health
Rapporteur:
Michael Hübel, Directorate-General V, Public health and
safety at work
Speaker:
Georgios Gouvras, European Commission, DirectorateGeneral V, Public health and safety at work
Günther Liebeswar, Austrian Ministry of Health
Sophie Petzell, free-lance journalist, Sweden
Forum VI, Congress Centre B (Panel)
Health systems in Central and Eastern Europe and particular health risks
Chair:
Volker
Leienbach,
Gesellschaft
für
Versicherungswissenschaft
und
-gestaltung e.V.
Rapporteur:
Fernando Esteves, Portugal
Speakers:
Marianna Fotaki, Senior Health Expert at the Russian Ministry
of Health, Greece
Arun Nanda, WHO Copenhagen
Magdalene Rosenmöller, IESE International Graduate School
of Management, Spain
Witold Zatonski, Marie Curie Cancer Centre and Institute of
Oncology, Warsaw, Poland
Jiri Nemec, General Health Insurance, Czech Republic
20:00
Festive Night dedicated to different themes
Grand Park Hotel
Hotel Kärnten
Hotel Palace Gastein
Friday,
2 October 1998
International night
Swing-time night
Viennese night
08:30 - 10:00
Parallel sessions continue
10:00 - 10:30
Break
10:30 - 11:30
Parallel sessions reconvene
11:45 - 13:30
Lunch sessions
Hotel St.Georg
Eberhard Pirich, Association of Pharmaceutical Companies Austria, Medicine &
Reason
Hotel Norica
Jürgen Bohl, Neuland & Partners, Tools for communication and interactive
problem resolution in the Public Health sector
Hotel Astoria
Mikko Vienonen, W.Kreisel, World Health Organisation, Health care reforms in
Europe and worldwide
Hotel zum Stern
Volker Leienbach, Gesellschaft für Versicherungswissenschaft und –gestaltung,
Health systems in Europe – status quo and reform trends
Grand Park Hotel
Baldur Wagner, Secretary of State, Germany, The future of the German health
system
Kursaal hall
13:30 – 13:45
Reception by Pádraig Flynn, Commissioner for Employment, Industrial Relations
and Social Affairs
Congress centre
14:00
-14:30
International Media Conference
Pádraig Flynn, Commissioner for Employment, Industrial Relations and Social
Affairs
Kursaal hall
13:45 - 15:00
Presentation of results from parallel working groups (15 minutes each)
Forum IV – Günther Danner
Forum I – Herwig Reichl
Forum II – Phillip Berman
Forum III – Tapani Piha
Forum V – Michael Hübel
Fourm VI – Magdalena Rosenmöller, Fernando Esteves
15:00 - 15:20
Break
15:20 – 16:50
Mikko Vienonen, WHO, Regional Adviser for Health Services Management
The Industry: Visions of the future
Werner Clement, Institute for Industrial Research, University of economics and
business administration Vienna
Health policy in Austria: Visions of the future
Wolfgang Routil, Vice-President of the Chamber of Doctor´s Austria
Pádraig Flynn, European Commission, Commissioner
Employment, Industrial Relations and Social Affairs
16:50 - 17:05
Concluding remarks
Prof. Frank E. Münnich, Consultant
17:05
Formal Conclusion by President Leiner
Stubnerkogel, Bad Gastein
19:30
Festive conclusion evening
responsible
for
EUROPEAN HEALTH
FORUM GASTEIN (EHFG) 1999
Creating a better Future for Health in Europe:
HEALTH & SOCIAL SECURITY
6 to 9 October, 1999
DRAFT PROGRAMME
Quality Assurance & Social Issues: Comparable quality standards in health systems at present and
their future role
• Potential effects of comparable standards on the availability of health services and treatment for all;
• Changes in the structure and transparency of health systems through European Integration – emerging
needs for the harmonisation of standards;
• Knowledge transfer between EU and CEE countries (Agenda 21);
• Market authorisation of health services & products and common therapy guidelines.
SOCIAL EXCLUSION & HEALTH SYSTEMS: Unequal access to health care in Europe.
• Benefits catalogues of social insurances, rationing of health services and impacts on access to health
care;
• Cross-border issues in health care with regard to free movement of services and people;
• Social exclusion & epidemiology in CEE ;
• Optimal policy – Potential for the integration of Social & Health Policies;
• Networks & self-help groups (communicable diseases, Healthy Cities, Health 2000).
HEALTH PROMOTION: The role of Health Promotion in an enlarged Europe
• Who is responsible for health promotion and how far does this responsibility go? (Regional, national
and/or European level);
• Costs & benefits of health promotion activities ;
• Health promotion in CEE countries and need for action;
• The Community Action Programme of Health Promotion;
• Health education , health & safety at work, health & safety at home.
R&D – RARE DISEASES & ORPHAN DRUGS: Research without Return on Investment
• Do those affected have a right to claim R&D for orphan drugs? Is society obliged to finance R&D
without return on investment?
• How can R&D without return on investment be financed?
• Intellectual property rights and orphan drugs: Particular problems in CEE countries
• Actual and the desirable legal frameworks and policies for orphan research
R&D – BIOTECHNOLOGY - Visions of the future: The Impact of Biotechnology on Health Systems &
Health Services
• Where do we have to set the ethical limits to biotechnology?
• Getting from R&D to the economic use of biotechnology
• Biotechnology in CEE: Legislation, real life and need for change with regard to EU membership.
• Which type of life should be registrable as intellectual property?
HEALTH & INFORMATION TECHNOLOGY - Visions of the future: The Impact of IT on Health
Systems & Health Services
• Telematics & IT in Health and their impact on data protection, data misuse and social exclusion
• Technology Assessment & Evaluation, and patrients management
• Monitoring of diseases and the need for a European system
Who is Who
Representatives
Dr. Günther Leiner (59), Austria, President of the
International Forum Gastein. Dr. Leiner, an internal
specialist, is medical superintendent at the Institute of
Rheumatology, Rehabilitation and Psychosomatic
Medicine at Bad Gastein, and Member of the Austrian
National Council for the Austrian People's Party.
Padraig Flynn (59). Ireland, European Commission in
Brussels, Commissioner for Employment, Industrial
Relations and Social Affairs.
Eleonore Hostasch, Austria, Austrian Minister for
Labour, Health and Social Affairs, Vienna.
Franz Schausberger , Austria, Provincial Governor of
the Austrian province of Salzburg.
Dr. Gerhard Buchleitner (56), Austria, since 1989
Deputy Provincial Governor; responsible for health in
the Salzburg provincial government, Salzburg; 19801989 Deputy Mayor of the City of Salzburg.
Key Speakers
Dr. Juerg Ambuehl (49), Switzerland, chemist, Master
of Business Administration (MBA) INSEAD; Managing
Director MSD Sharp & Dohme GmbH, Haar/Germany, &
Vice President MSD-Europe; Member of the Board of
the
"German
Association
of
Research-based
Pharmaceutical Companies" (VFA), Bonn.
Paul K. Brons (57), Netherlands, business
administration; Member of the Board of Management of
Akzo Nobel, responsible for the pharma group; Member
of the EFPIA Board, and in charge of EFPIA’s "EU
enlargement" project team; Pharmaceutical industry
spokesman in the Bangemann process on the free
movement of medicines within the EU and on EU
enlargement.
Jan Bultman (51), Netherlands, M.D., specialist in
Community Medicine; Secretary of the Dutch Sickness
Funds Council in Amstelveen, responsible for designing
the benefits package, subsidising experiments in health
care and health services research; short term consultant
on health (financing) policy in Central and Eastern
Europe.
Werner Clement, (57). Professor at the University of
Innsbruck (1970). Professor at the University of
Economics, Vienna (since 1973). Visiting Professor at
Cambridge University (U.K.), Stanford University (Ca.),
HEC Paris. Honorary Doctorate of the University Paris
XI (1984). Chairman of the "Institute for Industrial
Research (IWI)". OECD country examiner for France,
Switzerland, Australia, USA. Consultant to the State
Planning Committee, Hanoi/Vietnam. Co-ordination of a
series of projects in the field of health economics;
responsible for health economics at the University of
Economics in Vienna.
Prof. Dr. med. Christoph Fuchs, (53), Germany,
medical doctor specialised in internal medicine;
Professor of the University of Goettingen,1984-1990
Head of the Health Department in the Ministry of
Environment and Health of Rhineland-Palatinate; since
July 1990 Secretary General of the German Medical
Association; member of the Economic and Social
Committee of the European Communities, Academy of
Science and Literature in Mainz (Rhineland-Palatinate),
Academy for Ethics in Medicine.
Dr Árpád Gógl MD, PhD, MP (59), Hungarian,
Medicine; Minister of Health; Medical Science in Pécs
University of Medicine, specialised in internal medicine,
gastroenterology, clinicopharmacology; President of the
Hungarian Medical Chamber 1994-1998; President of
the Gastroenterology Gastroenterology Advisory
Committee of the Ministry of Welfare till 1998; Director
of the Postgraduate
Centre, Pécs University of
Medicine; Elected Assembly Member of the Hungarian
Academy of Sciences.
Bruno Hansen (57), Denmark, chemical engineer;
Director, Directorate General XII, Sciences, Research
and Development, Directorate E - Life Sciences &
Technologies,
European
Commission, Brussels;
Lectures on biotechnology, research, co-operation
between industry and academia, higher education and
research policy.
Prof. Walter Holland, CBE, FRCP, FFPHM (69). Great
Britain; medical research, epidemiology; visiting
Professorial Fellow at the London School of Economics.
he was President of the International Epidemiological
Association and the Faculty of Public Health Medicine at
the University of London; he has honorary doctorates
from the universities of Berlin and Bordeaux. He is
currently the Chairman of EHPRN at LSE Health.
Dr. William Hunter, Director of Public Health and
Safety at Work, Commission of the European
Communities, Luxembourg; Chairman of the High Level
Committee on Public Health; Chairman of the
Committee of Senior Officials of Public Health
composed of senior government officials responsible for
ensuring the free movement and mutual recognition of
the health care profession; Member of Jury "Europe and
Medicine" responsible for proposal for a programme an
drug demand reduction; Officer of the Order of St. John
of Jerusalem for humanitarian work.
Robert H. Jones (56), Great Britain, Director of Glaxo
Wellcome‘s Corporate Strategy Unit, Glaxo Wellcome,
Greenford, GB; Fellow of the Society of Business
Economists and of the Institute of Management;
Chairman of the European Pharmaceutical Federation‘s
Economics Policy Committee.
Prof. Dr. Frank E. Münnich (61), German, Economist,
Health Economist, consultant, formerly full professor of
economics, econometrics and health economics at the
Universities of Dortmund, Essen, Innsbruck and
München, formerly director of the Association of
Research Based Pharmaceutical Companies in
Germany, member of the “Verein für Socialpolitik”.
Professor Martin Pfaff Ph.D. (59), Germany; Chair in
Economics at the University of Augsburg; Assistant and
Associate Professor at the American University in
Washington D.C., Founder and Director of the
International Institute for Empirical Social Economics
(INFES), Member of the German Parliament (Social
Democratic Party) since 1990.
Mag. Herwig Ernst Reichl (41), Austrian, Biochemistry,
Virology; Founder, Owner and President of Haemosan
GmbH, an Austrian biotechnology company in Graz;
specialised in protein purification, virus inactivation and
TSE research; co-ordinator of 3 EU-funded R&D
projects in TSE research.
(TSE = Transmissible Spongiphorme Encephalopathies
= the newly emerging class of infectious agents phrased
PRIONS which i.a. cause diseases like CreutzfeldJacob Disease, Scrapie and BSE, the British mad cow
disease).
Edward R. Roberts (64), Great Britain, pharmacist,
Chairman of Pharmaceutical Partners for Better
Healthcare (PPBH) London; Member of the Board of
Visitors Duke University, Fuqua School of Business,
Durham, North Carolina.
Guiseppe Torchio, Italy; President of Commission 5,
Prof. Dr. Jef Van Langendonck (57), Belgium, law,
philosophy, economics; professor of social law and
comparative social law, Katolieke Universiteit Leuven;
expert for ILO, Council of Europe and EEC on social
security issues; honorary secretary general, European
Institute of Social Security.
Cornelia Yzer MP. (37), Germany, lawyer; since 1990
Member of the German Bundestag (Christian
Democratic Union); since 1997 Managing Director of the
Verband Forschender Arzneimittelhersteller e.V. (VFA),
the
German
Association
of
Research-based
Pharmaceutical Companies.
Chairmen
Volker
Leienbach
(44),
Germany,
business
administration; Managing Director of the Gesellschaft
für Versicherungswissenschaft- und Gestaltung e.V.
(GVG) in Köln (Germany); Consultant in the field of
social policy, working inter alia for German ministries
and a Swedish development association, international
consulting firms and the EU; since 1984 close cooperation with the EC-Commission.
Dr. Hans Stein (60), Germany, lawyer, government
official; European liaison officer at the Federal Ministry
for Health (Bonn); Member of a big number of
committees and groups of the European Union.
Dr. Franz Terwey (47), Germany, Law and political
science; European representative of German social
security, Director (Brussels); Speaker European Social
Insurance Partners (ESIP), Brussels; Member of the
European Institute for Social Security, Leuven
(Belgium).
Dr. Christoph Uleer (61), Germany, lawyer; 1971
Managing Director and 1976 Managing Member of the
Board of Directors of the Association of Private HealthInsurance (Verband der privaten Krankenversicherung);
since 1996 additional position as Managing Director of
MEDICPROOF GmbH, Cologne (company for providing
medical experts opinion in the fields of long term care
insurance).
Speakers at the Parallel Sessions
Dr Umberto Bertazzoni (61), Italy, pharmacy,
biological sciences, biochemistry; Head of the Medical
Research Unit DG XII-E (RTD Actions, Life Sciences
and Techologies) in Brussels; responsible for the
Chemistry Panel of Research Networks of the Training
and Mobility of researchers (TMR) programme; member
of the Società Italiana di Biofisica e Biologia Moleculare.
Jens Bostrup (34), Denmark, journalist, European
Affairs correspondent of the Danish daily "Politiken" in
Copenhagen. Author of "Denmark and EU in Europe"
(with Mr. Niels Ersbøll, former General Secretary of the
Council of the European Communities).
Martine Buron, France; Vice President of Commission
5, Committee of the Regions
Marianne Fotaki (38), Greece, medical doctor;
research fellow at the London School of Economics,
London (UK); long term consultant in health and social
policy in TACIS EU funded technical assistance projects
for the Ministry of Health, Ministry of Labour and Social
Protection and Ministry of Economy of the Russian
Federation.
Brussels. Since October
Petzell/Lagerlöf Text AB.
Georgios Gouvras (50), Greece, mechanical and
electrical engineering; from February 1992 was
concurrently in charge of Public Health, and from June
1992, in addition, in charge of the Unit "Europe against
Cancer", which was based in Brussels; in October 1992
he was appointed Head of Public Health and Europe
against Cancer.
Professor Ray Robinson (54), Great Britain; Professor
of Health Policy and Director of the Institute of Health
Policy studies at the University of Southampton (Great
Britain), Visiting Fellow at LSE Health, London School of
Economics.
Dr. Norbert Klusen (51), Germany; Chairman of the
Board of the Techniker Krankenkasse; comprehensive
experience at the management level of international
enterprises; until 1993 member of the Board and
Director of labour of a company of engineering and
construction.
Dr. Gunter Liebeswar (57), Austrian; Medical Doctor,
Director General of Health; Chairman of the Board of
the Austrian Federal Institute of Health and Vicepresident of the Fund “Healthy Austria”.
Dr. Daniel F. Mart (42), Luxembourg, medicine (private
general practice in Luxembourg); Member of the
European working group of patient data cards; Expert
on working groups Europe against Cancer (DG V);
Member of the Board of the CRP-Santé (Luxembourg
public
health
research
centre);
Luxembourg
representative with the World Medical Association
(WMA).
Dr. Bernard Charles Merkel (49), Great Britain, social
sciences and doctorate in political thought; working for
DG V of the European Commission on the development
of public health policy.
Arun Nanda (49), Great Britain, scientist for electrical
engineering and operational research; Regional Adviser
for Epidemiology, Statistics and Health Information at
the World Health Organisation (WHO), Regional Office
for Europe, Copenhagen, Denmark; Publication:
Evaluation of the European Strategy for Health for All by
the year 2000.
Jiri Nemec, Czech Republic; General Health Insurance
Sophie Petzell (58) , Sweden, free lance journalist, BA.
Principal Press Officer at the Secretariat for Information
on European Affairs at the Swedish Ministry of Foreign
Affairs 1993-1994. Until October 1997 Member of the
Spokesmen´s Service at the European Commission in
last
year
co-owner
of
Werner Reimelt (55), Austria, Director General of
MERKUR Versicherung, Graz; Chairman of the Health
Insurance Section in the Austrian Association of
Insurance Companies.
Dr. Magdalene Rosenmöller (38), Germany, medical
doctor (MD), Master of Business Administration (MBA);
Research Associate, IESE, Barcelona and LSHTM,
London School of Hygiene and Tropical Medicine,
London; large experience in technical assistance to the
health sector reform process in Central and Eastern
Europe and other health sector consulting in Spain and
South America, member of the Ordre National de
Medecins, France; Collegi Oficial de Metges de
Barcelona; American Medical Informatics Association,
US.
Dr. Wolfgang Routil (45), Austria, MD, general
practitioner in Graz, President of the Styrian Medical
Association; 2nd Vice-President of the Austrian Medical
Association and head of the section for medical training
and continuing training; member of the board of the
European Academy of Continuing Medical Training
(EAMF); Austrian delegate to the Advisory Committee
on Medical Training (ACMT) of the European Union and
member of the Advisory Committee on Medical
Training.
Wolfgang Schmeinck (52), Germany, economist;
Managing Director of the Federation of Company Health
Insurance Funds (BKK BV) in Essen (Germany);
together with its Regional Associations the Federation is
the parent organisation of about 378 Company
Insurance Funds (BKKs) with about 5,72 million insured
plus their families, altogether nearly 8,5 millions .
Dr. Corrado Sellaroli, (65), Italy, feature writer in
Brussels for Ansa, the Italian National News Agency,
and for several technical magazines, dealing mainly
with industrial and consumer issues. Formerly chief of
the Brussels Bureau for Ansa; previously chief of the
Public Affairs activities in FAO, Rome, and information
and liaison officer in the Paris office of the World Bank.
In the seventies and earlier, he was responsible for the
occasional supplements of the weekly "Mondo
Economico", and foreign editor with the economic daily
"24 Ore", both in Milan.
Lambertus van Nistelrooij (45), M.A.; Netherlands,
social geography (degree studies); Member of the
Provincial Executive for the Province of North Brabant
(The Netherlands), Portfolio includes public health,
social services etc.
Dario Pirovano, Italy, biomechanical engineering at the
Politecnico of Milan, 18 years experience in the medical
devices sector, one of the major contributors to the
drafting of the
European Union medical devices
directives, regular speaker on medical devices
regulatory matters, consulting director of Medical
Technology Consultants, Brussels.
Dr. Mikko Antero Vienonen (52), Finland, physician
(Specialist in general practice (Family Medicine));
Regional Adviser for Health Services Management
WHO-Regional Office for Europe, Copenhagen
(Denmark); in the late 1980’s he transferred to
international development co-operation in the health
sector working for several projects in Africa, Asia and
Latin America.
Baldur Wagner (49), Germany, national economist,
Under-secretary at the Federal Ministry for Health,
Bonn, 1977; 1984 Head of the department for economic
and social policies at the headquarters of the Christian
Democratic Party (CDU), Germany.
Joachim Weith (35), Germany, diploma in sociology
and management; examiner for organisation and
information technology at the Social Ministry of BadenWürttemberg for state-owned hospitals; Marketing
Manager Central & Eastern Europe at SMS Corporation
with headquarters near Frankfurt am Main (Germany).
Prof. Dr. Witold A. Zatonski (56), Poland, medical
profession (internal medicine and cardiology); Professor
of Epidemiology at Marie Curie Memorial Center,
Warsaw; UICC-Regional Co-ordinator Tobacco Control
Central & Eastern Europe; 1993 awarded Medal by
Jacques Chirac (Paris) for Disease Control in Eastern
Europe; Author of the Atlas of Cancer Mortality in
Poland.
Rapporteurs
Philip C. Berman Ireland, profession; Director of the
European
Healthcare
Management
Association
(EHMA); considerable experience of healthcare
systems in Western, Central and Eastern Europe;
currently directing a multinational project to assess the
impact of EU directives on health services in the
European Union.
Günter Danner, M.A.; Ph.D. (42), Germany;
economics, history, international relations. Personal
counsellor of the Board of Management of the
Techniker Krankenkasse (Hamburg). Deputy Director of
the European Liaison Bureau of the joint associations of
German social insurance (Brussels). Comparative
analysis of international systems of health care and
health insurance, health policy and health economics.
European and global developments and their
repercussions for health insurance systems and
markets. The socio-political consequences of the
accession of new Member States and the social reform
in CEEC. Co-operating with PHARE and TACIS
projects. 11 modern languages.
Jose Fernando Macedo Esteves (25), Portugal,
journalist, chief editor of the magazine "Medicine &
Health“ , Lisbon, Portugal; college degree in public
relations (University College of Social Communication)
and journalism (Independent University); was editor of
the news magazine “Olhares”.
Michael Hübel, M.A. (35); Germany; political science,
law and history; European Commission, DG V/F/1,
Public health analyses, policy development, and health
in other policies, Luxembourg. He works on public
health policy development and on links between health
policy and other health-related Community policies.
Previously, he was European representative of the
German Red Cross.
Mag. Herwig Ernst Reichl (41), Austrian, Biochemistry,
Virology; Founder, Owner and President of Haemosan
GmbH, an Austrian biotechnology company in Graz;
specialised in protein purification, virus inactivation and
TSE research; co-ordinator of 3 EU-funded R&D
projects in TSE research.
(TSE = Transmissible Spongiphorme Encephalopathies
= the newly emerging class of infectious agents phrased
PRIONS which i.a. cause diseases like CreutzfeldJacob Disease, Scrapie and BSE, the British mad cow
disease).
Dr. Tapani Piha (43), Finland, medicine; Counsellor on
health affairs at the Permanent Representation of
Finland to the European Union in Brussels; Regional
Adviser at the WHO Regional Office for Europe,
Lifestyles and Health Department, responsible for the
Action Plan for a Tobacco-free Europe.
Anja Alila
Finnish Red Cross
Planning Officer
Voluntary Social and Health Services
N
Anne Alvik
Norwegian Board of Health
Director General of Health
N
Jürg Ambühl
MSD Sharp & Dohme GmbH
Vorsitzender der Geschäftsführung
D
Christine Amstrong
Caldwell Communications Limited
Director
UK
Anthony Arke
Europabio
Secretary General
B
Skrabski Àrpàd
Hungarian Federation of mutual funds
President
H
Pance Arsov
PZO Dr. Pance Arsov
Chief Executive Officer
Macedonia
Hoxha Arta
Health Insurance Institute
Budget Expert
Albania
Friedemann Bachleitner-Hofmann
Apothekerkammer Salzburg
Präsident
A
Walter Baer
DG V Beschäftigung, Industrielle Beziehungen und
Soziale Angelegenheiten
Assistant European Commission
L
Edwin Bailey
Managed Care Europe
Editor
UK
Mette Bakkeli
Ministry of Health and Social Affairs
Adviser
N
Arno Barendregt
National Health Tariffs Authority
Secretary
NL
Barbara Baronin von Stackelberg
Deutsches Grünes Kreuz
Managing Director
D
Christopher L.R. Bartlett
PHLS Communicable Disease Surveillance Centre
Chief Executive Officer
UK
Mr. Bauer
ORF Salzburg
A
Philip C. Berman
Director
European Healthcare Management Association Ireland
IRL
Günther Bernatzky
Universität Salzburg
A
Naturwissenschaftliche Fakultät
Umberto Bertazzoni
Directorate-General XII,
Head of "Medical Research"
European Commission
B
Andreas Besche
Verband d. priv. Krankenversicherung e.V.
Head of department
D
Marko Bitenc
President
SLO
The Medical Chamber of Slovenia
Ulrich H. Bode
Glaxo Wellcome Pharma Ges.m.b.H.
Geschäftsführer
A
Jürgen Bohl
Neuland & Partner
Moderator
D
Nicholas Boreham
University of Manchester
Human Research Factor Group
UK
Jens Bostrup
Journalist
DK
Hans Werner Brede
Shared Medical Systems Europe (SMS)
Director Business Development
D
Waldemar Broniek
Agricultural Social Insurance Fund (KRUS)
Regional inspector of the medical certification
Paul Brons
Akzo Nobel
Member of the Board
NL
Gerhard Buchleitner
Salzburger Landesregierung
Gesundheitsreferent
A
Jan Bultman
Ziekenfonds Raad of the Netherlands
P
NL
Martine Buron
Vice President of Commission 5
F
Enrico Campanelli
ESIS
Journalist
I
Francisco Carreno
Fundacion Espriu
President, Vice President of IHCO for Europe
Jean-Jacques Chirikdjian
ZAK-PHARMA DIENSTLEISTUNG GesM.B.H.
Managing Director
A
René Christensen
European Investment Bank
Senior Health Economist
L
Hermann Chrzan
Betriebskrankenkasse der Alianz Gesellschaften
Abteilungsdirektor
D
Werner Clement
Wirtschaftsuniversität Wien
Institutsvorstand
Industriewissenschaftliches Institut
A
Anna Coss
Surrey Social Services, Surrey County Council
Professional Officer
UK
Günter Danner
Deutsche Sozialversicherung - Europavertretung
Vize-Direktor
B
Ludwig Dengg
Apothekenjournal
A
Annemie Doms
Flemish Community Belgium
Director Public Health Department
B
Gérard Dubois
Head of Department
F
E
University
Service Médical Hôpital Nord
Francois Enderlin
Fédération Nationale de la Mutualité Francaise
Chargé de mission/Secteur Europe
F
Hans Eriskat
Direktor e.h. der EU-Kommission
D
Fernando Esteves
Freelance Journalist
P
Klaus Fankhauser
Vorstandsdirektor
Steiermärkische Krankenanstaltengesellschaften m.b.H.
A
Miklós Fehèr
Hungarian Medical Association
Vice president
H
Lothar Feige
Professor
D
Jan Fertek
Nemocnice Pardubice
Director of Hospital Pardubice
CZ
Pádraig Flynn
EU-Commission DG V
EU Commissioner
B
Eva Maria Förster
und -gestaltung
Projektkoordinatorin
D
Marianna Fotaki
Russian Ministry of Health
Senior Health Expert
UK
Christoph Fuchs
Bundesärztekammer
Secretary General
D
Juozas Galdikas
Parliament of the Republic of Lithuania
Member of Parliament
National health Council
LV
José Garcia De Ancos
British Medical Association
Education and Informatics Adviser/International
UK
Károly Garda
Hungarian Medical Association
Österreichreferent d. ungarischen Ärztekammer
H
Elita Georgana
Administrator Committee of the Regions
Direction des travaux consultativs
B
Ian Gilmore
Royal College of Physicians
Registrar-Elect
UK
Camillus Glynn
Joint Committee on Health and Children
Senator
IRL
Árpád Gógl
Ministry of Health of the Republic of Hungary
Minister
H
John Gormley
Parliament
Member of Parliament
Joint Committe on Health and Children
IRL
Georgios Gouvras
European Commission, Directorate-General V
Head of Unit
Public health and safety at work
L
Alois Grüner
Salzburger Landesregierung
A
Sheila Gruselle
Surrey Social Services, Surrey County Council
Chairman of Social Services Committee
UK
José-Carlos Guisado
Fundación Espriu
Technical collaborator
E
Bruno Hansen
Europäische Kommission - Direktion E / BioWissenschaft und Bio-Technologie
Direktor
Generaldirektion XII - Wissenschaft,
Forschung und Entwicklung
B
Stefan Hartmann
Generali Versicherung AG
Abteilungsleiter
Krankenunfallversicherung
A
Kaija Hasunen
Ministry of Social Affairs and Health
Government counsellor
Dept. Of Prevention and Promotion
SF
Wolfgang Hauck
Medizinjournalist
D
Herbert Hauser
Ärzte Woche
Chefredakteur
A
Ralf Helenius
HANKEN Swedish school of economics and
business administration
Professor
Political Science
SF
Bruno Henrique Henriques
FNS/Federacao Nacional dos Prestadores de Cuidados de Saúde
P
Sabine Herlitschka
BIT-Büro für internationale Forschungs- und
Technologiekooperation
A
Abteilungsleiterin
Life Sciences
Judith Hoffmann
NTV Berlin
Walter Holland
London School of Economics - LSE Health
D
Professor
UK
Eleonora Hostasch
Bundesministerin
Bundesministerium für Arbeit, Gesundheit und Soziales
A
Helena Hren-Vencelj
Parliament of Republic of Slovenia
Member of the Parliament
Committee for Health, Labour, Family
and Social Policy
SLO
Ernst G. Huber
Österreichisches Grünes Kreuz
Präsident des österreichischen Grünen Kreuzes
Michael Huebel
Administrator
Directorate-General V,Employment, Industrial relations
EUFO, 3178
and Social Affaris
L
William Hunter
European Commission
Director Health and Safety at Work
Directorate-General V "Health and
Safety at Work"
B
Janusz Indulski
Director of the Institute
Director of the WHO Collaborating Centre
for Occupational Health
School of Public Health
PL
Jerzy Nofer Institute of Occupational Medicine
A
Eckhardt Jäger
Fachverband der chemischen Industrie
A
Hans Jahnel
Fresenius Pharma Austria GmbH
Vorsitzender des Aufsichtsrates
A
Andràs Jàvor
National Institute for Medical Information
Senior Consultant
H
Robert Jones
Glaxo Wellcome
Director
Corporate Strategy Unit
UK
Toomas Jukk
Central sickness Fund
Human resources development specialist
EE
Monika Kaiser
und -gestaltung
Projektkoordinatorin
D
Hillar Kalda
Estonian Red Cross
President
EE
Roger Kaliff
Vice President
B
Malcolm Kendrick
Gardiner Caldwell Communications Ltd.
Director of strategic communications
UK
Éva Kereszty
Deputy Secretary of State
H
Andreas Kiefer
Landeseuropabüro Land Salzburg
Leiter
A
Christian Klobucsar
Bohmann Verlag, Magazin Managemed
Redakteur
A
Norbert Klusen
Techniker Krankenkasse
Vorstandsvorsitzender
D
Mr. Knecht
Regionalhospital Biel
Chief executive officer
CH
Jacek Kossakowski
Doctor-in-chief of the KRUS
P
Boris Kramberger
Health Insurance Institute of Slovenien
Assistant General Director
SLO
Wilfried Kreisel
WHO Office at the European Union
Director
Cité administrative de l'Etat
B
Michael Thomas Kris
Science & Communication SC
Herausgeber
D
Marketing Report Gesundheit + Themenletter
Roman Kunyik
ÖVP-Parlamentsklub
Klubsekretär
A
Alain Lefebvre
Représentation permanente de la France
Conseiller santé
B
Volker Leienbach
Gesellschaft für Versicherungswissenschaft und
-gestaltung e.V.
Geschäftsführer
D
Günter Leiner
President
A
Ursula Leitner
Austria Presse Agentur
A
Günther Liebeswar
Austrian Ministry of Health
Head of Section
A
Paul Lincoln
Health Education Authority
Director
UK
Martin Link
Kleine Zeitung
A
James Logan
University of Wolverhampton
Dean of Health Sciences
UK
Michael Loicht
Parlament
Parlamentarischer Mitarbeiter
A
Javier Lopez Iglesias
Grupo Doyma
Redactor
E
Roman Lutynski M.D.
Jagiellonian University
Head of the Department of Hygiene and Ecology
Karl Mach
Österreichische Krebshilfe
A
Gloria Malaspina
Responsible department health policies
Confederazione Generale Italiana del Lavoro (C.G.I.L.)
Health policies
I
Birgit Mallmann
Neuland & Partner
D
Moderator
Minella Mano
Chairman
Trade Union Federation of Health Employees of Albania
Albania
Daniel Mart
Associaton des Medecins et Medicins-Dentistes
President
du G.D. de Luxembourg
L
Tanja Mate M.D.
Ministry of Health of the Republic of Slovenia
Adviser
SLO
Fredy Mayer
Landesrat a.D.
A
Stefan Mayer
Landespressebüro
Press officer for European Affairs
A
Bernard Merkel
Directorate-General V, Direction F
Mathioudakis Michalis
Federation Panhellenique des Travailleurs des #
hospitaux publics
L
European Commission
Conseiller des relations internationales
GR
PL
Peter Mirski
Management Center Innsbruck/MCI
Abteilungsleiter
A
Lou Molenaar
Boehringer Ingelheim
Abteilungsleiter
D
Frank E. Münnich
Consultant
D
Arun Nanda
Regional Adviser
Unit of Epidemiology, Statistics and Health Information
WHO
DK
Gerasim Nazarenko
Medical Centre Bank of Russia
RF
Director
Jiri Nemec
General Health Insurance
CZ
Thomas Neuhold
A
Horst Noack
Universität Graz
Institutsvorstand
Institut für Sozialmedizin
A
Jens Nordmeyer
Ausschuß der Regionen
Pressereferent
B
Katalin Novak
Head of Department
Department of International Relations
H
Edel O'Dea
Irish Parliament
Clerk
IRL
Batt O'Keeffe
Irish Parliament
Chairman
IRL
Ulla Olander
Mayor of Skörde
B
Berit Olsen
Norwegian Board of Health
Director of Department
N
Illiko Palik
Neuland & Partner
Moderator
D
Janos Palik
Neuland & Partner
Moderator
D
Markus Pasterk
Bundesministerium für Wissenschaft und Verkehr
Sachbearbeiter biomed. Forschung
Präs. 4
A
Hanna Pava
Deputy Head of Department
Department of Law
H
Sophie Petzell
Freelance Journalist
S
Martin Pfaff
Deutscher Bundestag
Abgeordneter zum Deutschen Bundestag
D
Tapani Piha
Ministry of Health, Finland
Health attaché
B
Franz Piribauer
Land Steiermark
Stellvertretender Abteilungsleiter
Fachabteilung Gesundheitswesen
Eberhard Pirich
Wirtschaftskammer Österreich
Fachverband der Chemischen Industrie
A
A
Dario Pirovano
Medical Technology Consultants
Consulting Director
I
Petra Pissulla
Dräger-Stiftung
Director
D
Peter Placheta
Bender Wien
Direktor Pharma
A
Uli Potocnik
Medical Tribune
A
Lydia Povie
Fédération Nationale de la Mutualité Francaise
Chargée de mission/Secteur Europe
Europe et Activites Internationales
F
Martin Praetorius
Siemens Business Service PS ES
Senior Consultant
D
Gerhard Pressl
Versicherungsanstalt öffentlicher Bediensteter
Generaldirektor-Stv
A
Klaus-Jürgen Preuß
Deutsche Krankenversicherung AG
Managing Director
Gesundheitsmanagement
D
Keith W. Price
Neuland & Partner
Moderator
D
Peter Pueller
BAYER-AUSTRIA
A
Key account management
Herta Rack
Bundesministerium für Arbeit, Gesundheit und Soziales
A
Sektion VII/3
Christian Raming
Allg. öffentl. Krankenanstalten des Landes Kärnten
Verwaltungsdirektor
Verwaltungsdirektion
A
Herwig Reichl
Hämosan Erzeugung pharm. Grundstoffe GesmbH
General Manager
A
Werner Reimelt
Vorsitzender der Sektion Krankenversicherung
Verband der Versicherungsunternehmen Österreichs
Francisco L. Reis
S.G. Relaciones institucionales y Alta Inspección
Technical Adviser
Burea 1419, M Sanidad y Consumo
E
Julio Reis
Health Regional Administration
President
P
Christian Richner
Owner
Richner Interdisciplinary Health Care Consulting Services
CH
Synnove Roald
Ministry of Health and Social Affairs
Adviser
N
Edward Roberts
Chairman
D
A
Pharmaceutical Partners for Better Healthcare
Ray Robinson
University of Southhampton
Prof. of Health Policy
Associate Prof. in European Health Policy
at the Dpt. of Social Policy of LSE
UK
Jadranka Rogan
CSC Pharmaceuticals Handels GmbH.
Medical Director
A
Franz Romeder
Österreichischer Gemeindbund
Präsident
A
Juan Carlos Romero-Abreu
Union Medica Gaditana
Director
E
Teacher and Research Associate
IESE International Graduate School of Management
E
Francoise Rossignol
A. GEMS SERVICES S.A.
Director Public Affairs Europe
B
Wolfgang Routil
Chamber of Doctors of Styria
President
A
Bruce Rowling
Neuland & Partner
Moderator
D
Barbara Sankiewicz-Pawlikowska
Doctor
P
Liivi Sarajeva
Trade Union Ass. Of Health Officers of Estonia
Project leader
EE
Michael Scannell
EU-Commission DGV
Assistant to the Commissioner
B
Xenia Scheil-Adlung
Internationale Vereinigung für soziale Sicherheit
Programmleiterin
Abteilung Fachstudien und
Programmdurchführung
CH
Wolfgang Schmeinck
BKK-Bundesverband
Geschäftsführer
D
Elfi Schmidt-Garrecht
Kassenzahnärztliche Bundesvereinigung
Leiterin Büro Bonn KZBV
D
Ulrich Schmitz
Siemens-Nixdorf Informationssysteme AG
Leiter Unternehmensbeziehungen
D
Friedrich Schreger
Pfizer Corporation Austria
Consultant
A
Helmut Schüchtle
Physiotherapieschule Konstanz
D
Rosemarie Schüchtle
Physiotherapieschule Konstanz
D
Leo Schütze
Gesellschaftspolitische Kommentare
Journalist
D
Regina Schwestka
Parlamentarische Mitarbeiterin Dr. Rasinger A
ÖVP-Klub Parlament
Ana Sedeno Mombriedro
Consejo General de Farmaceuticos
Gotthard Seethaler
Organon GesmbH
E
Departemento de Prenso e Comunicacion
Geschäftsführer
A
Corrado Sellaroli
ANSA Rome
I
Hans Sendler
Leiter der Abteilung Gesundheit
Ministerium für Frauen, Jugend, Familie und Gesundheit
Nordrhein Westfalen
D
Gert Siemons
NV Organon
NL
Renate Skledar
Patientenvertretung Land Steiermark
Patientenombudsfrau
A
Proko Sokrat
Health Insurance Institute
Vice Director
Albania
Maria Spernbauer
ICM/ International Confederation of Midwives
ICM-Delegierte
A
Jean Spray
Health Education Authority
Director
UK
Koutsioumbelis Stavros
Federation Panhellenique de Travailleurs des
Hospitaux publics
President
GR
Hans Stein
Bundesministerium für Gesundheit
Referatsleiter Z 21- Europäische Gesundheitspolitik D
Katja Straziscar
KRKA d.d
Assistant to the chief executive
SLO
Gerhard Stummerer
Roche Austria Gmbh
OTC-Manager Austria
A
Irina Y. Sugurova
Poljus Pharma
Geschäftsführerin
RF
Franz Terwey
European Social Insurance Partners
Director
B
Engelbert Theurl
Universität Innsbruck
Institutsvorstand
Institut für Finanzwissenschaften
A
Wendy Thorne
Deptartement of Health
Senior medical officer Dept. of Health
UK
Harald Thurnherr
Bohmann Verlag, Magazin Managemed
Chefredakteur
A
Uwe Tietze
Techniker Krankenkasse
Bereichsleiter
Verträge und Leistungsentwicklung
D
Guiseppe Torchio
President
I
Commission 5 of the Committee of the Regions
Sindaco di Spineda
Martin Toth
Health Insurance Institute of Slovenien
Assistant General Director
SLO
Christoph Uleer
Verband der privaten Krankenversicherung e.V.
Verbandsdirektor
D
Doris Van Buren
Province of Noord-Brabant
Staff member
International Affairs
NL
Bernard Van Gent
amicon-health insurance company
Manager Health care/sales
NL
Jef van Langendonck
European Institute of Social Security
B
Province of Noord-Brabant
Member of the Provincial Board of Executives/ Health Care
Dep. Of Health Care
Norbert Vanas
Hauptverband der österreichischen
Sozialversicherungsträger
Stellvertrettender Generaldirektor
Eleonora Verus
Medicinski Centar Ohrid
A
Macedonia
Mikko A. Vienonen
WHO
Regional Adv. for Health Services Management
Euro Health Policy and Services
DK
C. B. Visser
President of the Dutch Association for private
practioners
NL
Association for Physical Therapy
Rainer Vollmer
Gelber Dienst
Journalist
D
Stefan Vranckx
SmithKline Beecham
Director Public Affairs
Government Affairs and Public Policy
B
Baldur Wagner
Bundesministerium für Gesundheit
State Secretary
D
Wolfgang Wagner
A
Felix Wallner
Österreichische Ärztekammer
Kammeramtsdirektor
International Department
A
James Walsh
West Sussex County Council
Member of the Committee of the Regions
UK
Jennifer Wassermann
A
Gruppe Gesundheitspolitik
Mechthild Weber
Schering Aktiengesellschaft
Leiterin Konzerngesundheitspolitik
D
Ilona Wehner
Neuland & Partner
Moderator
D
Sabine Wehner
Moderator
D
NL
Neuland & Partner
Franz Weichenberger
Managing Director
A
Peter Weiland
MEDINORM AG
Marketing- und Vertriebsleiter
D
Joachim Weith
Shared Medical Systems SMS
Direktor Markt- und Produktforschung
D
Helmut Wiedenhofer
Joanneum Research Forschungsgesellschaft
A
Forschungsplanung
Stephen Withers
BUPA
Chairman, CEA Health insurance committee UK
Heinrich Wrbka
Gruppenleiter
Gruppe Gesundheitspolitik
A
Skender Xharo
Member of Presidency
Trade Union Federation of Health Employees of Albania
Albania
Cornelia Yzer
Verband forschender Arzneimittelhersteller e.V.
D
Hauptgeschäftsführerin
Klaus Zapotoczky
Joh. Kepler University Linz
A
Yervant Zarmanian
CSC Pharmaceuticals Handels GmbH.
Geschäftsführer
A
Witold Zatonski
The Maria Sklodowska-Curie Memorial Cancer
Center and Institute of Oncology
Head of Institute
Department of Epidemiology
PL
Zieba Zbigniew
Regional inspector of the medical certification
P
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10
Appendix 13
Illustration 1: "Extreme Variety of Health Systems"
An earlier publication (OECD, 1992) categorised the health care systems of seven OECD countries by their
main source of finance and the predominance of public or private providers. The countries were classified in
three groups:
The Netherlands
Belgium, France, and Germany
Ireland, Spain, and the United
Kingdom
Financed by a mixture of social and private insurance with mainly
private providers.
Financed mainly by social insurance with mixed public and private
providers.
Financed mainly by taxation with mainly public providers.
The health systems of the additional 17 OECD countries are classified as follows:
Austria, Japan and Luxembourg
Financed mainly by social insurance with mixed public and private
providers, although Austria does have a large private insurance
sector.
Italy
Financed almost equally by social insurance (52 per cent) and by
taxation (48 per cent) with mainly public providers.
Denmark,
Finland,
Greece,
Financed mainly by taxation with mainly public providers.
Iceland, Portugal, Norway, and
Sweden
Canada
Australia, New Zealand
Switzerland and the United States
Turkey
Source: OECD
Financed mainly by taxation with mainly private providers.
Financed mainly by taxation with mixed public and private providers.
Financed mainly by voluntary insurance with mainly private
providers.
No dominant source of finance; mixed public and private providers.
Appendix 14
Illustration 2: ”No close correlation between the organisational form of the health system and consumer
satisfaction with the health system":
Appendix 15
Illustration 3: "Need for reform of health care: opinion poll - 1993"
Appendix 16
Illustration 4: Health Outcome Indicators - Life expectancy and perinatal mortality rate
Perinatal mortality per 1 000 live
and still births
Life expectancy at birth 1996
Female
Male
1980
1995
Annual change 1980-95
Australia
81,1
75,2
8,9
5,0
-3,77
Austria
80,2
73,9
14,1
6,9
-4,65
Canada
81,5
75,4
10,9
7,0
-2,91
Denmark
78,0
72,8
9,0
7,5
-1,21
Finland
80,5
73,0
8,4
5,1
-3,27
France
82,0
74,1
12,9
7,4
-3,64
Germany
79,9
73,6
11,6
6,9
-3,40
Greece
80,4
75,1
19,9
10,4
-4,24
Japan
83,6
77,0
11,1
7,0
-3,03
Luxembourg
80,0
73,0
9,8
7,0
-2,22
Netherlands
80,4
74,7
11,1
7,9
-2,24
Portugal
78,5
71,2
23,9
9,0
-6,30
Spain
81,6
74,4
14,4
Sweden
81,5
76,5
8,7
6,5
5,5
United Kingdom
79,3
74,4
13,2
United States
79,4
72,7
13,3
Notes:
1994. b)
1980-94.
a
-5,52
-3,01
b
8,9
a
-2,78
b
7,9
a
-3,65
b
Source:
OECD HEALTH DATA (1998)
Appendix 17
Illustration 5: Financial Indicators - Real GDP per capita, health expenditures as a percentage of GDP, and the
public share of health expenditures 1996
Per capita GDP (ECU
Country
000)
a
Health expenditure as % of
GDP
Public health expenditures
as % of total
Luxembourg
29.4
6,8
92,6
United States
26.2
14,0
46,7
Japan
21.4
7,2
78,7
Denmark
21.0
8,0
65,2
Belgium
20.5
7,8
87,7
Austria
20.1
8,0
72,0
Germany
19.6
10,5
78,3
Netherlands
19.6
8,6
72,1
France
19.2
9,7
80,7
Italy
18.7
7,8
69,8
Sweden
18.2
8,6
83,0
Ireland
17.9
7,0
74,2
Finland
17.7
7,4
78,4
United Kingdom
17.4
6,9
84,5
Spain
13.9
7,4
78,7
Portugal
12.2
8,3
59,8
Greece
11.9
6,8
77,5
Notes:
a)
Measured by purchasing power parities.
Source: OECD HEALTH DATA (1998)
Appendix 18
Illustration 6: Efficiency Indicators – Performance - Life expectancy after birth versus health expenditures per
capita in PPP-ECU 1995
Appendix 19
20
10
0
Be Ge Gr
S
we lg rm ee
de u
an ce
n
y
Ita Gr
ly eat
Bri
tai
n
Sp Fr De
ai an n
n ce m
ar
k
Au Fi
str nl
ia an
Lu
xe
m
bu
Ne Ire
ht la
erl
an
EU
1960
1996
Appendix 20
16
14
12
10
8
6
4
2
0
Germany
Austria

Congress report 1998 - European Health Forum Gastein

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