Tackling Inequalities in Health: Mind the Health and Wealth Gap

Volume 8 Number 3, Summer 2002 eurohealth

Tackling inequalities in health: Mind the health and wealth gap

Globalisation and health

Octavi Quintana on the Sixth Framework Research Programme

Stimulating interest in public health Tackling inequalities in health: a global challenge eurohealth Regardless of healthcare system, some degree of inequality in health outcomes is inevitable; this reflects informed individual LSE Health and Social Care, London School of choice, for instance on lifestyle and diet. Many inequalities in Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom C health however are not a consequence of free choice. Final tel: +44 (0)20 7955 6840 outcomes, as well as access to and utilisation of health fax: +44 (0)20 7955 6803 promotion and health care interventions will be influenced by email: [email protected] factors beyond individual control. For instance individuals may website: www.lse.ac.uk/Depts/lsehsc be genetically predisposed to disease, they may live in abject EDITORIAL poverty, have little education, be unemployed or suffer from EDITOR: O social exclusion. They may have to contend with environmental David McDaid: +44 (0)20 7955 6381 hazards, such as industrial pollution. Many of these factors are email: [email protected] external to health care systems. If governments’ desire to SENIOR EDITORIAL ADVISER: promote policies to tackle health inequalities and promote Paul Belcher: +44 (0)7970 098 940 health, this is unlikely to be achieved through investment in email: [email protected] health care systems alone. A ‘joined up’ approach integrated DESIGN EDITOR: M with other agencies such as those responsible for employment, Sarah Moncrieff: +44 (0)20 7834 3444 email: [email protected] social security, environment or education at local and national levels is required. Evidence of some recent and on-going cross EDITORIAL TEAM: Julian Le Grand, Josep Figueras, Walter Holland sector initiatives in Europe is provided in this issue. Martin McKee, Elias Mossialos

While such approaches, taking account of evidence on effective- SUBSCRIPTIONS M ness and costs may help reduce some health inequalities within +44 (0)20 7955 6840 countries, these problems are also in part a consequence of email: [email protected] global actions, requiring global solutions. Globalisation has witnessed increased movement of labour and goods both within Published by LSE Health and Social Care, the European Health Policy Research Network, and the European and between nations (including illicit activities), widespread Observatory on Health Care Systems, with the financial international travel heightening the risk from communicable support of Merck & Co and the European Observatory disease, and more recently the threat of global bio-terrorism. on Health Care Systems. News section compiled by ENHPA, EHMA and HDA. The growth in world trade in the last fifty years, while leading E Eurohealthis a quarterly publication that provides a to phenomenal economic development, some contend is heavily forum for policy-makers and experts to express their slanted in favour of major trading nations in the developed views on health policy issues and so contribute to a world. Income and health inequalities between the developed constructive debate on public health policy in Europe. and developing world continue to grow. The views expressed in Eurohealth are those of the authors alone and not necessarily those of LSE Health World Trade Organisation initiatives to promote free trade may and Social Care, EHPRN or the European Observatory N increase economic prosperity. Such prosperity it is argued has a on Health Care Systems beneficial impact on health and the development of health care The European Observatory on Health Care Systems is a partnership between the WHO Regional Office for systems. Others dispute this, claiming that trade exploits the Europe, the governments of Greece, Norway and Spain, developing world, and can even have a harmful effect on health. the European Investment Bank, the Open Society They suggest that the health consequences of globalisation need Institute, the World Bank, the London School of Economics and Political Science and the London School to be taken much more seriously, and that international bodies of Hygiene & Tropical Medicine. require an even more coordinated approach to address health T Advisory Board aspects of globalisation. Some of these issues on health and globalisation are discussed in this issue. Dr Anders Anell; Professor David Banta; Mr Nick Boyd; Professor Reinhard Busse; Professor Johan Calltorp; One way of building on existing joint initiatives in setting Professor Correia de Campos; Mr Graham Chambers; common standards and developing strategies for tackling global Professor Marie Christine Closon; Professor Mia Defever; Dr Giovanni Fattore; problems, would be greater facilitation by international Dr Livio Garattini; Dr Unto Häkkinen; agencies of the exchange of knowledge on innovations and Professor Chris Ham; Professor David Hunter; Professor Claude Jasmin; Professor Egon Jonsson; experience across countries. The links between economic Dr Jim Kahan; Dr Meri Koivusalo; Professor Felix Lobo; development and health need to be strengthened. The WHO Professor Guillem Lopez-Casasnovas; Mr Martin Lund; Commission on Macroeconomics in Health recently estimated Dr Bernard Merkel; Dr Stipe Oreskovic; Dr Alexander Preker; Dr Tessa Richards; that carefully targeted investment in health in developing Professor Richard Saltman; Mr Gisbert Selke; countries of $66 billion per annum by 2015 could save more Professor Igor Sheiman; Professor JJ Sixma; than 8 million lives and produce substantially greater economic Professor Aris Sissouras; Dr Hans Stein; benefits of $360 billion per year by 2020. In Europe the newly Dr Jeffrey L Sturchio; Dr Miriam Wiley

launched Sixth Framework Research Programme recognises the © LSE Health and Social Care 2002. No part of this importance of developing networks for knowledge exchange in publication may be copied, reproduced, stored in a retrieval public health across Europe. Our challenge is to create global system or transmitted in any form without prior permission from LSE Health and Social Care. networks to address the interface between sustainable economic Design and Production: Westminster European, development and health. email: [email protected] Printing: Seven Corners Press Ltd David McDaid Editor ISSN 1356-1030 Contents Summer 2002 Volume 8 Number 3

Octavi Quintana Contributors to this issue Director of ‘Life Sciences: Research For Health’, RUDOLF ADLUNG is Counsellor in the Trade in Directorate General for Research, European Services Division of the World Trade Commission Organization, Geneva , Switzerland. CATHERINE ANCION was a project 1 Interview by Paul Belcher coordinator for the Flemish Institute of Health Promotion.

PAUL BELCHER is Head of European Affairs at the European Health Management Association and Senior Editorial Advisor, Eurohealth.

YVE BUCKLAND is the Chair of the Health Tacking Inequalities in Health Development Agency for England and a member of the Inequalities and Public Health 3 Mind the health and wealth gap Task Force. Clive Needle MANUELA CABRAL is a specialist in bioethics and humanities working for the General 5 Europe supports health promotion as a Directorate of Health, Ministry of Health, Portugal. method to tackle social inequalities in health Catherine Ancion MAGGIE DAVIES is Head of European and International Programmes at the Health 8 National Perspectives on health inequalities in England Development Agency for England. Yve Buckland and Nick Doyle NICK DOYLE is Special Advisor, Policy and Projects at the Health Development Agency.

11 Approaches to address health inequalities in Portugal JANE HUTT is Minister for Health and Social Manuela Cabral and Pedro Ribeiro da Silva Services, Welsh Assembly Government, Wales, UK. 13 The Inequalities in Health Fund: Helping disadvantaged communities TIM LANG is Professor of Food Policy, City Jane Hutt University. GRAHAM LISTER is Senior Associate at The 16 Copenhagen follows up lead on equity for young people Nuffield Trust and Secretary of The UK Partnership for Global Health. Hanne Nielsen GUILLEM LOPEZ-CASASNOVAS is Professor of Public Economics, and Director of the Center for Health and Economics, University Pompeu Globalisation Health Policy Fabra, Barcelona, Spain. OWEN METCALFE is Associate Director, 17 Globalisation and health: 36 Devolution of health care in Institute of Public Health in Ireland. An introduction Spain to the regions becomes CLIVE NEEDLE is Head of the Brussels Office of Maggie Davies reality the European Network of Health Promotion Guillem Lopez-Casasnovas Agencies. 18 Health services in a globalising world HANNE NIELSEN is Head of Section, Danish Rudolf Adlung 38 Stimulating interest in Ministry of the Interior and Health. European public health OCTAVI QUINTANA is Director of ‘Life 21 Public health after globalisation: Owen Metcalfe Sciences: Research For Health’, Directorate Injecting health into the General for Research, European Commission. post-Washington consensus GEOF RAYNER is Chair of the UK Public Geof Rayner and Tim Lang Health Association. PEDRO RIBEIRO DA SILVA is a medical doctor, 41 European Union 26 Globalisation: An Idiots Guide psychotherapist and specialist in communication studies working for the Julius Weinberg News by the European Health General Directorate of Health, Ministry of Health, Portugal. 29 European Union foreign and health Management Association, European Network of FRITS TJADENS is Senior Adviser at the policy International Centre of the Netherlands Graham Lister Health Promotion Agencies Institute for Care and Welfare and project and the Health coordinator at the Dutch National Forum on International Health and Social Issues. 33 Health care shortages: Where global- Development Agency, isation, nurses and migration meet England JULIUS WEINBERG is Director of the Institute of Health Sciences, City University, London. Frits Tjadens INTERVIEW WITH OCTAVI QUINTANA

There appears to be a greater focus on clinical, biomedical research priorities Dr Octavi Quintana rather than on policy-related research Director of ‘Life Sciences: Research for compared with the previous programme. What future is there for Health’, Directorate General for ‘public health and health services’ Research, European Commission. research in FP6 as we appear to have lost the FP5’s specific focus on these areas? Interview with Paul Belcher, I believe the focus has not been lost Senior Adviser, Eurohealth but rather has become more intense. In order to move towards the creation of a European Research Area, initial Congratulations on your new post. oped to respond to the new and analysis indicated that critical mass Could you describe your areas of unprecedented opportunities offered needs to be created in terms of finan- responsibility in the European by the sequencing of the human cial, material and human resources, Commission’s Directorate-General for genome both to improve human that flexibility of human resources Research? health and also to stimulate industrial and mobility of researchers, engineers My responsibility is to manage and economic activity. Genomic research and technicians has to be tackled, promote the creation of the European relevant for human health will be sup- while improving the general working Research Area, in life science concern- ported, as will mechanisms to acceler- and research environment in order to ing medical and health research. ate the transfer of results from basic attract scientists. The result therefore Specifically this means the implemen- research to the bedside. is a concentration of research efforts on selected priority fields. tation of the new 6th Framework A second area is the fifth theme: food Programme for research, technologi- quality and safety with a budget of This principle is a major new policy cal development and demonstration A685 million. This is aimed at ensur- direction, requiring a difficult policy activities (FP6). The services under ing the health and well-being of citi- choice largely avoided in previous my responsibility will work to estab- zens through a better understanding framework programmes, with the lish Priority 1 as a reality, that is of the influence of environmental fac- inevitable result that the research advanced genomics and applications tors and diet on health. This end-user effort was spread too widely and too for health, combating major diseases approach is reflected in seven research thinly. Concentration is essential to including cancer and poverty-linked objectives including: epidemiology of achieve added value in European disease. The Framework programme food-related diseases and allergies, research integrating national potential states that the objective in the medical and achieving the critical mass field is to develop improved patient- impact of food on health, ‘traceability’ along the production chain, detection, required by scientific and technologi- oriented strategies for the prevention cal progress in a global world. Public and management of disease and for control and safe production methods, health is not lost, one of the essential living and ageing healthily. This work as well as the impact of animal feed on aims under Priority 1 is the transla- also includes the Article 169 initiative human health. tion of new knowledge into applica- to bring about a national and An eighth theme focuses on support- tions that improve clinical practice European programme for clinical ing policies and anticipating the EU’s and public health. Surely health ser- trials in poverty-related diseases. I scientific and technological needs, this vices’ research will play a part but also have responsibilities for elements sets the context for the EC’s public probably within the framework of a of the Framework Programme, such health policy. It concentrates on the much larger patient-oriented strategy as policy-oriented research and coor- development of strategic positions on than in previous programmes. dination activities, as well as the con- the cutting edge of knowledge, antici- tinued implementation of the fifth pating major issues facing European The section on policy-oriented research will also offer opportunities Framework Programme (FP5), which society including public health. is in its last six months. for public health and health services’ Lastly under the heading research especially in the context of With the launch of the new Sixth ‘Strengthening the foundations of the efficient health care systems. Health Framework Research Programme you European Research Area’ support for care systems of all member states are have arrived at an exciting time of the coordination of activities is pro- under increasing pressure to cope change. Could you outline the health vided. One area covered is health with population demands. An ageing aspects of the new programme? where related activities will be imple- population, technological innovation There are four main areas of major mented, for instance through coordi- and greater patient expectations are relevance to health research in FP6. nation of research and comparative likely to continue to exert pressures These include Priority Theme 1: studies, the development of European on social welfare systems, and health genomes and biotechnology for health databases and interdisciplinary net- systems in particular, over coming where a budget of A2.2 billion is antic- works, the exchange of clinical prac- years. This is a priority policy area for ipated. This priority has been devel- tice and coordination of clinical trials. the European Community.

1 eurohealth Vol 8 No 3 Summer 2002 INTERVIEW WITH OCTAVI QUINTANA

The new research programme aims to address policy relevant questions, and FP6 to promote and coordinate and contribute to the implementation of DG Research will assist in this integrate public health aspects within other EU polices including the new process. Furthermore, scientific crite- DG Research and also with other poli- EU health programme. How will ria will remain the most important cy directorates and external agencies? research priorities be decided? element in the selection process. This is an interesting idea, reflecting The section on supporting policies You have received many thousands of the way in which public health per- will play a major role in the develop- responses to your call for ‘expressions meates various themes under the new ment of the European Research Area of interest’ earlier this year. These will Framework programme. Coordina- since policy-orientated research will play an important role in deciding tion is undoubtedly necessary, and to help to create a more efficient envi- what research activities are actually a large extent work to establish ronment for policy research. It pro- carried out when funding comes on Priorities 1, 5 and 8 as realities will vides policy actors throughout the stream. Given the quite overwhelm- reflect this concern. ing response, how will you evaluate EU with a facility to access relevant What input will DG Health and these ‘expressions of interest’? Community research. It makes the Consumer Protection have in writing link between research and policy Indeed we have been hard at work the work programme for priorities 1 stronger, more responsive and more evaluating the 3,000 plus expressions, and 8? coherent. It also opens opportunities an exercise allowing a bottom-up All participating policy DGs will have for research support in a wider range approach within the context of FP6. equal input to the elaboration of the of policy areas. Public health can be We are very pleased by the response work programme, for both priorities found in the strand on “providing and some very interesting ideas and 1 and 8. However the process is some- health, security and opportunity to areas have emerged. It is certainly a what different for each. The call for the people of Europe”. This section way forward for future evaluations. expressions of interest affects only must of course support the new EU We have chosen to engage in a peer Priority 1, this will to a great extent health programme, calls for proposals review of proposals and process, and determine the way forward in the must complement work envisaged by as in the past, this has borne fruit, theme. The distillation process for DG Health and Consumer Protection allowing us to identify cutting-edge policy-oriented research started over a and where relevant by DG research topics. We hope to publish year ago, and the Commission in Employment. This is why there has the results early in the autumn. been, and will continue to be, close November 2001 presented an amend- collaboration between our services. There has been criticism of the dissem- ed proposal concerning FP6, incorpo- ination of outcomes of previous pro- rating policy priorities. I must say that Just to mention some of the topics grammes, particularly to potential we enjoy good working relationships under this section, one finds health users beyond the scientific community. with our colleagues in DG Health and determinants, the provision of high How can that be improved? Consumer Protection. quality and sustainable health care services and pension systems (particu- One of the objectives of creating the What is your vision for the future of larly in the context of ageing and European Research Area will be the public health and health services demographic change), public health development of a dialogue between research at EU level? science and society. This is a prerequi- issues including epidemiology con- Public health is an area of major con- site for good performance of the sci- tributing to disease prevention, cern for all European citizens. The ences and building trust with society. responding to emerging rare and com- issue occurs ever more frequently and Dissemination has an important role municable diseases, allergies, proce- is increasingly evident on the political to play here, and is reflected in the cri- dures for secure blood and organ agenda. Many Directorates are teria against which proposals for inte- donation and non-animal testing involved, for example: Health and grated projects and networks of excel- methods, and quality of life issues Consumer Protection, Employment, lence, for example, will be evaluated. relating to handicapped/disabled peo- Environment, Enterprise, Information We have just published an impact ple (including equal access facilities) society, Internal Market, even the assessment of the BIOMED 2 pro- Joint Research Centre covers public In the past some have criticised the gramme under FP4 and these types of health activities. Then we have agen- evaluation process for research propos- exercises will continue, but research cies such as EMEA European Agency als as being weighted towards scientif- of course takes time to mature. A sep- for the Evaluation of Medicinal ic rather than policy relevant criteria? arate but related challenge is to take Products and the EMCDDA Do you think this is still the case? these results and feed them into other European Monitoring Centre for on-going processes, such as policy- First of all, we must not forget that we Drugs and Drug Addiction covering making. I hope that our Forum on are talking about running a science public health. My vision is that these ‘Public Health Research and programme and only the best scientif- activities should be carefully coordi- European Community Policies’ at the ic proposals are selected. In FP6, the nated and that all these initiatives European Health Forum Gastein, in philosophy and principles of evalua- should be complementary. DG September this year, will raise some tion will not change. However, a new Research should be providing the pol- interesting discussions and ideas. element has been introduced, a specif- icy DGs with elements for questions ic budget has been earmarked for EC Would it not be interesting to set up a and issues that they encounter while policies within the ‘eight priorities’ to ‘public health research’ task force in dealing with public health matters.

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mistakes being made in other policy areas. Healthy longevity requires a Mind the health and life-long process of maximising opportunities for economic, physical, social wealth gap and mental well-being. –Health promotion and primary healthcare are the most cost efficient health interventions and with the best popula- European governments will no longer meet tion health gains. in a single Health Council. Bureaucracy streamlining means that a new combined –Health promotion offers a comprehen- council for Employment, Social Policy, sive approach, ranging from the personal Health and Consumer Affairs will be responsibility to make the healthy established. Is this just administrative shift- choice, to public policy options which ing of deck chairs or politically significant? support the healthy choices and envi- Some will argue that this means a reduction ronments.” of the EU health policy element just as it Indeed, not conference rhetoric, but backed becoming important, taking us back to the up by statistical evidence from various bad old days when health was subservient sources. So will the EU turn evidence into to employment policies. Others will con- policy and into practice? tend that a new opportunity has been creat- Clive Needle ed to prioritise an aspect of public health Commission action that has so far been largely neglected by On examination of the Commission web- European policy makers: the health equity site (www.europa.eu.int) for information gap. on social inclusion, DG Social Affairs and Eurostat reports that health is of increasing Employment pages contain Community importance to social and economic devel- Action Programmes to combat social opment and of prime concern to most exclusion and discrimination, European Europeans.1 We are living longer in good Council objectives and decisions, joint health and differences in life expectancy reports, common indicators and National between member states are fairly small. Yet Action Plans against poverty and social within states differences in life expectancy exclusion. The European Foundation for and health status are quite substantial. Only Living and Working Conditions is well 72% of people in low-income groups are established and active. Splendid, but where “Surely it is the duty satisfied with their health compared to over is the health community contribution? 90% in the highest income groups. The Certainly, contained within actions are of policy makers to links between health status and factors such health related projects, but there is relative- as income, education and employment are ly little evidence yet of input or definition. prioritise actions to well documented. Women tend to live Whenever I ask health policy, research or longer but the evidence suggests that their care organisations how they contributed to address greatest need quality of life is generally poorer, particu- the consultation required within National and promote quality larly in those extra years. By 2004 there will Action Plans, I receive quizzical responses. be ten new member states, it would be a This tallies with work on links between of life?” mistake to treat them homogeneously, but health status, poverty and social exclusion, life expectancy remains lower and health where the health/exclusion interaction is status is more affected by national spending comparatively less developed. on health care than in western counterparts. The website for Health and Consumer Pro- As the EU and member states grope uncer- tection is being revamped, but it is striking tainly towards dealing with market realities how little interaction there is with a field in health care systems, Eurostat states: that Eurostat reports to be a major determi- –“Health is created, by and large, outside nant of health, and how thin and vertical are the healthcare sector in settings of every- the contents. That is less the fault of day life. The ways in which policies in unevenly resourced Commission services, other areas are organised have a pro- than the realities of political priorities and found effect on the health of populations. legacy of dubious legal bases. Perhaps key figures do not want EU action to help those –The healthcare sector often pays for who may need it most? I recall a (former) senior health official saying that in his home Clive Needle is Head of the Brussels Office of the European Network of country “peasants” enjoy the best health as Health Promotion Agencies. they eat little but fresh food, the main prob- E-mail: [email protected] Website: www.eurohealthnet.org lems concern the well-off!

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Perhaps measures to address health authorities, but it has been less well inte- inequalities should be left to national health grated with health communities because of systems? Certainly it was the most contro- subsidiarity misunderstandings. Not so in versial aspect of my report on the future of Wales where the European dimension is “It is a challenge for EU public health policies.2 Some argued integrated with national initiatives in inter- that I wanted to make all hospitals provide esting ways, as the article by the Minister the health community the same. I do not, but in a modern for Health and Social Services in the Welsh Europe, where the health of millions is Assembly Government explains. to ensure that effective affected by EU decisions, whether travel- In England the national prioritisation of policies and ling across borders or set in communities, work to address health inequalities is high- surely it is the duty of policy makers to lighted by the Health Development programmes are put on prioritise actions to address greatest need Agency, amid rumours of the possible and promote quality of life? to Council agendas.” establishment of a new national centre to Although health policy makers tend to specialise in equity policies. Finally, as part dwell on the restrictions of Article 152 of of the Danish Presidency, a European the Treaty, others look at the ambitions of Conference on social inequalities in health Article 2: “to promote economic and social in children and young people will take place progress … and to achieve balanced and in Copenhagen in December. The organis- sustainable development … through the ers describe their objectives and how the strengthening of economic and social conference builds on previous work. cohesion.”3 Work on health at EU level must be of Conclusion benefit to all 370 million citizens. So does that suggest national interest, com- Nevertheless it is contrary to the funda- mitment and some appreciation of the mental objectives of the social and econom- potential EU dimension? The imperative ic entity that has become the rapidly now transfers firmly to the Commission. enlarging EU, that the health and life There are relevant actions concerning indi- expectancy of a diner in one of the many cators, impact assessments, and social and elegant restaurants in Brussels, economic determinants contained within Luxembourg or Strasbourg is likely to be provisions of the new programme. There hugely better than the person serving or are encouraging indications of stronger washing the plates. Much more needs to be partnerships than hitherto between relevant done as a new EU Health Action Commissioners and the World Health REFERENCES Programme begins in 2003. Organisation. The European Commission multi stakeholder Health Policy Forum is 1. Eurostat, European Commision. The Social poised to study the link between health and Initiatives across Europe Situation in the EU. Brussels, social policies. There is a new dynamic to A two-year EU wide project, coordinated 2001. via the European Network of Health inter service coordination across policy Promotion Agencies (ENHPA), to sectors. Yet it is difficult to be convinced 2. Needle C. Report to the examine how health promotion can address that tackling the health aspects of social European Parliament on the Future of EU Public Health health inequalities, came to a useful inequalities will be given sufficient priority Policies.Brussels: ENPHA, conclusion earlier this year, following to make a real difference: one that would do 1999. meetings to agree recommendations in the much to improve how the EU is perceived. 4 3. Treaty on European European Parliament and with Ministers. Do we need more studies or more practical Union, Title 1, Common interventions? Probably both. Do we know To follow up, seminars have been held in Provisions. Prague and Budapest to share and apply which interventions work? Not sufficient- learning to EU candidate countries. Atten- ly. Have needs and benefits been communi- 4. Flemish Institute for Health Promotion and tion should also be paid to separate and cated well? I suggest not, proactive articu- ENHPA. The Role of Health successive EC funded work, lead by Prof- lation of the case by health professionals to Promotion in Tackling essor Mackenbach, which will contribute policy makers will be necessary to increase Inequalities in Health. to the general body of evidence, in particu- priority. Brussels, 2001 Available on- lar to the field of women and tobacco.5 When politicians sit in their big new line at The Portuguese Ministry of Health con- Councils, usually they will not be health www.vig.be/doc/kansarmen/ tributed greatly to the ENHPA project and experts. They have political priorities that social_inequalities.doc sets out here its perspectives on national may well conflict with the needs of huge 5. Scientific Research. activities. Portugal has made highly visible numbers of European citizens, who fall Department of Public Health, use of significant regional and social fund- into the health and wealth gap in the single Erasmus University, ing from EU programmes, including initia- market. It is a challenge for the health com- Rotterdam. Available at tives for health. EU funding has generally munity to ensure that effective policies and www.eur.nl/fgg/mgz/index. been well applied by regional and local programmes are put on to Council agendas. html

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Europe supports health promotion as a method to tackle social inequalities in health

“It is essential to develop more effective strategies to enable disadvantaged groups to have a better control over their health behaviour and other determinants that influence their health.”

Despite the existence of a well-developed (VIG) coordinated a two-year research healthcare system in the EU, its population project in collaboration with the European continues to be affected by social inequali- Network of Health Promotion Agencies ties in health, morbidity and mortality. (ENHPA). The purpose of this project, Catherine Ancion This has led to increasing policy attention which involved the participation of experts at regional, national and European levels. from 13 EU countries and Norway, was to Although social inequalities in health can, examine the availability and extent of infor- to some extent, be addressed through mation with regard to social inequalities in improved curative healthcare, reducing the different European countries, develop them also requires the use of health promo- policies and health promotion strategies for tion strategies specifically targeted at the the reduction of inequalities in health, and socioeconomically disadvantaged. Research reach a consensus and better communica- has revealed that traditional health education at a European level. tion messages tend to be ineffective among the socially disadvantaged, whose daily Methods confrontation with a harsh socioeconomic To reach these objectives, a twofold reality often leads them to give a lower pri- approach was used. To assess the availabili- ority to their personal health. For this rea- ty and extent of information related to son, it is essential to develop more effective social inequalities in health within Europe, strategies to enable disadvantaged groups a systematic literature review of health to have a better control over their health monitoring systems and indicators in EU behaviour and other determinants that member countries was performed, using influence their health. Nutbeam’s health promotion outcome In order to explore these strategies, the model as a theoretical framework1 (see Flemish Institute for Health Promotion Figure 1).

Figure 1 OUTCOME MODEL FOR HEALTH PROMOTION DISTAL Health and social Mortality and morbidity (e.g., chronic disease, perceived health) outcomes

Intermediate Healthy lifestyles Effective health services Healthy environments health (e.g. smoking and (e.g. access to and (e.g. housing, outcomes dietary habits) use of services) working conditions)

Health Health literacy Social mobilisation Healthy public policy promotion (e.g. knowledge, (e.g. community and organisational

outcomes attitudes, skills) development) practice PROXIMAL

Catherine Ancion coordinated Health Health Education Facilitation Advocacy this project at the Flemish promotion Institute of Health Promotion. E-mail: [email protected] Source:Nutbeam D, 1998.1

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Various information sources were consult- “There is a growing tendency within governments towards ed, including information from Ministries of Health and Social Affairs, National joined up policy making in areas which have traditionally Institutes for Statistics, reports and other information from National Institutes for been determined independently, such as education, Public Health or Health Promotion, review employment, housing, and health.” studies from the European Working Group on Socio-Economic Inequalities in Health, and references from studies in the international literature. The latter were identified using the Health-Promis database of the Parliament in Brussels. During this expert Health Promotion Information Centre at meeting, specialists refined the recommen- the Health Development Agency (HDA), dations of the research report and reduced using the following key words: their number to eight. These eight consen- – Socioeconomic status OR inequality. sus-based recommendations focused on: – Health OR mortality OR morbidity. 1. Identification and promotion of national – Cohort studies. and regional health targets focussing on health inequalities. Defining national health – NOT United States. inequality targets requires reliable data and – NOT Canada. evidence that go beyond mortality and morbidity statistics, and which are Additionally, use was made of the OECD concerned with determinants of health. For Health Database, as well as the European governments, health inequality targets not Health and Safety Database (HASTE) only provide a clear framework for relating developed by the European Foundation for health inequalities to the overall aims of the Improvement of Living and Working health services. They also serve as a sym- Conditions. bolic statement of support to the active The second stage of the project focused on reduction of health inequalities. the practice of tackling health inequalities 2. Integration of health factors into other through health promotion and furthering policy areas and the importance of cross- the policy environment. National coordi- sectoral policies. Since social inequality in nators and experts were selected in each health is such a complex problem, involv- member country to collect data and supply ing the entire domestic and professional information, in the form of a national environment of the socially disadvantaged, report, on policies, strategies and the prac- health promotion workers need to cooper- tice of tackling health inequalities within ate with partners from other professions the context of health promotion (see Figure and sectors. Likewise, there is a growing 2). Reports were received from Austria, tendency within governments towards Belgium, Denmark, Finland, Germany, joined up policy making in areas which Greece, Ireland, Italy, the Netherlands, Norway, Portugal, Spain, Sweden and the United Kingdom. France, Iceland and Figure 2 Luxembourg were not able to allocate KEY STEPS IN THE PROJECT sufficient resources to produce a report within the timeframe of the project. Phase 1 (July 1999–December 1999)

Findings Selection and appointment of key informants (national coordinators) A total of 67 policies and 60 interventions were described in these national reports. Agreement of theoretical basis and definitions Using these national contributions, VIG Design and agreement of proforma/questionnaire and analytical framework issued a research report The Role of Health Promotion in Tackling Inequalities in Data collection – construction of national reports Health.2 Two initial drafts of this report (including consultation of experts) were distributed to national coordinators and experts in June and August 2001. Their Phase 2 comments and corrections were included in the final version of the research report, Report assessment and follow up further information published to coincide with an expert seminar on the Role of Health Promotion in Analysis Tackling Inequalities in Health, held on Report – findings, conclusions and recommendations September 28–29, 2001 at the European

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“cooperation at the have traditionally been determined inde- health inequalities. The European Centre pendently, such as education, employment, for Health Policy (ECHP) has defined European level should housing, well-being and health. health impact assessment as “a combination of procedures, methods and tools by which 3. Recognition and encouragement of the be encouraged to a policy, program or project may be judged community development approach as a way as to its potential effects on the health of a enhance the compara- of tackling social inequalities in health. population, and the distribution of those Working at the local or neighbourhood effects within the population.”3 This last bility of data on health level often has more immediate effects than element is of crucial importance for tack- working at regional or national level. It also ling health inequalities: it must ensure that inequalities and to lends itself much better to the formation of an assessment is not only made of the cross-sectoral networks, which are vital if develop guidelines for aggregate impact of the assessed policy on health issues are to be tackled across other the health of a population, but also on the closely related policy fields, such as hous- data collection.” distribution of the impact within the ing, transport, leisure, education or the population, in terms of gender, age, ethnic environment. Besides this geographic background and socioeconomic status. focus, a community approach based on participation and involvement is well suited 7. Allocation of sufficient financial resources to serving the needs of a particular type of and training for the evaluation of health vulnerable group, through a closer and bet- promotion initiatives/policies focused on the ter understanding of these needs. reduction of social inequalities in health. Without the information which evaluation 4. Reduction of barriers that prevent effec- provides, it is difficult for project tive utilisation of healthcare and prevention approaches to be replicated, or for practi- services by socially disadvantaged and vul- tioners and policy-makers to learn from a nerable groups. Accessing healthcare and project’s successes, or failures. prevention services can be very difficult for certain groups in society because of 8. Creation and encouragement of opportu- language or cultural barriers, or due to legal nities to disseminate models of good or financial problems. Solutions include the practice. For example, by creating a data- use of cultural interpreters/advocates, the base for interventions that have successful- training of ‘peers’ within the same commu- ly reduced health inequalities. nity or the establishment of outreach The above-mentioned recommendations services. were used in an awareness campaign to 5. Importance of good monitoring systems promote the issue of inequalities in health, and indicators to measure health inequali- in EU member states and at a high political ties. More specifically, there should be level. Eight recommendations were more data uncovering the determinants of presented to the Health Ministers of the health (behaviour), such as structural fac- European Union in November 2001, tors and health literacy, rather than just during the European Health Council. A mortality and morbidity. This information round table conference on the issue of should be gathered according to social inequalities in health took place in Brussels class, gender, ethnicity, etc. Cooperation at in December 2001, in the presence of the the European level should be encouraged federal and regional health ministers of to enhance the comparability of data on Belgium, as well as Commissioner Byrne health inequalities and to develop guide- and high-level representatives from EU and lines for data collection. accession countries. This conference recog- 6. Use of health inequality impact assess- nised that social inequalities in health were ments as an effective means of tackling a political priority at European, national and regional levels. Congratulating the Flemish Institute for Health Promotion on its research, policy-makers recognised the importance of health promotion as a REFERENCES method to reduce social inequalities in 1. Nutbeam D. Evaluating health promotion – progress, problems and solu- health. The Danes also promised to take up tions. Health Promotion International1998;13(1):27–44. the issue of social inequality in health 2. Flemish Institute for Health Promotion and ENHPA. The Role of Health during their EU presidency in 2002. Promotion in Tackling Inequalities in Health. Brussels, 2001 Available on-line Further information on the project The at www.vig.be/doc/kansarmen/social_inequalities.doc Role of Health Promotion in Tackling 3. European Centre for Health Policy. Health Impact Assessment. Available Inequalities in Healthcan be obtained at on line at www.eurohealthnet.org and clicking on the www.who.dk/eprise/main/WHO/Progs/HPA/HealthImpact/20020319_1 link for Inequalities in Health.

7 eurohealth Vol 8 No 3 Summer 2002 TACKLING INEQUALITIES IN HEALTH National perspectives on health inequalities in England

“The NHS Plan contained a commitment to reinforce local action by setting the first ever national health inequalities targets.”

The change of government in the UK in The following year saw a change in politi- 1997 brought an immediate shift in public cal sentiment in favour of national targets Yve Buckland health policy in England – from a focus so that the plan for modernising the nation- solely on individuals and their lifestyle al health service in England, the NHS choices towards a focus on the broader Plan,4 contained a commitment to reinforce determinants of health and health inequali- local action by setting the first ever national ties (see Box 1). Emblematic of this shift health inequalities targets. The purpose of were the creation for the first time of the these targets was to help ‘narrow the health post of Minister for Public Health with gap in childhood and throughout life responsibility ‘for attacking the root causes between socioeconomic groups and of ill health’,1 and the establishment of an between the most deprived areas and the independent inquiry to report on the state rest of the country’. of the evidence on inequalities in health.2 The Department of Health set up a number of taskforces to oversee implementation of Target setting the various aspects of the NHS Plan. One The national public health strategy for of these was the Inequalities and Public England, Saving Lives: Our Healthier Health Taskforce and a key task was to Nation,3 made reducing health inequalities lead the development work on national Nick Doyle one of the twin aims of public health poli- targets. After much debate about technical cy, alongside improving the health status of issues, these were published in February the population as a whole. It set national 2001, as follows: ten-year targets for cancer, coronary heart disease and stroke, accidents and mental Starting with children under one year, by health, but declined to set national health 2010 to reduce by at least 10% the gap in inequalities targets, preferring instead to mortality between manual groups and the give local agencies the responsibility for population as a whole. jointly setting local inequalities targets.

Box 1 DETERMINANTS OF HEALTH AND HEALTH INEQUALITIES Yve Buckland is the Chair of the Health Development Fixed Social & economic Environment Lifestyle Access to services Agency for England and a member of the Inequalities and Genes Poverty Air quality Diet Education Public Health Task Force. Sex Employment Housing Physical activity NHS Ageing Social exclusion Water quality Smoking Social services Nick Doyle is Special Advisor, Policy and Projects at the Social environment Transport Health Development Agency. Alcohol Leisure Sexual behaviour E-mails: yve.buckland@hda- Drugs online.org.uk [email protected] Source: Department of Health, 1998

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Starting with health authorities, by 2010 to are an important dimension. These themes reduce by at least 10% the gap between the of ‘joined up thinking’, partnership and fifth of areas with the lowest life expectancy social exclusion have been reflected in at birth and the population as a whole. some innovative structural changes and initiatives. These ‘headline’ targets are part of a suite of targets which also include national tar- At national level, the UK Treasury has gets on reducing teenage pregnancies, imposed a more corporate approach on smoking and, most ambitiously, ending policy making. Individual government child poverty: departments must now show how their spending plans help achieve overarching By achieving agreed local conception reduc- policy goals on abolishing child poverty, tion targets, to reduce the national under 18 providing educational opportunity for all, conception rate by 15% by 2004 and 50% increasing employment opportunity for all, by 2010, while reducing the gap in rates raising prosperity, and delivering strong between the worst fifth of wards and the and dependable public services, all of which average by at least a quarter. are of great public health significance. To reduce smoking rates among manual A particular benefit of the Treasury groups from 32% in 1998 to 26% by 2010. approach has been the way it has focused To make substantial progress towards the attention on ‘cross-cutting’ issues, and eradication of child poverty by reducing the there has been a cross-cutting spending number of children living in child poverty review on health inequalities, led by the by a quarter by 2004. Treasury. Its effect should be to ensure that mainstream funding for public services, such as housing and early years provision, is ‘bent’ in such a way as to contribute towards the targets on health inequalities “There is a strong cross-government interest in tackling Also at national level, there have been innovative attempts within central government social exclusion, of which inequalities in health are an to achieve better coordination of policies. important dimension.” The Social Exclusion Unit has been highly influential in developing cross-cutting strategies to tackle problems arising from social exclusion. The national strategy for neighbourhood renewal is the most significant of these,6 and can almost be viewed as A consultation document5 on a ‘delivery an action plan on health determinants in plan’ for meeting the targets has proposed England’s most deprived areas, particularly that the priorities for action should be: as there are targets for the public sector in promoting health in pregnancy and early those areas covering housing, the environ- childhood, promoting opportunity for ment, employment, education and crime, as children and young people, strengthening well as health inequalities. disadvantaged communities, improving primary care services, and tackling the Additionally, there have been a number of wider determinants of health. centrally inspired but locally based programmes (though also complaints from The implication of these priorities is that locally agencies about ‘initiative overload’). government departments other than the Among the most successful have been Sure department of health, and national, regional Start and health action zones (HAZs). Sure and local organisations other than the Start (www.surestart.gov.uk) aims to health agencies, particularly local authori- improve the health and well being of ties, must play a crucial part in meeting the families and children before and after birth, health inequalities targets. so that children can flourish when they go to school. The government sees it as the Towards an inter-sectoral approach cornerstone of its policies on child poverty What are the prospects for an inter-sectoral and social exclusion. approach to public health? Fortunately, there are some favourable trends. For HAZs (www.haznet.org.uk) are partner- example, there is a drive to make all ships between the NHS, local authorities, government policy more ‘joined up’ and community groups and the voluntary and partnership-based. Also, there is a strong business sectors aimed at tackling health cross-government interest in tackling social inequalities and modernising services exclusion, of which inequalities in health through local innovation. There are 26

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HAZs in England of varying sizes and of interventions, and as the basis for setting covering over 13 million people. Although standards. It was for this reason that it they will be winding down in the next year announced the establishment of the Health or so, HAZs are providing valuable learn- Development Agency (HDA), with the ing about partnership working and dual task of identifying what works to integrated approaches to tackling health improve people’s health and reduce health inequalities. inequalities, and supporting policy makers and practitioners in putting evidence into At a local level, new partnership bodies practice (see www.hda-online.org.uk/). called local strategic partnerships (LSPs), are beginning to coordinate local planning by bringing together different parts of the public sector as well as the private, business, community and voluntary sectors. A core task of LSPs is to prepare and imple- “A cross-cutting spending review on health inequalities, ment the community strategy for the area, i.e. the plan for promoting the economic, led by the Treasury, is almost complete.” social, and environmental well-being of the community. Local authorities have a leading role in LSPs but health agencies must play a full part, particularly primary care trusts, the REFERENCES new local health agencies responsible both for commissioning health care services and 1. Department of Health. Message from the for public health. As enhancing community government to the World Health Assembly well-being and reducing health inequalities in Geneva, 1997. News release 97/089. are intimately related tasks, the future Available at www.newsrelease- should see increasing integration of the archive.net/coi/depts/GDH/coi8633c.ok primary care trust’s local strategic plan for 2. Department of Health. Report of the health and health improvement the Independent Inquiry into Inequalities in community strategy.7 Health. HMSO: London, 1998. Finally, the regional level of government is 3. Department of Health. Saving Lives: Our growing in significance: first as an adminis- Healthier Nation. HMSO: London, 1999. trative tier that ensures coordination of Available at www.ohn.gov.uk/ policies and initiatives coming down from 4. Department of Health. The NHS Plan. A central government; second, as a provider Plan for Investment. A Plan for Reform. of developmental support for LSPs engaged HMSO: London, 2000. Available at in neighbourhood renewal in the most www.doh.gov.uk/nhsplan/index.htm deprived areas; and third, as a focus for 5. Department of Health. Tackling Health strategic planning concerned with econom- Inequalities. Consultation on a Plan for ic, social and environmental regeneration. Delivery, 2001. Available at In the years ahead it may also be a new www.doh.gov.uk/healthinequalities/ level of democratic governance.8 tacklinghealthinequalities.htm 6. Social Exclusion Unit. A New Conclusion Commitment to Neighbourhood Renewal. There are reasons to be optimistic about National Strategy Action Plan. Cabinet the chances of making an impact on health Office, 2001. Available at www.cabinet- inequalities. There is high-level political office.gov.uk/seu/published.htm support, there are targets to aim at, and a 7. Health Development Agency. Planning cross-sectoral infrastructure is beginning to Across the Local Strategic Partnership (LSP). emerge. However, there are also worries Case Studies of Integrating Community that perennial concerns about the perfor- Strategies and Health Improvement, 2002. mance of health care services will again dis- Available at www.hda- tract policy makers from public health online.org.uk/html/resources/publications. issues. html Furthermore, there are deficiencies in the 8. Department of Transport, Local public health system. For example, the Government and the Regions. Your Region, Saving Livesstrategy noted that the quality Your Choice: Revitalising the English of public health practice was patchy. A par- Regions. HMSO: London, 2002. Available ticular concern was the lack of robust at www.regions.dtlr.gov.uk/governance/ evidence to guide strategic planning, choice whitepaper/index.htm

eurohealth Vol 8 No 3 Summer 2002 10 TACKLING INEQUALITIES IN HEALTH Approaches to address health inequalities in Portugal

“Cultural differences are an extremely important aspect of health promotion interventions.”

In Portugal, social policies related to problems faced by relocated disadvan- disadvantaged people have improved taged populations). dramatically over the last twelve years, –Projects to eliminate the exploitation of both in quantitative and qualitative terms. Manuela Cabral child labour, prevention of school One relevant reason for this improvement dropouts and failure. has been the inter and cross-sectoral approach adopted at all levels, from –Protection of disadvantaged and dis- governmental policies right through to abled children. local interventions. Inter-sectoral work –Rehabilitation of people with disabili- involves partnerships between health, social ties. welfare, education, employment, housing, –Social support and continuity of health transport, and justice agencies as well as care to dependent people. local municipality authorities and different non governmental organisations (NGOs). –Accommodation and resettlement programs for deprived populations. In recent years many policies, regional measures and local interventions were –Basic education programmes for travel- implemented taking into account the needs ling gypsies. of deprived populations vulnerable to –Special professional training programs social exclusion: low income families, at for ethnic minorities, immigrants, pris- Pedro Ribeiro da risk children, older people with no family oners and the long-term unemployed. support, disabled people, drug addicts, sex Silva workers, homeless people, ethnic minori- A governmental institution was established ties including gypsies, Africans from for immigrant and ethnic minority groups, Portuguese speaking countries, other not only implementing measures to legalise immigrants and illegal residents. their stay in Portugal but also guaranteeing them various rights: both to vote and be Some examples of the main social policies, elected in local elections, to have access to measures and interventions carried out school and professional training, to gather include: with their families, to take up employment, –Guaranteed minimum income. to have access to social protection, and live in decent surroundings. –A network for combating poverty. The municipalities of Lisbon and Oporto, –An integrated program to support older where most homeless people live, are con- people. tinuously monitoring this group: collecting –A project promoting micro-enterprise information on numbers, gender, and ways (this policy measure was set up especial- of living. They have created organisations ly to tackle long term unemployment in partnership with NGOs in order to provide shelter, food and washing facilities, the intention being to support individuals Manuela Cabral is a specialist in bioethics and humanities. Pedro Ribeiro da so that they may be fully integrated in soci- Silva is a medical doctor, psychotherapist and specialist in communication ety, with both employment and a social studies. They both work for the General Directorate of Health, Ministry of life. Drug addicts and people with Health, Portugal. HIV/AIDS have also been the object of E-mail: [email protected] governmental measures delivered by public

11 eurohealth Vol 8 No 3 Summer 2002 TACKLING INEQUALITIES IN HEALTH institutions, municipalities and NGO’s. empowerment, helping them take owner- They provide health care and some social ship and control of their daily lives. All key support, (namely shelter, food and personal social and cultural partners are involved, hygiene facilities) as well as rehabilitation addressing simultaneously various specific and social integration programmes. bio-medical, psychosocial and cultural needs. Training is provided in several Gypsies different skills (literacy, computing etc), for Gypsies, a minority group in Portugal, use in different settings and contexts that have access to some programs sensitive to provide an option for an alternative their nomadic tradition, which involve occupation in future, if they so choose. The members of their community as cultural centre also provides a breathing space to mediators. Programmes for instance alleviate prostitutes’ isolation and loneli- provide education, professional training ness, allowing them to grow socially, and accommodation, in order to promote culturally and in citizenship in a progres- settlement and integration. These interven- sive and supported environment. tions are particularly important because cultural traditions and a high rate of An intervention targeting legal and illiteracy make engagement on health and illegal immigrants social care issues difficult. Programmes are The Quinta do Mocho project in Lisbon is “Research shows that culturally specific, with teachers specially a good example of an intervention targeted trained in gypsy history and custom. towards legal and illegal immigrants. The in every European Gypsies acting as cultural mediators majority of this group come from African support schoolwork and serve as interme- countries (Angola, Cape-Verde Islands, country there is a diaries between their own people, and Guinéa, San Tomé ), fleeing from war, other groups in society which are provid- hunger and poverty in their countries. health gap between ing support. Goals include increasing Again they are subject to a high rate of the top and bottom awareness about health care needs, which illiteracy, problems with housing and in turn will increase uptake of vaccination crime, are often unemployed or in poor, social classes” programmes, as well as providing materni- temporary jobs. Their children are victims ty and child health promotion/ health care of violence and sexual abuse, are not vacci- services. Activities to combat racism nated, have a high dropout rate from complement this policy, racism prevention school and suffer from nutritional prob- programmes are based upon the dissemina- lems. Adults may choose not to use health tion of information about customs and and community resources, for instance traditions, throughout municipalities where women wish to be self-sufficient and do gypsies most commonly live. not have assisted pregnancies. This is a very complex group of problems, Male and female prostitutes but the involvement of the target group in There are several projects engaged with this the development of the project since the population, but the Espaço Pessoa project beginning has been very important. They is special. Taking into account the link remain a key partner in developing action between prostitution and social exclusion, strategies, which are frequently amended as this meeting and support centre for a result of their contributions. The training male/female prostitutes in Oporto city is and role of Health Promotion Peers and really innovative and emerges as an attempt Health Cultural Mediators had an to address special needs, and improve living outstanding and positive impact on the standards. The centre is not only concerned development of the project. All the with sexually transmitted diseases and strategic actions respect the culture and condom distribution, but principally tradition of these populations. A final but adopts a psychosocial approach, improving crucial aspect was the acceptance and self-esteem, and providing psychological adaptation of health care professionals to and emotional support. the cultural differences and patterns of this These prostitutes come from troubled low- population. income families in the lowest strata in society. They have poor educational attain- Conclusion ment, illiteracy is high, and few have The Europe wide project coordinated by professional skills. Long-term unemploy- Flemish Institute of Health Promotion, ment, substance abuse and delinquent/ Tackling Inequalities in Health is in our illegal activities, act as a serious hindrance opinion very important, for several reasons. to attempts to improve their living Research shows that in every European conditions. The centre promotes their country there is a health gap between the

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top and bottom social classes, and that this stronger Europe, to facilitate communica- gap in life expectancy, for example, which tion and promote ways of dealing with could be five to ten years, is not decreasing problems, while decreasing ethnocentric but widening every year. An EU project is views. an excellent way to spread information on This project provides good tools to examples of best practice. In every country improve our knowledge of some of the there are good health promotion projects, causes of inequalities in health in the EU. It which help to tackle inequalities in health. also informs on how to overcome obstacles Dissemination of this data is very useful for that affect the health of disadvantaged everyone working in the field nationally, or people. Consensus is required between at local level. This information exchange researchers to achieve a cross-sectoral helps facilitate partnerships and the imple- approach and policy. This includes consid- mentation of a common policy acceptable eration of other political areas related to the for all EU countries. determinants of health and well being, in Cultural differences are an extremely both the strategy and fieldwork of Tackling important aspect of health promotion Inequalities in Health. Finally we applaud interventions, directly related to human the excellent coordination role of the behaviour. This project provides data on Flemish Institute of Health Promotion in the dissimilarity of cultural approaches this project and the strong team spirit of between EU Members. This is fundamental expert members of the European Network when working together, to build a new and of Health Promotion Agencies.

The Inequalities in Health Fund: Helping disadvantaged communities

“Action to promote healthy lifestyles is important but as an integrated part of wider action to tackle people’s social and economic circumstances and the conditions in which they live.”

While life expectancy in Wales is rising, individuals’ direct control, for example, health is not evenly distributed across the social and economic factors. The Assembly population. The lives of people in some of Government’s approach encompasses both. Wales’ most deprived communities are Action to promote healthy lifestyles is Jane Hutt nearly five years shorter than those in its important but as an integrated part of most affluent areas. This is unacceptable wider action to tackle people’s social and and is why reducing inequalities in health is economic circumstances and the conditions one of the Assembly Government’s priori- in which they live. ties. We have in place a range of actions to Given that inequalities in health are the address inequalities including healthy result of several interrelated factors, action schools initiatives, health alliances and is needed on two fronts. First, to address community food projects. Action on health factors over which individuals can exert also features in the work of other policy some control, for example, lifestyle choices areas including, for example, the and risks people take with their health. Assembly’s flagship community regenera- Second, to address factors that are beyond tion initiative Communities First, our National Economic Development Strategy Jane Hutt is Minister for Health and Social Services, Welsh Assembly and the European Union supported Government, Wales, UK. Objective 1 Programme.

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The Inequalities in Health Fund viding sufficient information for the assess- While these initiatives and many others ment of proposals. The aim was to avoid help to address inequalities in health, our the process becoming a test of an organisa- Inequalities in Health Fund may be of tion’s bidding ability instead of its ideas to wider interest given that inequalities in improve people’s health in deprived com- health are highlighted in the European munities. Union’s new Public Health Programme. The response was very encouraging in I am pleased to say that the idea received terms of both the number of proposals support across the political spectrum. I received – 112 – and their quality. It launched the Fund last year with a budget demonstrated the commitment that exists of £17 million (approximately A24 million) throughout Wales to joint action to address over three years. The Fund’s purpose is to inequalities in health and to reduce heart stimulate and support new local action to disease. tackle inequalities in health and the factors that cause it, including inequities in access to health services. Of the total budget, £14 million has been targeted at coronary heart disease as Wales’ “The Fund has achieved its aim of stimulating and biggest health priority while £1 million per year has been allocated to specific action to supporting new local action” reduce inequalities in dental and oral health.

Design Given the Fund’s purpose, and partnership All proposals were assessed against the cri- working as a key principle, the core criteria teria by at least two people and ranked for projects were: accordingly. An Advisory Group of officials and representatives of health, local – The involvement of primary health government and voluntary sectors was teams to enhance and expand their role established. The group considered the in preventing ill health and in addressing results of the assessment process and rec- inequalities in health. ommended projects for support. I was – Action that reinforced partnership and pleased to announce a first tranche of 54 joint working between organisations in projects in July 2001 and a second tranche the health, local government and/or vol- of 13 projects in January this year. untary sectors. Interim evaluation – Targeted action to help deprived communities and/or disadvantaged groups Given that the majority of projects (91%) within the population. are of three years duration, their impact will take time to appear. Our interim evalu- – Action that helps to address inequalities ation therefore focuses on an assessment of in health and the factors that cause it, the portfolio of projects supported against action that contributes to the National the criteria set for the Fund. The data was Service Framework for Coronary Heart collected from the administrative records of Disease, and action that is consistent projects. with the evidence base. The Fund has achieved its aim of stimulat- – Sound project design, with costs ing and supporting new local action. It is normally in the region of £50,000 – currently supporting 67 projects, which is £100,000 (per project/year). well in excess of the original target of 20–30 Recognising the need for a sustained effort, projects. All projects are operational the Fund’s design allowed projects of up to although some have experienced delays due three years duration. While partnership to recruitment difficulties. was an important element, any organisation All projects have primary care involvement from the health, local government or vol- through individual practices or via Local untary sectors could lead a project. Health Groups. Ninety-sic per cent of projects involve Local Health Groups, which Project selection places the Fund’s projects at the heart of A streamlined application process was the new Local Health Boards currently designed to minimise the work involved in being established in Wales. This will help submitting bids while at the same time pro- to ensure that preventing ill health and

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grants of less than £50,000 (21%) and those Table 1 of more than £100,000 (24%). One aim of INEQUALITIES IN HEALTH FUND PROJECTS the Fund was to support action than meets (by contribution to Standards of the National Service Framework for locally identified needs and the funding cri- Coronary Heart Disease) terion was applied flexibly in response to this. % of projects (n=67) Anecdotal evidence suggests the Fund is Standard 1 Action to decrease risk factors for CHD 61 having a positive impact on the morale of staff involved in projects through a clear focus on practical, positive, action that Standard 2 Primary care action to identify those at risk for 55 helps people to improve their health. assessment/treatment There is considerable coherence between Standard 3 High quality care for everyone with an acute 13 the Fund and the Communities First initia- episode of CHD tive and my officials are taking a proactive approach to ensure links are made between Standard 4 Identification and treatment of those with 3 the two sets of projects. This will reinforce heart failure our integrated approach to programmes.

Future development Standard 5 Identification and treatment of those with -- arterial fibrillation Heart disease builds up over time. Unfortunately, this can lead many people to ignore the risks to their health or at least tackling inequalities in health sits alongside set them aside. The Fund’s projects are effective and efficient health services as an reaching into the community and are help- equal priority. ing to improve access to health services and raising the profile of preventing ill health. Partnership is a strength of projects. At the time of approval, local authorities were The evaluation of action is important and partners in 52% of projects and voluntary project leaders are required to build it into sector organisations in 37%. NHS Trusts their projects to demonstrate effectiveness. (hospitals) were partners in 82% of pro- Arrangements have been made for projects jects, which is helpful to developing their to be able to access advice and guidance on role in their local community. It is expected evaluation to assist them, and this support that partnership working will increase fur- is being taken up. Arrangements for the ther as projects develop and as links are overall evaluation of the Fund over the made with wider community development three-year programme are also in hand. action. Local Health Alliances with their I have visited several projects and while it is multi-agency participation are partners in early days, I must say that the action is 40% of projects. very encouraging. The need for the The National Service Framework for Inequalities in Health Fundhas been rein- Coronary Heart Disease is an evidence- forced by the recommendations of our based plan of action to tackle coronary NHS Resource Allocation Review.1 We heart disease in Wales. Table 1 summarises will continue to develop its use as a discrete its main components and illustrates the source of support for targeted action as way that projects supported by the Fund part of wider action to tackle inequalities in are contributing to its implementation. health through health services and through joint work across policy areas. Some projects are contributing to more than one Standard by, for example, com- bining screening with wider action in the community to help people to improve their health. It is anticipated that this will REFERENCES increase further as projects develop. 1. Welsh Assembly Government. Report of Most of the projects (55%) fall within the the Welsh Assembly’s National Steering £50,000 – £100,000 range (full year cost) Group on the Allocation of NHS Resources. while the remainder are split between Cardiff: Welsh Assembly Government, 2001.

For more information, contact: Ceri Breeze, Public Health Strategy Division, Welsh Assembly Government. E-mail: [email protected]

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International Conference A conference will take place in Copenhagen follows Copenhagen, December 9–10, 2002 under the Danish EU Presidency. Entitled Reducing Social Inequalities in Health up lead on equity for among Children and Young People, it is organised by the Ministry of the Interior and Health and Copenhagen Health young people Administration. The conference will be of specific interest to those working in the field of health promotion, as well as to planners, decision makers and politicians Danish initiatives throughout Europe. Conference goals are The EU Public Health Action Programme consistent with the Copenhagen has given priority to addressing health Declaration, which among other things states: inequalities. The Belgian Presidency placed social inequalities in health, and the role of “Environmental and emotional factors health promotion in tackling this issue, on in childhood and adolescence, including its official public health programme, and conditions of physical development and organised a Round Table Conference in experience of caring, understanding and December 2001. A number of policy respect, are critical determinants of health recommendations and ways to carry these that influence people’s ability to cope and to forward in policy-making and practice at change their living conditions as adults. global, European, national, regional and Policies to promote equity in health should local levels were discussed. Hanne Nielsen give high priority to providing equal The Danish Presidency has also placed the opportunity and protecting against adverse reduction of social inequalities in health on environmental exposure early in life, for the agenda, both as a continuation of the both moral and health reasons. Measures to efforts at EU level and also work begun in support families and good parenting should Denmark some years ago. In September be linked with measures to support the local 2000 the Danish Minister for Health and community as a whole.” the Mayor for Health in Copenhagen The conference provides an opportunity to hosted a conference on Social Inequalities bring forward existing documentation on in Health. One of the visible results of the social inequalities in health among young conference was The Copenhagen people. It will focus on policies and best Declaration on Reducing Social Inequalities practice to reduce these inequalities, in in Healthpassed on the last day of the order to diffuse this knowledge to other conference. Conference delegates also countries and settings. Prior to the confer- decided to organise both a national and ence, a research seminar, organised by the European follow-up. Institute of Public Health at Copenhagen A national follow-up took place in March University, in cooperation with the Danish 2002. It consisted of a two day coach trip National Institute of Public Health, will by participants from most Danish counties. focus on the following questions: A number of cities were visited, from –Are there social inequalities in health Aarhus to Copenhagen, in order to learn among adolescents? more about how to tackle problems related –Are there social inequalities in health to social inequalities in health. Participants behaviour among adolescents? had great experience and knowledge from their daily work in prevention and health –Which national and regional/local promotion. The purpose was mainly characteristics are important to health professional development and exchange of and health behaviour in adolescence? new ideas. Individuals working on local Findings will also be presented at the and regional projects were both the organ- conference. The preliminary programme isers and the expert speakers for the tour. includes keynote speeches by Lars Lokke This ‘conference-on-wheels’, was a great Rasmussen, Minister for the Interior and success. Another event will take place in Health; Inger Marie Bruun Viero, Mayor Hanne Nielsen is Head of Spring 2003. A small report, including a of Health for Copenhagen; and Section, Danish Ministry of short description of about 20 projects was Commissioner David Byrne. More infor- the Interior and Health. recently published. It will be translated into mation about the conference is available at E-mail: [email protected] English. www.inequalities-copenhagen.dk.

eurohealth Vol 8 No 3 Summer 2002 16 GLOBALISATION Globalisation and health: An introduction It is worth remembering that Maggie Davies is Head of European and impacts do not necessarily have to be negative, aspects of globalisation International Programmes at the Health may have a public health enhancing Development Agency for England impact. Nations aspire to join the WTO expecting economic benefits. A view subscribed to not only by international organisations, but also The Health Development Agency such as the World Trade by public health professionals sug- for England (HDA) as a national Organization (WTO) and the gests that national economic growth public health body has an interest in International Monetary Fund can will automatically lead to improved the impact of globalisation on override national democratic population health. Certainly health. Like many of our peers we processes. economic growth generally leads to are also struggling to understand not expansion of the health care sector. Why is this of importance to public only what the health impacts are, but It is also true that population health health? When discussing health also exactly what is meant by global- in high-income countries is generally impacts of globalisation, it is often isation. Globalisation is a term better than in low-income countries. assumed that these will all be nega- frequently used, but seldom under- However, once basic needs are met, tive, concentrated on specific health stood, whose health impacts are a increased wealth does not necessari- care policy, agreements and legisla- matter of study and debate. Before ly help close the health gap between tion. Attention is often focused on asking whether it is good or bad for the richest and poorest in society, in questions such as: Will we be able to health, perhaps we need to come to some cases, health inequalities can prevent imports of goods that have some common understanding of the increase. A very evident health gap the potential to harm the health of term’s 21st century meaning and exists not only between Europe and the population (such as asbestos)? prominence in the current public low-income countries such as those Will we have to open our National health debate. in Africa, but also across Europe, Health Service provision to foreign where there is an east/west divide. Since the 17th century trading days, competition? What is the impact on at times there have been open mar- low-income countries of patents If we accept that there are economic kets and significant movements of protecting pharmaceutical products? benefits to countries from interna- goods and people between countries. tional trade agreements, the question These issues are clearly related to While globalisation, as experienced must be whether benefits will reach health and need to be kept under the now, is associated with freedom of those who most need them, or watchful eye of public health profes- movement, this is clearly not the whether there is potential for an sionals. Health is not just about whole story. Many in the health field increase in health inequalities within absence of disease; the broader issue see these freedoms as a benefit, but and between countries? of the location of power in and out- globalisation also suggests some- side the framework of civil society is Phenomena covered by globalisation thing threatening to others. The crucial. Health promotion literature are too complex and dynamic for nature of the threat is often ill demonstrates that the amount of easy judgements on whether they are defined, felt rather than known, but control we feel we have over our good or bad for health. Public health felt strongly enough to engender lives is a key factor in determining professionals will require a high demonstration and conflict, requir- health. The sense that democracy is degree of sophistication to pull ing democratically elected leaders to not working, that we have no voice factors likely to impact upon health be separated from their people by in shaping the world we live in, is out of the globalisation bag. This is fences and armed guards. This street likely to have a negative impact essential, not only to develop under- rage is in part due to a sense that we upon health and well being. standing of what the real issues are, are dealing with something not Additionally, many other important but also to identify meaningful entirely understood. Moreover, determinants of health lie outside the actions to take in order to advocate there is a perception of disempower- health sector control; issues such as for a reduction in aspects that are ment; an inability to find legitimate employment, education, transport harmful to health and an increase in routes to influence those with power and the environment are of the those which can offer positive health making decisions affecting lives in greatest importance. A narrow benefits. The HDA has approached direct and often unwanted ways. health focus will not provide a true authors who can help us better This occurs when communities understanding of the health impacts understand some of the issues. We believe that international bodies of globalisation. hope that this will be the start of a meaningful debate and will help to E-mail: [email protected] take our thinking forward.

17 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION Health services in a globalising world

“A day will come when the only fields of battle will be markets opening up to trade and minds opening up to ideas. A day will come when the bullets and the bombs will be replaced by votes, by the universal suffrage of the peoples” Victor Hugo, World Peace Conference, 1848, Paris

Globalisation is one of the great buzz- the Atlantic.2 The prime momentum appar- Rudolf Adlung words of our time. It has very many facets, ently came from falling transport costs, due cultural, social and economic, and may to the introduction of railways and convey an array of meanings, expectations steamships and complementary public and, not least, concerns. There are few investment, coupled with a favourable Ministers, whether responsible for finance, policy environment. industry, culture or health, who would not The distributional implications of econom- currently use globalisation as the leitmotiv ic globalisation, including changing land of a speech or article. Ministers for finance prices and real wages, caused a political and or industry might want to stress fiscal economic backlash, even before the First constraints and the need for wage discipline World War and the Great Depression took perceived to arise from international their toll. Nationalism triumphed, in market integration and capital mobility. By politics, economics and beyond. Victor contrast, their colleagues for culture or Hugo’s vision proved elusive for at least health might call for more funds to support two more generations. the arts or to launch information campaigns (AIDS etc) in order to cope with … but the vision has come in new the challenge of globalisation. There seem to be few policy messages that could not be guises linked to, or blamed on, globalisation. Like its nineteenth-century predecessor, Globalisation, it is often implied, is the modern globalisation seems to be driven defining feature of modern life, all embrac- mainly by technical innovation, in this case ing, unstoppable and, possibly, inescapable. new communication technologies, and policy reforms. The latter included not only Globalisation is not new … the creation of open, market-based systems in many countries, but also of common Economic historians paint a slightly differ- international institutions, most notably in ent picture, putting modern developments the form of the IMF, World Bank, and in a broader context. A recent essay by GATT/WTO. The underlying intention is Borchardt points to various periods of eco- to ensure transparency, consistency and nomic globalisation in history, including predictability in international economic the creation of a “medieval world econo- policies and to prevent sudden reversals or my”.1 Driven mainly by technical and/or institutional innovation, early attempts slippages. eventually collapsed. As a likely explana- There may also be additional protection tion, Borchardt refers in particular to the against the resurgence of economic nation- tensions generated by the re-distribution of alism and isolationism. First, the role of political and economic status, and the individual channels through which globali- Rudolf Adlung is Counsellor absence of sufficient compensation. sation proceeds, labour and product market in the Trade in Services Similarly, one study of nineteenth century integration, investment and information Division of the World Trade globalisation traces very profound changes flows, seems to have changed. While many Organization, Geneva, in economic integration – in terms of trade nineteenth century economies experienced Switzerland. expansion, international financial flows, rapid trade expansion and large-scale E-mail: [email protected] and migration, on both sides of, and across migration, not least across the North

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Atlantic, the main driving force today is the economic position. Tellingly, among the combination of trade and foreign invest- main opponents against nineteenth century ment. Growing equity and production globalisation in Germany were large-scale links across national frontiers and between grain producers, affected by cheaper continents, and the emergence of truly Ukrainian and American imports, rather multinational companies, are among the than the underprivileged working class. hallmarks of modern-day economies. The latter were even compelled to foot part While possibly posing new challenges for of the protectionists’ bill, in the form of policy cooperation, including “non-trade” higher food prices. areas such as competition, the multination- als tend to foster commonalties of interest Globalisation may have a direct between home and host countries. impact on public health … Second, trade relations no longer focus on The links between economic globalisation, goods alone, but increasingly cover intangi- development, and health are multifaceted. ble products (software, design, education, For instance, using strong empirical insurance, medical and legal advice) and evidence, many have stressed that interna- information flows. The latter cannot easily tional market integration helps to spur be subjected to conventional border con- economic development. The ensuing trols, regardless of government intentions. increase in disposable income, in turn, Viewed from that angle, modern products enables better working conditions, “International market and markets are more immune from pro- education, nutrition, and access to medical tectionist interference. care. These factors are directly related, in a integration helps to clearly supportive way, to a country’s Third, while the empirical evidence of the health status. Additionally, there is a posi- spur economic past two or three decades points to a tive link between health and labour powerful impact of globalisation on productivity and, further, between labour development. The economic growth, it has not apparently productivity, growth, and development. ensuing increase in come at the expense of increased inequality While it is true that trade, and especially in per-capita incomes. Developing coun- migration, also pose health risks, this does disposable income, in tries that have opened up to trade over the not appear to be a compelling counter- past two decades have grown much faster argument. People have moved throughout turn, enables better than rich countries and the non-globalisers, history and continue to do so, sometimes but have not experienced any significant even more intensively and violently, in working conditions, increases in income disparities.3 Thus, all periods of economic disintegration. population groups seem to have participat- The strongest line of causation seems to education, nutrition, ed in overall economic expansion. run from trade and investment expansion and access to medical A note of caution may be necessary, how- to development, and from development to ever.While these findings may sound reas- health. What factors could otherwise care.” suring from a social policy (and health!) explain the strong health-indicator perspective, they do not necessarily imply improvements in Hong Kong, South Korea that social acceptance of globalisation, in its and Singapore (e.g. infant mortality), various facets, is more deeply rooted today compared with neighbouring, less interna- than a century ago. For example, there are tionally integrated countries?3,4 Is there understandable sensitivities against the any evidence of exogenous changes that, emergence of what could be considered a first, might have helped to enhance the uniform world culture and the attendant three globalisers’ health situation and, next, loss of national identity. Many resent the pushed them onto a higher and steeper global village and are not prepared to swap growth path? Concerning the perceived their native habitat. link between mobility and health risks, it is worth noting that, although Hong Kong From a purely economic perspective, it and Singapore are among the world’s would be naïve to infer that globalisation busiest travel hubs, they apparently found (i.e. openness to international trade, invest- it possible to contain such risks. ment, expertise, etc.) is painless for all participants at all times. Even if the relative This is not to suggest that economic global- position of large income groups has not isation necessarily translates into better life changed significantly over a reference and health conditions or, even more period, this does not imply that there have daringly, that people in richer countries are been, and that there will be, no adjustment necessarily healthier and live longer. Of costs. Like a century ago, there are always course, social, cultural and institutional beneficiaries of the status quo who wish to differences matter, impinging on lifestyle, defend their professional, social and/or diet, public sector involvement, etc, but so

19 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION do many other factors, including income The main elements of GATS are firstly, distribution. Countries where large popula- that it applies only to commercial services tion groups live below the poverty line are and/or services supplied in competition. likely to fare worse in terms of health, This exempts core areas of governmental education etc. than comparable countries competence, in most countries possibly with more equal income distribution. including primary and secondary education Globalisation offers opportunities for or even medical care, from trade disci- health and social policies and makes better plines. It would not be possible, in new care affordable; it does not, however, rounds of negotiations or otherwise, to substitute for responsible and prudent require a member to reconsider institution- governance and institution building. al arrangements in such sectors, let alone to open them to commercial investors. … but not necessarily on public Second, even if a service is covered by health systems GATS, this does not imply acceptance of Health-sector institutions differ widely private participation. Members are obliged between otherwise comparable countries, to open their markets and to extend nation- including EU countries. Public health al treatment to foreigners only in sectors systems, based on government-owned and they have chosen to include in their coun- -operated facilities (for example, Spain, try-specific Schedules of Commitments, “[the GATS does not UK), coexist with various types of mixed and only to the extent that no qualifications affect countries] systems made up of public, other non-com- have been inserted. In other words, if a mercial, and private suppliers. Whatever country decided to schedule medical or freedom to organise the system, however, there have been hospital services, which is the case for discussions in virtually all EU countries slightly more than one third of members, it their public sectors as about changes needed to ensure quality, might attach various limitations reserving curb waste, contain costs, reduce waiting the right, for example, to limit foreign they see fit; rather, it lists, etc. While globalisation may have equity participation, cap the total number exposed weaknesses in current systems, it of hospital beds or doctors, or exclude protects national policy has not affected governments’ scope for foreign-owned facilities from subsidies. decisions from health sector policies or policy reform. Countries are thus able to adjust their Unlike its predecessors, modern globalisa- commitments to all sorts of national policy international tion proceeds within a framework of objectives or constraints. There is one min- international agreements and institutions, imum obligation, however, that applies encroachment.” such as the WTO. WTO governments are across all services covered by the committed to applying trade measures – Agreement. Regardless of whether a tariffs on goods, restrictions on foreign Member permits or restricts access to any services, etc. – only within pre-defined such sector, the relevant conditions must limits, regardless of how they feel about not discriminate between services and other members’ policies. This is particular- service suppliers from other WTO ly important for small and poorer trading Members (most-favoured-nation principle). nations, who would suffer most from expo- Third, the GATS does not affect a govern- sure to unconstrained economic clout, and ment’s right to impose licensing or qualifi- has possibly been the strongest incentive cation requirements or standards that may for ever more countries joining the WTO. be needed to ensure national quality Potentially relevant for service-related objectives. Nor does it compromise mem- policies, in any sector, is the 1995 General bers’ rights to regulate markets for social Agreement on Trade in Services (GATS). and other policy purposes. Any allegations that the Agreement could undermine WTO rules are potentially relevant universal service obligations are thus com- for all services … pletely unfounded, even in fully liberalised The GATS provides the WTO’s 140-odd systems.5 Private hospital and other health- members with a legally enforceable, com- service suppliers can be subjected to all mon set of rules. These are possibly more types of universal services, (free treatment flexible than those contained in any other of needy patients, obligation to invest in WTO Agreement, including the GATS’ rural facilities, training requirements counterpart in merchandise trade, the 1947 exceeding own demand for staff) or obliged General Agreement on Tariffs and Trade to source universal service funds. If such (GATT). Neither affects members’ free- requirements were to be imposed only on dom to organise their public sector as they foreign suppliers, and if the country decid- see fit; rather, they protect national policy ed to include the sector in its schedule, a decisions from international encroachment. limitation would need to be attached.

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… and may help to promote basic those remaining behind. The ensuing REFERENCES policy objectives distributional implications, for example, 1. Borchardt K. Die Globalisierung Globalisation, in the form of increased better medical care for patients who can ist nicht unumkehrbar [Globalisation mobility and enhanced information, afford to escape waiting lists by travel- is not irreversible]. Handelsblatt may prompt more governments to con- ling abroad, might prove difficult to 2001;112. reconcile with basic equity objectives. sider the case for domestic regulatory On the other hand, accepting commer- 2. O’Rourke KH, Williamson JG. adjustment. Economic growth has cial providers within a country may Globalisation and History: The enabled large segments of the popula- carry similar risks. In the absence of Evolution of a Nineteenth Century tion not only to compare their supply proper regulation and enforcement, a Atlantic Economy. Cambridge. MA situation with that in other countries, dual system could emerge: wealthy and London, 1999. but to act accordingly and, if need be, patients and qualified staff might shun 3. Dollar D. Is globalisation good for move abroad. It would be hard to public hospitals in favour of better your health? Bulletin of the World prevent dissatisfied consumers equipped and more pleasant private Health Organization2001;9:827–33. (patients) from such movement, or facilities. The resource and equity 4. Adlung R, Carzaniga A. Health qualified domestic staff (nurses and implications do not seem to differ at services under the General doctors) from following. Mobility, i.e. first glance. However, since the invest- Agreement on Trade in Services. the right to vote by feet, and access to ment is in the country, it is easier to use Bulletin of the World Health information are inalienable entitlements domestic regulation to pursue the Organization2001;4:352–364. in an open society. public interest. 5. Adlung R. Healthcare systems and Mobility tends to be selective, however. Whatever a government’s decision, it the WTO: no grounds for panic. The affluent and well-educated are could be accommodated under the WTO Website. www.wto.org/eng- usually over-represented compared to GATS. lish/tratop_e/serv_e/sanaly_e.htm

Public health after globalisation: Injecting health into the post-Washington consensus

“Too often public health voices engage globalisation with an upbeat optimistic tone, which belies the worrying evidence.”

In recent times, the public health move- public health voices engage globalisation ment has veered between awe at the power with an upbeat optimistic tone, which of globalisation (as though it is a homoge- belies the worrying evidence. In fact the neous entity and process) and the academic modern era of globalisation has unleashed response of monitoring its impact (as astonishing wealth for some while confin- though epidemiology alone, amounts to a ing others. These gross inequalities are public health position!). In our view, it is themselves factors in determining ill health. time that proponents of public health took Geof Rayner Secondly, it is unacceptable that health is a new, tough stance on globalisation – marginalised from discussion of globalisa- tough in the sense of knowing where they tion. In our view, health is a, if not the, key stand. Globalisation is, of course, immense- to showing how a narrow definition of ly complex, but our concern here is to globalisation on economic growth is symp- encourage the public health movement to tomatic of a partisan approach to public question two specific arguments about policy in which public health is seen as a globalisation and health. luxury of the rich. Why is it that after the Firstly, it has mostly adopted an argument decade of water, there is no end in sight for that globalisation generates wealth enabling world water shortages? Why are there still societies to invest in healthcare. Too often 800 million people suffering chronic

Geof Rayner is Chair of the UK Public Health Association. E-mail: [email protected]

Tim Lang Tim Lang is Professor of Food Policy, City University. E-mail: [email protected]

21 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION malnutrition? Why are so many countries principally the capacity of the system to crippled by debt? These are health ques- overproduce in conditions of a narrow base tions, not just economic ones. of ownership and massive inequality. Given the acuity of this analysis why did Globalisation, old and new their diagnosis of breakdown and progno- Globalisation is, of course, nothing new. sis of socialism turn out so far from what This is but the latest era of globalisation, was to occur? One of the reasons, among characterised by greater global reach and many, is that the globalisation process they pace, and by the sheer power of economic described came to a halt with the First forces. Goods and ideas may have circulat- World War. Class loyalties did not cement ed the globe for millennia before, but in the as anticipated. The working class slaugh- last half century the scale and focus has tered each other in a triumph of national- been awesome. ism, laying down political divisions The debate around globalisation mirrors between East and West that dominated the the magnitude of the topic. Researchers and 20th century. A second reason is that the “It is unacceptable that commentators are now demanding a front economic and social crises which did occur, row seat on the affairs of international for instance the 1930s depression, resulted health is marginalised institutions like the World Bank, the in new counterbalancing mechanisms International Monetary Fund (IMF) and within major states. from discussion of the World Trade Organisation (WTO) or Furthermore, capitalism splintered into globalisation” are issuing books and papers charting various different forms, American (or global trends in economics, culture, and latterly Anglo-American), European, everyday life. Japanese and most recently Chinese, this To the chagrin of those who think globali- latest being an accommodation between sation a wholly new historical event, we capitalism and communism. If states at the have been here before, not only in terms of periphery resembled Marxist depictions of analysis of the phenomenon, (which existed industrialising Britain, a revised hegemonic in a fully fledged state in the late nineteenth system was put in place to contain the century), but also its advocacy and dispar- spread of discontent. To be fair, as early as agement. If today the study of globalisation the 1880s Engels, in observing the success occupies at least one academic department of British public health measures, said that in every noteworthy university, 150 years the British elite had looked into the abyss ago much of the debate could be encapsu- and pulled back.2 The middle classes, not lated in the writings of Marx and Engels. just the elite, realised that investment in the The Communist Manifesto, implicitly public health was self-interest. Public drawing upon the work of outstanding health measures were key components in British political economists, Adam Smith the foundation of European Welfare- and David Ricardo, was both pro- Keynesian and regulatory state action. globalisation and also a critique. “The need Globalisation advocates today also draw of a constantly expanding market for its their inspiration from the same economic products chases the bourgeoisie over the theorists who influenced Marx: Adam entire surface of the globe. It must nestle Smith, for analysis and advocacy of free everywhere, settle everywhere, establish markets, and David Ricardo for his 1 connections everywhere.” They considered doctrine of comparative advantage. While capitalism a progressive force, releasing these writers viewed circumstances flexibly, new productive forces and breaking down over time the advocacy of free markets, the backwardness and oppression of privatisation and deregulation became the tradition. formulaic answer to the question of Rapid communications are said to be a tackling economic growth, poverty and defining feature of modern globalisation economic relations between states. This but Marx and Engels had already spoken of became known, even to insiders within the ‘connectedness’ of the new industrial these organisations, as the ‘Washington system, the “immensely facilitated means of Consensus’. This might be seen as the final communication”; a diffusion of ideas and point of destination for free trade philoso- commodities which produced “a world in phy, in some respects a revival of British its own image” among the developing attempts to secure fully open markets at the states. Nevertheless, despite this power for height of its empire. This was mercantilism good, Marx and Engels thought capitalism rather than ‘pure’ free trade, a doctrine to be self-destructive and ultimately defining geographical and political limits to doomed through internal contradictions, the exchange of goods.

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According to Pfaff this version of globali- developing countries alongside a significant sation, an “aggressive program for the trade in capital goods. Multinational enter- imposition of Western norms of national prises have also played a larger part, and economic management, economic deregula- the shape of investment has differed tion and market opening, and facilitating considerably, with a shift away from trans- takeovers of indigenous industries and agri- port and government sectors to banking culture by multinational companies”, was and industry. “launched by the Clinton administration The globalisation debate has been far wider during its first term”.3 Seen as an than new economic structures or additions, American-led enterprise, as with the covering issues such as the reduced power British, it bears the hallmark of an attempt of nation states, the impact of digital of a major power to stamp its authority on technologies, the question of whether glob- the rest of the world. This point requires alisation equates with Americanisation, the amplification, as it is key for the public impact of IMF-inspired Structural “A tough line on health. Adjustment Policies (now rebranded funding international If the current phase of globalisation begins ‘development policy support lending’ in with the conclusion of the Second World order to boost exports and reduce indebt- public health action is War, then it did so under an American, edness in developing countries), alongside required.” rather than a British hegemony while its public health and environmental debates on progress was hindered by a world divided disease, links with global warming, defor- into two ideologically opposed camps. The estation, etc. The breadth of issues suggest- policy forerunner to today’s globalisation ed to be explained by globalisation, stretch theories emerged in the 1950s, Rostow’s onward, perhaps too far from what always ‘stages of growth’ theory.4 Similar to was an imprecise notion. modern day advocates of globalisation, the The debate usually focuses on whether theory stated that the developing world globalisation is a good or bad thing. was in the process of economic change and Pro-globalists are typified as supporters of would inevitably pass through a five stage neo-liberal theories of trade (Washington transition from an agricultural society to an Consensus supporters); anti-globalisers, are industrial society (‘mass consumption’), a varied band ranging from those who providing, that is, the alternative, commu- oppose global capitalism per se, to those nism (‘the disease of transition’), did not who support protectionism for reasons of take root. environmental sustainability. International Subsequently, fierce ideological collisions bodies such as the World Bank, IMF or between east and west have diminished WTO, have strongly asserted that the while development economists have reject- opening up of markets, deregulation or ed linear models of transition for more dif- privatisation are pathways to economic ferentiated types. This fact, together with growth, which itself is the sure route to the Welfare-Keynesianism of the times and poverty alleviation. Meanwhile, critics the marginalisation of neo-classical argue that the GATT and WTO are merely economics, was hardly conducive to the new projects for ‘rigging the rules’.5 liberal-economic themes underscoring One analysis prepared for the IMF is that contemporary globalisation. This is not to the developing world can be divided into a say the pressure for more open markets globalising group of countries that have was not present at the time, rather that the seen rapid increases in trade and foreign ideological conditions were not available to investment over the last two decades, well solidify a trend. Under the 1947 General above the rates for rich countries, and a Agreement on Tariffs and Trade (GATT), ‘non-globalising’ group that trades even the encouragement of economic transac- less of its income today than it did twenty tions occurred by means of a “substantial years ago. Openness to foreign trade and reduction of tariffs and other barriers to investment (along with complementary trade”, having the purpose and effect of reforms) explains the faster growth of the “raising standards of living”. The World globalisers. It asserts that globalisation has Bank and IMF were seen as benign institu- not resulted in higher inequality within tions, and terms like privatisation did not economies. Where shifts in inequality have exist while the regulatory state was still in occurred they stem more from domestic ascendance. education, taxes, and social policies. Globalisation has taken on a new shape Generally higher growth rates in globalis- since its first appearance, including the ing developing countries have translated relative rise in manufacturing exports by into higher incomes for the poor.6

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Those who challenge this view interpret the growth underpinning globalisation was same evidence quite differently. Galbraith already shaky, it now appears unbelievable. argued that world growth rates were Where does this leave public health? The systematically higher under the structured liberal welfare model under which health- international financial regime of Bretton care receives investment generated by Woods from 1945 to 1971 than in the era of growth is now shaky. Healthcare has deregulation after 1980. Furthermore, always had a greater pull on finance minis- analysis of economic data suggests that ters’ attentions than prevention. Public forces of globalisation, including high health proponents now need to return to global interest rates, debt crises, and shock core principles. Prevention has to be the liberalisations, are associated with rising priority. There is an urgent agenda ranging inequality in pay structures.7 One group from climate change to the wastefulness of stated that out of eighty-nine countries, consumerism. It has long been recognised 77% saw their per capita rate of growth fall that while the consumer boom of the by at least five percentage points in North has suited the affluent, a huge slice 1980–2000 compared with 1960–1980. of humanity has been excluded. What is Only 14 countries, 13%, saw their per capi- now apparent is that the model of affluence ta rate of growth rise by that much from rolled out over the last half century is both (1960–1980) to (1980–2000). While US eco- bad for health and unsustainable. The evi- nomic dominance might suggest benefits dence that (ill)health is socially determined accruing to the US workforce, the median now means Ministers of Health have real wage remained about the same as a to stand up to their finance, trade and quarter century before, meaning a consid- economic ministry colleagues. A new erable widening of income disparities.8 approach to health is called for. This implies that increases in trade are linked to lower growth and rising inequali- The challenge to the UN ‘family’ ty, both in developed and undeveloped Firstly the simmering discontent between countries. various international ‘arms’ of global The most vocal element of the debate governance must be dealt with. Health has between globalisers and their adversaries, a been a source of some contention was represented by the dispute between between the UN agencies charged with Joseph Stiglitz, former chief economist to promoting public health, notably WHO the World Bank, and the International but arguably FAO and the United Nation’s Monetary Fund. Stiglitz’s charge was not Children’s Fund (UNICEF), and the against globalisation as such, but against stronger economic agencies, notably the what he regarded as IMF’s slavish imposi- IMF and World Bank. Gradually, in recent tion of ‘text book’ liberalisation of capital years, the World Bank in particular has markets. This was “the single ingredient entered the health arena. This has been most responsible for the global financial resented by some, indeed the Bank has on prices which caused such havoc in S.E. Asia occasions taken a strict approach to public and Korea, Indonesia, Thailand and else- health, but this is changing towards a more where around the world.”9 progressive position, notably on tobacco and food/ agriculture. Over the years, the The implication, perhaps, is that despite the World Bank has been subject to campaigns suggested close equation between econom- for closure because of its stance on devel- ic growth and globalisation, the reverse oping country debt, among other matters. may be true. While there is little argument Some critics forget that, however flawed, that the level of trade has increased, most the World Bank, IMF, etc. are public has been between countries on a more organisations, which although not immedi- secure path of growth, exporting industrial ately apparent from their behaviour, are products, while for those countries depen- enterprises in global governance. dent upon primary commodities, such as agriculture or mining, growth went into All these international bodies urgently need reverse as these products were oversup- to regain public credibility. Taking public plied, leading to tumbling basic commodity health seriously could be one way of doing prices. While the stock market boomed and this. The primary intent, therefore, is to get technological progress was rapid, the claim health on the agenda of major international that economic growth was associated with entities within the UN system, through the open markets on the American (or Anglo- introduction of matters like global gover- Saxon) model had considerable force. In nance, gathering and sharing knowledge, the wake of the US stock market collapse development of country-based action, key post 2001, it ceases to convince. While the targets for areas, such as tobacco, alcohol

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and illicit drugs, influencing trade agree- important steps in the direction of conser- ments to promote equity, actions to vation, the shift from commodity support improve global disease surveillance and the (pillar one) to rural development and promotion of actions around both commu- agri-environment schemes (pillar two) nicable and non-communicable diseases, funding, but health is not mentioned. Yet especially those having an impact on the CAP funds a huge production of dairy fats, poor . distorts production and distribution of fruit and vegetables, and also constrains A tough line on funding international pub- market access from the developing world. lic health action is required. UN bodies, starved of funds are pressurised to take Ironically, the prime driver for CAP funds from unacceptable sources under reform is not so much a desire to tackle REFERENCES duress. This has meant the UN mingling intensive agriculture’s environmental prob- 1. Marx K, Engels F. The with globalising forces directly. In 1999, lems, but to address the political challenge Communist Manifesto. the United Nations Development of EU enlargement. CAP’s current expen- London: Verso Books, 1848 Programme (UNDP) announced the diture system is simply unsustainable if ten (reprinted 1998). Sustainable Development Facility (GSDF) poorer countries join the EU. Reform also a partnership with around 15 corporations. addresses USA and Cairns Group inspired 2. Engels F. The Condition of The GSDF was one of many partnerships challenges to EU subsidies through the the Working-Class in England with the private sector pursued by the UN GATT system. in 1844[translated 1892]. and many of its agencies under the umbrel- London: George Allen & Why is public health so inactive at the la of the “Global Compact.” The GSDF Unwin reprint, 1968. European level? We believe that there is a was to include major chemical, mining, huge health agenda requiring urgent policy 3. Pfaff W. The West’s global- energy and pharmaceutical companies. attention. Taking food policy, the EU went ization drive is proving a mas- Participating companies paid $50,000 each into crisis, as did many member states, over sive failure. International to underwrite costs. Activists questioned the comparatively rare health problem of Herald Tribune whether sponsorship of the programme BSE. A new programme of health-driven 29 September, 2000. promised to brighten corporate image more work has emerged and a new European than serving the needs of the world’s poor. 4. Rostow W.W. Stages of Food Safety Authority is being created. Yet Over 100 organisations signed a letter to Economic Growth: A Non- this health focus has been remarkably the head of UNDP calling for GSDF to be Communist Manifesto. narrow, centring on food safety and food abandoned, as indeed happened in June Cambridge: Cambridge contamination, when the evidence is that 2000. University Press, 1971. non-communicable diseases such as heart 5. Kevin Watkins. Rigged In July 2002, UNICEF and a worldwide disease and cancers are far more significant. Rules and Double Standards hamburger restaurant chain, announced These diseases go to the heart of modern Trade, Globalisation and the plans for a joint fundraising initiative, life. EU public health policy has been Fight Against Poverty. ‘World Children’s Day’. The partnership reluctant to criticise let alone tackle these, Oxford: Oxfam, 2002. has been criticised by some who feel that which is symptomatic, we suggest, of financial assistance to combat communica- policy inactivity before globalisation. 6. Dollar D, Kraay A. ble disease is seen as tradable against non- Spreading the wealth. Foreign communicable disease, such as obesity and Conclusion Affairs2002;81(1):120–33. type 2 diabetes. Thus in seeking such links The so-called Washington Consensus – the 7. Galbraith J K. By the num- agencies risk being seen in alliance with alliance between the World Bank, bers. Foreign Affairs2002; corporations whose commitment to either International Monetary Fund, and US July/August. sustainable development or children’s Treasury, has dominated public policy for www.foreignaffairs.org/ health may be perceived at being superficial too long with its mix of support for open 20020701faresponse8531/ or at worse part on an exercise in brand markets, de-regulation and privatisation. james-k-galbraith/by-the- management. For public health advocates, there is now a numbers.html great opportunity to return to basics, one The challenge to Europe in which the aspirations of earlier times are 8. Weisbrot M, Naiman R, Globalisation, whatever version subscribed re-engaged, such as the Alma Ata Kim J.The Emperor Has No to, reminds us that public health is no Declaration and Ottawa Charter. This Growth: Declining Economic respecter of national boundaries. Yet requires some critical distance from the Growth Rates in the Era of within the EU, health is still primarily a love affair with globalisation, and demands Globalization. Center for member state responsibility. The much- that the public health movement becomes Economic and Policy vaunted Article 152 of the Amsterdam more involved in defining a new meaning Research, 27 November 2000. Treaty is more celebrated in principle than for public health, which overcomes the dis- 9. Stiglitz J. Presentation in practice. The Common Agricultural ciplinary separation from economics. given at the ICO World Policy (CAP) which accounts for nearly Health has to be central to economics not Coffee Conference, London half of the entire EU budget has never been something which is bolted on or which is Hilton Hotel, Friday 18 May properly audited for health. The recently paid for by surpluses generated in an anti- 2001. announced Fischler reforms might make health manner.

25 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION Globalisation: An Idiots Guide

“To what extent are the relationships between objectives to further trade and public health in conflict?”

Globalisation means different things to dif- ly modified crops as well as the response to ferent people. It describes a process where- threats, such as trade in pharmaceuticals by companies have become involved in and health related services. The essence of markets around the world, and where there conflict revolves around the principle that Julius Weinberg is concern that they can, by shifting capital local authorities should be enabled to take between markets, leave individual compa- appropriate measures to control threats to nies powerless. It describes the fate of poor health. There should be minimal impedi- traditional producers whose livelihood may ments to trade, with common regulation of be undermined by a technological advance standards. in a wealthy country many miles away. The International Monetary Fund (IMF) However it also describes the increasing and the International Bank for interconnectedness of countries and peo- Reconstruction and Development (IBRD ples, clearly better than isolation and igno- or World Bank) are UN specialised agen- rance. The mantra of globalisation has been cies, established as part of the international local good, global bad, but this analysis is infrastructure at the end of World War simplistic. This article describes some of Two. Besides strengthening a particular the key international agencies involved in economic model, it was hoped that creating ‘Globalisation’ and indicates where their stability in international monetary affairs activities impact on health. and facilitating the expansion of world trade would reduce the possibility of future Establishing International Agencies wars. Members of the World Bank are also and Agreements required to be in the IMF. The World Bank The possibility of interactions between was responsible for long-term financing for commerce and health has been recognised nations in need, while the IMF’s mission for many centuries. One of the few evi- was to monitor exchange rates, provide dence based health care interventions was short-term financing for balance of pay- quarantine, a restraint on trade. Attempts ments problems, provide a forum for dis- to regulate the international response to cussion of international monetary con- infectious disease were one of the drivers cerns, and give technical assistance to mem- for international collaboration in health. ber countries. Since the first International Sanitary Conference in 1856, balancing the interests Negotiations also began in 1946 to reduce of trade with disease control has proved tariffs, and dismantle protectionist mea- problematic. International Health sures in place since the 1930s, thus boosting Regulations explicitly state that any mea- trade. Negotiations resulted in 45,000 tariff sure taken should be the appropriate mini- concessions affecting $10 billion, one-fifth mum for disease control, with the least of world trade. Agreements on tariffs and possible disruption of trade. provisional acceptance of rules concerning employment, commodity agreements, busi- As trade and travel between countries has ness practices, international investment and increased, and problems associated with services defined the 1948 General infectious disease diminished, issues have Agreement on Trade and Tariffs (GATT). become more complex. Concern now includes the internationalisation of non- Major changes in international trade liber- infectious disease threats to health includ- alisation have occurred through multilater- ing food, tobacco, pesticides, and genetical- al trade negotiations, or ‘trade rounds’, the Uruguay Round being the latest and most extensive. Trade rounds offer a package Julius Weinberg is Director of the Institute of Health Sciences, City approach; negotiations address a wide University, London. E-mail: [email protected] range of issues. It is claimed this is advanta-

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geous, making concessions easier in a pack- administrative procedures with its obliga- age also containing benefits. Less powerful tions as provided in the annexed participants have a greater chance of influ- Agreements.” WTO members constrain ence than if bilateral negotiations dominat- their ability to act under the agreement. ed. Fundamental reform of world trade sec- Provisions assert that “domestic health, tors appeared more feasible within the con- safety, and environmental policies must be text of a global package. Although trade designed in the “least trade restrictive” rounds have concentrated on reducing tar- manner and national laws and standards iffs other issues such as the GATT Anti- should be standardized internationally, to Dumping Agreement were negotiated. maximize economic efficiency in cross-border trade.” Standards providing more protection to consumers, public health, local communities or the environment can be challenged as unfair trade barriers. “The essence of conflict revolves around the principle that Global standard setting local authorities should be enabled to take appropriate The WTO has provision for global standard setting, in international standard-set- measures to control threats to health.” ting institutions, as well as equivalency agreements. Specific global standards are set by organisations such as the International Organization for Standardisation (ISO) and the Codex Alimentarius Commission GATT helped spur high rates of world (Codex). Regulatory systems and standards trade growth seen in the 1950s and 1960s. in countries can be declared ‘equivalent’ However the economic recessions of the to domestic regulatory systems. Once a 1970s and early 1980s, lead to governments foreign system is declared equivalent, it seeking bilateral trade agreements, using must be treated as domestic. Mutual subsidies to protect indigenous industries Recognition Agreement (MRA) is a recip- and farming. This and the rapid develop- rocal agreement between nations, allowing ment of international trade in services (not a country to rely on another’s verification covered by GATT rules) and other factors that a product meets required standards. convinced GATT members that a new Codex was established by WHO and the effort to reinforce and extend the multilat- U.N. Food and Agriculture Organisation eral system should be attempted. That in 1962. It is a voluntary standard-setting effort comprised the Uruguay Round, cov- body, facilitating international trade of ering all aspects of trade policy, including food and agriculture products. Codex com- trade in services and intellectual property. prises government representatives, with This resulted in establishment of the World active and formal assistance from official Trade Organization (WTO) in 1994. industry advisors, serving as members of WTO replaced GATT and is very different. country delegations. One 1993 study The WTO is a permanent institution with reported that over eighty per cent of non- its own secretariat, and unlike GATT, com- governmental participants on delegations to mitments to WTO are full and permanent. Codex committees represent industry, It covers trade in goods and services while only one per cent represented public (GATS) and trade-related aspects of intel- interest organisations. lectual property (TRIPS). A dispute settle- The ISO in Geneva is a private, industry ment system is provided, designed to elimi- standard-setting body, recognised by WTO nate world trade blockages. Tribunals com- as the international standards body for all prising three trade experts rule on disputes. non-food products. From the 1950s ISO However the criteria for choosing panellists began to standardise sizes for consumer has been criticised as ensuring that they products (i.e.batteries). ISO’s areas of inter- favour current trade rules. Normally to est have expanded and now include stan- qualify for a tribunal an individual must dards for environmental products, eco- have worked at GATT or WTO or repre- labels, and humane fur trapping standards; sented a country there. it is now developing standards of manage- WTO has provisions concerning domestic ment practices. public health, food safety, consumer, work- General Agreement on Trade and Services er and environmental protection policies. Agreement constrains members to “ensure Since the 1999 Seattle meeting on interna- the conformity of its laws, regulations and tional trade rules, talks have begun to

27 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION strengthen one of 28 agreements overseen affected. TRIPS allows for action to be by the WTO, the General Agreement on taken against countries with inadequate Trade in Services, (GATS). This covers sec- patent laws. tors like banking, construction, education, Some safeguards exist within TRIPS to insurance, retail, telecommunications, protect public health interests. tourism, health or waste disposal. Via Governments can justify compulsory GATS, private companies can insist on licensing; including undefined “national being allowed to enter the market for pub- emergencies”. Under TRIPS, products licly funded services. In OECD countries made using compulsory licences should be public expenditure on health services and “predominantly for the domestic market”, education accounts for 13% of GDP. Much but countries may not have capacity and of this goes to public or voluntary bodies wish to use compulsory licenses for import. but could go to for-profit groups. By 1998, Parallel imports are also allowed, however 59 countries had one or more aspects of there is concern that this might lead to re- professional (medical, dental, veterinary, export of cheaper products. nursing, midwifery, physiotherapy) services or health-related and social services (including hospitals) under GATS. 39 countries had agreed to open up hospital services to foreign suppliers. Seventy-six “Via GATS, private companies can insist on being allowed countries have made financial services sector commitments, (including health to enter the market for publicly funded services.” insurance). The US Coalition of Services Industries have stated that “We believe we can make much progress in the [GATS] negotiations to allow the opportunity for US businesses Key Issues to expand into foreign health care markets If trade/investment liberalisation generally … Historically, health care services in many improved goals of human development, foreign countries have largely been the and lead to fairer distribution of goods, it is responsibility of the public sector. This pub- likely that it would be widely supported. lic ownership of health care has made it dif- Economic liberalisation enthusiasts claim ficult for US private-sector health care that open markets are a necessary condition providers to market in foreign countries.” for this. However empirical evidence is doubtful, some would claim that poorer TRIPS economies suffer under trade liberalisation. TRIPS covers a wide range of subjects, There are concerns that increased liberalisa- including copyright and trademarks as well tion, in particular the move for liberalisa- as patents. A patent on a pharmaceutical tion of services (health, education) under product can cover products, or a manufac- the GATS process, may increase their pri- turing process if novel. Patents reward vatisation, decreasing access. inventors and enable research costs to be A number of questions need to be recovered. Upon patent expiry, other com- answered. To what extent are the relation- panies can make the product. Generics are ships between objectives to further trade often cheaper, as they do not have to cover and public health in conflict? Does trade research costs, furthermore competition liberalisation improve health and reduce lowers price. TRIPS standardises the use of inequalities in health? What are the respec- patents, all WTO members have to grant tive rights, responsibilities and capacities of twenty year patents. Previously some the private and public sector? Should inter- countries used shorter periods, permitting national standards serve as a ceiling or as a earlier production of generics. All coun- floor that all countries must meet? What tries, including those without previous assessments have we of the efficacy of patent procedures, will be expected to service liberalisation? Finally how do we implement the provisions of TRIPS. strike a balance between the need to There is concern that attempts to balance provide incentives for innovation and the public health interests with those of inno- need to enable all people to benefit from vation are tilted towards the pharmaceuti- innovation? cal industry, and without access to generics new drugs will remain too expensive for poor countries. Generics manufacturers in This article is based upon a talk previously given at the European Health developing countries will also be adversely Policy Forum 2001.

eurohealth Vol 8 No 3 Summer 2002 28 GLOBALISATION European Union foreign and health policy

“There are increasingly important links between global health and foreign policy in relation to: human security, economic development and global citizenship.”

In April this year an international confer- psychiatric cases. Health was a subject for ence at Ditchley Park, supported by The monitoring, advice and support orchestrat- Nuffield Trust and RAND, discussed the ed by the WHO, but was not central to relationship between foreign policy and foreign policy. health. It concluded that there are increas- The fall of the Berlin Wall in 1989 was a ingly important links between global health Graham Lister milestone in the redefinition and expansion and foreign policy in relation to: human of national foreign policy. As international security, economic development and global trade became more important to prosperity citizenship. One of the actions identified as and power, rising from 4% to 10% of a result of the conference was to promote World GNP from 1955 to 1989 and then further research into, and support for, poli- accelerating to double again by 2001, it cies at European Union level directed became more central to foreign policy. It towards global health as a foreign policy also became apparent that in trade, as in issue. This paper sets out some of the other areas of foreign policy, collective thinking behind this conclusion as a start- power and action were crucial to the coming point for discussion with researchers mon interests of states. and policy analysts. Conference papers can be found at www.ukglobalhealth.org . The ‘Neo-liberal’ perspective, which emerged, no longer saw foreign policy as a Growing links between foreign policy zero-sum game. States had to cooperate to and health create open markets for trade and invest- The traditional view of foreign policy, as ment, which was seen as mutually benefi- exemplified during the cold war era, was cial. The ‘Washington consensus’ can be narrowly focussed on national security and seen as agreement between rich countries national interests. The main concern was and trading blocks to replace national mar- with the balance of power and the creation ket controls with international agreements of military and political alliances to protect to open trade in industrial products and national self-interests in competition with privatised services, but not agriculture, those of other states. This so-called while protecting intellectual property ‘Realist’ perspective is still apparent in rights. The rules of globalisation are clearly 2 much of the debate on foreign policy.1 stacked against the poorest countries. Over time the focus of foreign policy By 2001 trade and foreign direct invest- expanded to include trade, aid, and human ment accounted for seven times the level of rights. Investment in health was an element aid flows to poor countries; official aid of aid, but less than 10% of the total. consistently fell as a proportion of GNP, Health was also a basic human right, as until 2001/2. Non-government organisa- defined in the UN Universal Declaration of tions became more important both in the Human Rights, but in practice health was channelling of aid and as agencies for the not prominent on the foreign policy agenda delivery of services. unless health services were abused, as for For these reasons multi-national companies example, the detention of dissidents as and NGOs became important to foreign policy. “Foreign policy today is no longer the property of chancelleries and diplo- Graham Lister is Senior Associate at The Nuffield Trust, and Secretary of The mats. The world’s great trading firms and UK Partnership for Global Health. great civil society movements make foreign E-mail: [email protected] policy too.”3 Policy issues relating to

29 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION health and trade are addressed at interna- report notes that poor countries can tional levels through the WTO and WHO, achieve economic benefits from investment which increasingly seek to engage with the in health from the reduction in productive private sector and civil society. years lost to disability and death of up to six times the level of investment. Security remained at the heart of foreign policy but was now defined more broadly The events of September 11th underlined a thus ‘food security’, ‘water security’ and further link between foreign policy and ‘economic security’ have all been promot- health. Terrorism is not directly caused by ed. ‘Human security’4 was redefined to poverty, ill health or lack of education. But encompass a wide full range of threats to these underlying inequities feed resentment safety and well-being, including health and despair and are linked to the develop- threats to individuals and communities. ment of failed states and failed cities, in which civil order breaks down and illicit Attitudes towards health investment as an activities and terrorist groups flourish. This aspect of foreign policy changed because: “Poor countries can demands the reaffirmation of basic health, – Infectious diseases and abuse of anti education and civil protection as human achieve economic microbial agents are no longer issues rights of citizenship together with concert- confined to poor countries, the extent ed action to ensure that these services reach benefits from and speed of international travel is such every part of our global community. that new and re-emergent diseases (30 in Health can be a bridge to peace both in investment in health the last 20 years) now threaten every conflict situations and in reinforcing civil from the reduction in country. society to avoid the emergence of failed states or cities. – The scale and extent of the HIV/AIDS productive years lost to pandemic clearly required major inter- The evolution of European foreign national effort and investment, raising disability and death of policy the political stakes so that heads of state up to six times the level must engage with the issue. The evolution of European foreign policy exemplifies the slow shift from ‘realist’ to of investment.” – While health investment used to be seen ‘neo-liberal’ approaches and hence from as a drain on economic development, the state centred foreign and health policies to experience of the ‘tiger’ economies a realisation of the need for collective shows that longer, healthier productive agreement and action. lives are essential to economic growth. European foreign and security policy has In the US, influential reports by the been a contentious issue since the signing Institutes of Medicine (1997), Council on of the European Defence Community Foreign Relations (2001), National Security agreement, and its failure three years later Council (2001) argued that health should in 1954. It proved impossible to move from be an important factor in American foreign a general agreement on defence, to agree- policy, because of the threat to the human ment on common military actions or other security of Americans. aspects of foreign policy. This may be ascribed to the general weakness of the The HIV/AIDS pandemic was discussed at emerging European Union as a political the Davos World Economic Forum, at the entity and its inability, at the time, to UN Security Council and at G7/8 meet- “assert its identity in the international ings. This was followed in 2001 with the scene” as proposed by the Treaty on announcement by Kofi Annan of the estab- European Union. This weakness was lishment of a Global Health Fund to exposed by the EU’s inability to respond to address the problems of HIV/AIDS, the Soviet invasion of Afghanistan or the Malaria and TB, this was originally project- Islamic revolution in Iran. ed to raise some $7–10 billion per year but so far has reached only a quarter of this in Progress in achieving practical cooperation total. on foreign policy was marked by the adop- tion of the London Report in 1981. This The latest estimate from the Commission required member states to consult each on Macro Economics and Health is that other and the European Commission on some $29 billion per year will be required foreign policy issues of mutual concern. from donor countries to address basic But this was still a difficult area, as demon- health needs in poor countries by 2007, and strated by the inability of the EU to take that this will need to be matched by efforts timely, concerted action in response to the of poor countries both to invest $37 billion disintegration of the former Yugoslavia. more in health and to improve the efficiency and targeting of health expenditure. The Gradually the political processes of the EU

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have matured. The debate between ‘federal- inter ministerial, professional and NGO ists’, arguing for cooperation between collaboration in health predates this. autonomous states and ‘functionalists’, Similarly while the 1992 Maastrict Treaty, arguing for transfer of certain powers to a gave explicit recognition to the importance European level, has largely been resolved. of public health protection measures While there remain differences of emphasis, including the strengthening of European there is a general appreciation that national health surveillance networks in relation to governments need to be supplemented by communicable diseases, some of these net- European institutions with responsibility works were already established. Echoes for those areas in which joint action is of the debate between federalists and more effective. functionalists can be seen in discussions as to whether to strengthen public health col- The 1997 Treaty of Amsterdam provided a further stimulus to the extension of foreign laboration by creating networks of national policy by creating the decision making and centres or by establishing single suprana- funding mechanisms for pursuing common tional centres of excellence. Agreement was strategies in relation to foreign policy finally reached in 1998 to adopt a network objectives. The treaty designates the approach and to strengthen early warning 5 Secretary General of the European Council and rapid reaction systems. as the “high representative for common The 1997 Treaty of Amsterdam, both foreign and security policy” and estab- reinforced the provisions of Maastrict and lished a policy planning and early warning promoted a wider perspective on the deter- unit in the General Secretariat of the minants of health by stressing that a “high Council. level of health protection shall be ensured The EU now has the capability to define in the definition and implementation of all and express common foreign and security Community policies and activities.” This policy, but it is more difficult to ascertain initiative should provide the basis for the what the current common foreign policy is. application of health impact assessment to EU foreign policy objectives have been EU policies, as developed for example summarised as: through the Verona Initiative, promoted by the WHO Regional Office for Europe. – Safeguarding the common values, funda- However, it has proved difficult to make mental interests and independence of the progress in this area, there were delays in Union. applying health impact assessment to past “[In low income – Strengthening the security of the Union EU policies, in identifying EU policy and its Member States in all ways. proposals with potentially important health countries] the economic impacts and in promoting the practical – Preserve peace and strengthening inter- implementation of health impact assess- benefits from the national security. ment at national level. The treaty also led to reduction in productive – Promote international cooperation. the establishment of the European Health Forum bringing together health profession- – Developing and consolidating democra- als with an interest in public health (but years lost to disability cy, the rule of law, and respect for strangely omitting patient groups). and death are human rights and fundamental freedoms. It should be noted that the powers and actions of the EU relate to public health estimated to be up to If this seems rather a general statement it and exclude reference to health delivery should be noted that UK foreign policy has systems, since this is an issue for member six times the level of recently been summed up in four words states. However, this does not mean that “prevent conflicts – promote well-being”.3 [necessary] health systems are unaffected. A review of the implications of EU action for health The emergence of EU health policy investment.” and health systems6 showed that, while By contrast to foreign and security issues, explicit European Union health policies health appears to have crept almost had limited impact, there were many unnoticed onto the agenda of the European consequences arising from aspects of EU Union. The 1987 Single European Act may trade, competition and labour policies, be said to have provided the basis for the including the working hours directive development of European cooperation in and, in parallel, the case law developed by public health surveillance, development of the European Court of Justice had very European standards for health information significant implications. and the Europe Against Cancer and Europe Against AIDS programmes. In fact This may have been in part because it was cooperation in these spheres and wider only in 1999 that the Directorate General

31 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION for Health and Consumer Affairs was total EU budget directed towards health established, bringing together EU responsi- protection. bilities for public health. For this reason it We believe it would be helpful and timely is difficult to discern a EU health policy to develop a European Union strategy for before this date. Current European public global health, bringing together foreign and health policy is aimed at: health policy perspectives. In the first place – Improving information on health for all it would be helpful to see the development levels of society. of a ‘pathfinder’ strategy; a set of proposals “It would be helpful exploring the potential for strategy in this – Setting up a rapid reaction mechanism to field and identifying research, development and timely to develop respond to the major health threats. and political hurdles that would need to be – Tackling health determinants, particu- addressed in a full strategy. a European Union larly by addressing harmful factors This could be supported by examination of strategy for global related to lifestyle. the current impact of EU policies and actions on health and foreign policy health, bringing A European Union strategy for global objectives. It might be helpful to attempt to health discern broad impacts arising from policies together foreign and The relatively late development of explicit such as enlargement or the Common health policy foreign and health policy perspectives Agriculture Policy and to promote case within the EU does not mean that such studies to examine the health and foreign perspectives” issues were not important. The agenda of policy impacts of EU actions in relation the EU includes many topics, which might to a specific poor country or accession naturally be thought to occupy the ‘policy candidate. At the same time we hope to space’ between health and foreign policy, stimulate debate within EU member for example: countries to develop their own strategies for global health and to examine how – Trade policies have recognised the action by government, the health industry importance of ensuring the safety of and NGOs can contribute to global health food products and controlling the health and human security. We hope to proceed impact of trade in products such as with such programmes in the UK and the tobacco, blood and anti-microbials. Netherlands over the next year. This will in – Development assistance policies focus turn identify common policies and actions on the impact of trade and particularly that might be taken forward in discussions agricultural trade on development, but at EU level. We welcome comments the debate has also widened to include and suggestions for taking forward this issues concerning health and safety, initiative. environmental standards, child labour and the development of civil society. REFERENCES – Humanitarian aid programmes have focussed on emergency assistance, food 1. Fukuyama F. The End of History and the and refugee support, of which health is Last Man. New York: Avon Books, 1992. an element. 2. Stiglitz J E. Globalization and its – Enlargement of the EU raises issues Discontents. New York: WW Norton & Co, relating to public health, the movement 1992. of health professionals within Europe, 3. MacShane D. The Return of Foreign phyto-sanitary controls, occupational Policy. Chatham House, 13 February, 2002. health and safety and health consumer 4. MacLean G. The Changing Perception of protection. Human Security: Co-ordinating National – Security discussions have recently and Multilateral Responses. Winnipeg; focussed on the prevention of bioterror- University of Manitoba, 1998. ism. 5. McKee M, MacLehose L. Enlarging the There are of course tensions and inconsis- European Union Implications for tencies between aspects of EU policy, for Communicable Disease Control. Eurohealth example, while promoting free trade to 2001;6(5):6–8. support development of poor countries the 6. Busse R, Wismar M, Berman P C, (eds). Common Agriculture Policy also offers The European Union and health services. EU farmers the highest level of agricultural The impact of the single European market subsidies in the world. Subsidies available on member states. Biomedical Research to tobacco growers are greater than the 2002; 50:1-274.

eurohealth Vol 8 No 3 Summer 2002 32 GLOBALISATION Health care shortages: Where globalisation, nurses and migration meet

Europe is ageing rapidly, affecting health –Retired expatriates requiring care in care for patients as well as care providers. country of residence. During the recent economic boom several –People abroad on holiday or business. EU countries were unable to meet the demand for health care personnel, and now Although data are scarce, incomplete and that the economic tide has turned, it will unreliable, nevertheless, there appears to be prove even more difficult to provide health an upward trend in cross-border patient care. Although structural shortages may flows: increasing from 0.17% of European decrease due to the cyclical nature of the public health expenditure in 1989 to 0.5% 1 nursing labour market, as soon as by 1997. Subsequently personnel short- economies flourish once more, nations will ages have increased and European Court again face the full force of personnel prob- judgements made. In-depth analyses of lems. How should countries deal with mobility flows are needed, as they may Frits Tjadens structural health care personnel shortages have consequences for systems, care 2 when populations are ageing? How do they providers and patients. Nickless, for deal with it? This article explores whether example, states ‘the Kohll and Decker cross border movements by patients and decisions have enabled patients to make health workers provide possible answers. uninformed decisions about medical treatment in other Member States…. By making The immediate reaction to health care an uninformed decision to receive lower shortages is care rationing. This results in quality care, patients could be putting their waiting lists and major economic and ethi- health at risk without knowing it’. “The drain of health cal questions concerning the distribution However one study reported that only a workers from poorer and allocation of care. Countries such as minority of German patients on holiday Norway, the UK and the Netherlands all abroad experienced problems: (5% quality, countries can be a have waiting lists, leading to further ques- 6% access and 13% language barriers).3 tions about the management and funding of One question is whether these figures are severe blow to their health care, subsequent political debate, similar for all categories of patients or just and possible ‘unorthodox’ cross border those on holiday, who may be more health care systems” approaches. compliant and grateful given their sudden need? Furthermore is patient assessment Cross-border care similar to expert assessment? One ‘unorthodox’ possibility is to ‘export patients’. The European Court of Justice, Labour migration: universal motives in the Smits-Peerbooms cases, ruled that and consequences waiting lists are a legitimate reason for The second approach is to ‘import’ health patients to seek treatment abroad. In the workers. In a study commissioned by Netherlands, health care insurers were WHO Pacific Region on the migration of urged to be more creative in shortening skilled health personnel (nurses, pharma- waiting lists by contracting cross border cists, doctors) from small Pacific Island care. Generally a number of factors con- countries (PIC) such as Fiji, Palau, Samoa, tribute to mobility of health care utilisation Tonga and Vanuatu, many reasons were in the EU: given why professionals leave the health care sector and migrate for instance to –Individuals can seek treatment abroad of Australia and New Zealand. These include Frits Tjadens is Senior Adviser their own accord, be sent abroad by low remuneration, inflexible hours, heavy at the International Centre of their health care payer, follow the workload, lack of continuing education, the Netherlands Institute for physician (who, for various reasons, limited training facilities, poor career devel- Care and Welfare (NIZW) and may be able to perform his duties opment, poor working environment, project coordinator at the abroad more effectively), or be sent resource shortages, and patient demands Dutch National Forum on abroad on medical grounds. International Health and and complaints.4 At a recent presentation, Social Issues (LOIB). –Cross-border workers and border strikingly these motivations turned out to E-mail: [email protected] inhabitants. be identical in the EU. Reasons for leaving

33 eurohealth Vol 8 No 3 Summer 2002 GLOBALISATION the profession in the Pacific and in western Table 1 Europe are similar. This raises fundamental SKILLED HEALTH WORKERS IN PACIFIC ISLAND COUNTRIES AND questions about the long-term sustainabili- SELECTED OECD-COUNTRIES ty of health care, which need to be Doctors Nurses Population Year of data addressed. If answers could be found, they (per 10,000 population) (million) would not only support the sustainability of health care systems, but would reduce Fiji 3.57 19.35 0.84 1998 migratory flows as well. Palau 11.04 14.40 0.02 1998 Samoa 3.36 14.87 0.17 1998 From low to high: migration world Tonga 4.99 22.34 0.10 2000 wide Vanuatu* 26.00 0.20 1997 From Table 1, excluding nursing data from the Netherlands, which includes non-active UK** 18.41 42.50 58.9 2000 and part-time working nurses, the richer The Netherlands*** 18.12 130.50 15.8 2000/June 2001 countries have more health workers. The Australia 26.00 82.00 18.76 2000 drain of health workers from poorer coun- New Zealand* 22.60 84.50 3.81 1999 tries can be a severe blow to their health care systems, not in the least because it Source:WHO, Pacific Region. puts additional strain on fragile education * New Zealand and Vanuatu: nurses including midwives. systems. In the Pacific, Australia, New ** UK: statistics exclude Northern Ireland; NHS-staff only; nurses include midwives and health visitors. Zealand, and, to a lesser extent, Fiji are Source: www.statistics.gov.uk/statbase/Expodata/ Spreadsheets/D5035.xls. major recruiters. When the UK recruits *** The Netherlands: doctors in curative sector only (2000). from Australia, as in 1998–99 (see Table 2), Source:NIVEL, PRISMANT & OSA: Rapportage Arbeidsmarkt Zorg en Welzijn 2001, p.67. Registered nurses only (June 2001). Same source, Bijlagen, p. 93). the result is globalisation in action, where Australia becomes a transit country, just like Fiji and South Africa. Countries can be resources. Debate on the Philippines also both importers and exporters of nurses at focused on the supposed shortages in nurs- the same time. Not only do nurses migrate ing staff. Parliament also discussed the from one country to another, leaving gaps Dutch Development Ministries refusal to to be filled perhaps by a colleague from cooperate with the Philippines because of abroad, but sometimes they also ‘hop’ their national debt, and bad relationship countries. with the IMF. However, the Philippines deliberately train nurses for export and do International recruitment in Europe have an infrastructure in place to receive International recruitment occurs all over financial compensation for training, factors Europe. With the exception of the UK ignored in the debate. Labour is one of the which recruits globally, this has involved few natural resources and export goods in relatively small numbers of individuals the Philippines. usually from neighbouring countries. This will probably increase as personnel Table 2 shortages become more structural and INTERNATIONAL NURSING RECRUITMENT BY THE UK AND THE pressing, draining resources in source NETHERLANDS countries and even increasing exploitation of workers. Hence WHO, trade unions, Work permit First work permits and professional associations not only Source applications in the UK granted in 2001 5 6 7 speak out against recruitment abroad, but countries 1998–99 2001 UK* Netherlands also propose more ethical practices. Australia 1,771 601 277 South-Africa 1,114 2,514 1,163 35 Ethical recruitment: some experiences Philippines 972 10,050 7,422 39 Comparing figures and populations, Dutch imports would have to increase by 2,900% Nigeria 920 1,100 354 in order to reach the UK level. The UK has India 2,612 1,759 been increasingly active on the global mar- Zimbabwe 1,801 261 ket, unlike the Netherlands. Both countries Ghana 493 147 recruit from their former colonies, as well Trinadad & Tobago 357 43 as the Philippines. Surinam 25 In the Netherlands recruitment abroad Indonesia 10 invariably leads to parliamentary debate. Other 3,525 1,336 5 The Dutch Minister of Health advised that recruitment in South Africa and Surinam Total 4,777 23,063 12,726 114 be halted, following worries about draining * up to 17/12/2001.

eurohealth Vol 8 No 3 Summer 2002 34 GLOBALISATION

Subsequent policy guidelines announced facing staffing shortages, and unclear that recruitment ought to take place in the migration processes. Netherlands first, in the EU/EEA second, If they decide to recruit from abroad, and only then in the rest of the world, with whom do they hire and how do they deal a preference for pre-accession states, such with the consequences? Do they hire as Poland. Recruitment abroad also should young flexible nurses or only the experi- be restricted to countries with a plentiful enced, people without children to minimise supply. This led to debate on whether this homesickness, or those with children to would seriously hinder nurses moving maximise economic profit of wages for the abroad, if they wish to do so, or whether it source country? Should they only accept would only mean that they will not travel unemployed nurses to reduce the strain of to the Netherlands, but elsewhere, instead. systems? The Netherlands considers from an If EU countries decide to collaborate and economic perspective its position in the adopt identical ethical stances, will this international market, and ethically the limit their recruitment area, leading to consequences of external recruitment. The fishing in the same pond, and thus to even UK went further developing guidelines on harder competition? ethical recruitment from abroad. REFERENCES Interestingly this begins with a statement What would this imply for a small country 1. European Commission. that one can learn from foreign experience. like the Netherlands, with its language Health & Consumer As yet this notion has not reached the disadvantage? Should it consider a unique Protection Directorate- Netherlands, hence differences in selling proposition to compensate for this, General. The Internal Market perceptions on recruitment between the and if so what should it be? and Health Services. Report of UK and the Netherlands. Another differ- Could processes lead to a scenario where the High Level Committee on ence is language, the UK has a huge larger member states (with language advan- Health, 17 December 2001. recruitment backyard, as English is the tages) recruit abroad, smaller member 2. Nickless J. A guarantee of lingua franca of the western world. Dutch states ‘export’ patients, and accession states similar standards of medical recruiters have thus far tried to recruit in become suppliers of skilled health workers? treatment across the EU: Were countries where people speak some form of What are the effects of migratory flows on the European Court of Justice Dutch (Surinam, South Africa), and by a the quality of care? Finally to what extent decisions in Kohll and Decker selection system that includes language is language still a crucial variable, given that right? Eurohealth courses. Nevertheless it is clear that the societies have become increasingly multi- 2001;7(1):16–18. competitiveness of the Netherlands is not cultural? 3. Agasi S. Cross border health good in an increasingly global labour care in Europe. A perspective market. Epilogue from German patients. Mobility within the EU will have an Eurohealth 2002; 8(1):37–40. Economy and ethics: questions for increasing impact on health care systems. the near future 4. Connell J. The Migration of In fact, it might lead to an increasing inter- There are a number of questions relevant Skilled Health Personnel in the nationalisation of systems. For employers, for all EU countries facing health care Pacific Region. Sydney: non EU countries are certainly not the first labour shortages now or in the future. University of Sydney, School place to look for personnel, as indicated by of Geosciences, 2001. How should small countries act in an a Dutch survey earlier this year. But when increasingly global labour market for 5. Irwin J. Migration patterns all is said and done, that is what they will health care personnel, and how can we of nurses in the EU. do. More and more EU countries face deal with third-country workers who Eurohealth 2001;7(4):13–15. severe staffing problems in their health care then decide to try their luck in other EU systems, not only including nursing and 6. Buchan J. International countries? If countries need to ‘import’, Recruitment of Nurses: United medical staff but also less qualified care can this be turned around into a win-win Kingdom Case Study. Queen personnel. No solutions have yet been situation for all parties involved and if so, Margaret University College, found for this problem. There is a need for will rich countries inevitably win more Edinburgh, Scotland, July EU-wide monitoring and evaluation of often than the poor, or is a more equitable 2002. innovative initiatives to balance supply and distribution possible? How does this relate demand, including cross border mobility of 7. Centre for Labour and to country-hopping by health workers? Income (CWI). In: Ad hoc both health care workers and patients. The werkgroep Buitenlandse ver- How should EU countries act, will they Social Protection Committee, in its think- pleegkundigen. De CAZ- end up as competitors, colleagues or in ing about its Open Method of afspraken ten aanzien van de coalition? They need to deal with issues Coordination on health care and care for werving en tewerkstelling van concerning basic human rights for workers, the elderly, proposes a focus on accessibili- buitenlandse verpleegkundigen voters that want adequate health care and ty, quality and financial viability. All three en verzorgenden van buiten de an end to immigration at the same time, issues are heavily influenced by the avail- EU. Utrecht: Sectorfondsen ethical and practical questions surrounding ability of skilled workers, but no mention Zorg en Welzijn, 2002. operating theatres, health care employers has been made of this.

35 eurohealth Vol 8 No 3 Summer 2002 HEALTH POLICY Devolution of health care in Spain to the regions becomes reality

Even the most optimistic observer did not believe that the Conservatives would decentralise health service management to all Spain’s Autonomous Communities (AC). Nevertheless, the government surprised everyone in July 2001 by agreeing new fiscal arrangements with ACs (some under socialist control), including the devolution of health care responsibility.

It came as a surprise expectations by partisan politicians that The speed and comprehensiveness of the transferring health responsibilities would Guillem Lopez- transfer came as a surprise. First, because change the political balance both between some had argued; including trade unions, Nationalist/Socialist and Conservative Casasnovas that previous decentralisation in seven administrations, and also in Conservative regions (60% of overall expenditure) had areas of influence. If not already begun, eroded social cohesion. Second, the opposi- decentralisation would not have started tion party was divided, representing on one now, but given its progress, any return hand a regional partisan view, and on the back to centralisation appears worse than other, an alternative government keen not further devolution. Extending devolution is to weaken central control. Third, some also a way of weakening the search for areas lacked detailed agreements, notably differential power positions by more on finance (for example, on costing services nationalistic ACs (Catalonia, Basque and redistribution parameters), and on country and Navarre) in favour of so called basic central regulation of health planning ‘café para todos’ (coffee for all). and coordination. The latter is not trivial as ten ACs have populations under two The new fiscal agreement million. Some key features of the new arrangements are summarised: Why then has this happened? One political interpretation is that politicians believe 1. Regional health care finance is now public health care is unmanageable (for included in general financial AC agree- example, complaints, demands for extra ments. Previously it was decided by resources, resistance to administrative separate negotiation between the national change etc) and decentralisation is therefore and corresponding regional Ministers of the first step towards privatisation. Health. Given that health care budgets Additionally, by limiting central commit- accounted for 40% of regional expenses, ments the Government may protect its negotiation could seriously affect regional own purse, leaving the regions facing the finance. Now it will not be determined by political consequences. political bargaining between central and regional Departments of Health, but firstly However the Conservatives are involved in by finance ministers initially, and secondly, a number of ACs, Madrid, Galícia, Castilla by regional ministers within each AC. – Leon and Cantabria, and there is only Regional parliaments will now have a more anecdotal evidence suggesting they favour decisive say on heath policy. privatisation of provision and funding. Guillem Lopez-Casasnovas is Alternative arrangements may have looked 2. There is a minimum level of health Professor of Public extremely complex. For example, organis- expenditure. This may be based on (i) Economics, and Director of ing health care for 40% of the population, expenditure at time of transfer or (ii) share the Center for Health and with high disparities between centrally of overall central expenditure weighted by Economics, University managed regions (because of the generous population (75%), age (24.5%) and ‘insular- Pompeu Fabra, Barcelona, treatment of Madrid AC) under consortia ity factor’ (0.5%) (Balearic and Canary Spain. agreements; with regulated cross boundary Islands only). If the former is greater, the E-mail: flows and other mechanisms appeared central government is committed for three [email protected] complicated. Additionally, there were years only to maintain expenditure

eurohealth Vol 8 No 3 Summer 2002 36 HEALTH POLICY

increased by nominal GDP growth and at reimbursement of new drugs and new factor costs. However, above the basic level, technologies. Without compensation, each AC in future can use its own funds regional acceptance is less likely. discretionally to increase expenditure. 6. A defined basic entitlement package will 3. From 2002, funds to finance all AC become a necessity if patients are not to services (including health) now come from exploit differences. Diversity should not be a share of taxes collected regionally: income a cause for concern, (so legal precedent tax (33%), VAT (35%), petrol, tobacco and suggests) provided the basic minimum alcohol taxes (40%), and 100% of minor package is covered, and additions financed taxes (for example, car registration, energy by regional sources. Handling other tax, inheritance, property transfer, gam- variations in policy, such as for drugs, may bling). Initially, everything, including the not be straightforward. Regions will not central transfer equalisation, will be com- negotiate drug prices, but may well influ- puted to guarantee that all basic needs ence the prescribing habits of professionals, (health, and education – in per capita posing new challenges to drug company terms) will be covered. This applies also to marketing departments. some pre-set increases over time. If revenue sharing capability increases, e.g. if regional The future: fewer geographical consumption indicators increase in per- equity taboos and more fiscal centage terms, or if a surcharge on income accountability tax is applied (+/- 20%), no restrictions Integration of health care within the gener- will apply to this additional revenue. al financing system for all AC indefinitely 4. To preserve cohesion, and avoid should end a very contentious political ‘excessive’ deviation in per capita health process. The present system has promoted spending, central transfers will help those little consensus among health authorities, AC that have increases in public health the only common interest being their coverage (for example, legal immigration) demand for more resources from central three points above the Spanish average. government. There have been endless Additionally, all AC will have to finance at disputes on the share of funds allocated least some of the increase in basic health between ACs, consequently all health care. No maximum level is defined, a vari- problems are blamed on a lack of resources, able average according to the effectiveness with little discussion of new evidence- of regional revenue raising capacity may based policies. result. Increases in funding, may arise from Now, complaints about central under the possibility of setting a petrol tax on funding of regional health care will have to consumers (as a surcharge) just to finance cease. This is appropriate because, despite health care. This is not a real earmarked common perception, Spain is not an tax, but a way to build a more politically unequal country in terms of health delivery acceptable tax. The Central Administration and finance. This is borne out by a recent has already approved a central tax on petrol study that evaluated the impact of regional to finance planned health expenditure. AC health policies since the first health strongly complain that this makes it more transfers to Catalonia in 1981.1 Indeed the difficult to impose their own taxes as stated coefficient of variation in regional health in fiscal agreements. At any rate Madrid care finance per capita is one of the lowest has recently created the surcharge for the in systems for which territorial health care fiscal year 2003. expenditure may be identified. Contrastingly, France and England are 5. A Cohesion Fund from the central among countries with the most uneven budget will allocate resources to compen- distribution of health care resources. This is sate for cross boundary flows of patients probably because their health regions are amongst regions. The central state plans to geographical artefacts, with no parallel create a homogeneous information system in regional government. Therefore, with DRG type billing, subject to negotia- differences are not readily translated into tion with regional health authorities. Some the political arena, as in Spain or Italy, and regions seem prepared to coordinate central governments are under little themselves to avoid central intervention, political pressure to justify variations. for example, in the extended central (Madrid and both Castillas) health region. Additionally, differences observed between Caveats exist on compensation for new Spanish regions relate to relatively few central regulations or pricing policies that programs that have little practical relevance affect regional expenditure, for example, to health status. For example, Andalusia

37 eurohealth Vol 8 No 3 Summer 2002 HEALTH POLICY finances certain low therapeutic value Having said this, we should also recognise drugs, which are excluded in most regions. that we know relatively little about health Only a few regions will finance sex change differences deriving from variations in operations or the ‘morning after’ contra- quality of care or clinical practice. Probably ceptive pill. These differences should cause there is no fundamental regional pattern to few equity concerns, as they reflect differ- such disparities. The main equity concern REFERENCES ent political views on public preferences. probably relates to intra-regional differ- G Lopez (ed.) Evaluacion de Such interventions should be self-funded, ences rather than inter-regional differences. las Politicas Sanitarias en el as there seems little basis for inter-regional Those who have spoken loudest against the Estado de las Autonomias. transfers to support them. Indeed, where dangers of inter-territorial inequities have Generalitat de Catalonia: conducted, regional opinion polls seem to not usually made as much effort to redress BBVA Foundation and The favour keeping such decisions close to imbalances between local areas within Institute for Autonomic citizenry affected. regions. Studies, 2001.

Stimulating interest in European public health

The relationship between individual states established Institute of Public Health in and the European Union is brought into Ireland was seen as ideally placed to sharp focus with current moves towards explore the implications of the new EU greater integration and enlargement. programme for all on the island. Historically the economy and security have Responding to feedback obtained from this been to the fore in debates but after the and many other responses throughout Maastricht and Amsterdam treaties were Europe, the Commission produced an adopted, the EU was awarded specific amended proposal. At their June 2001 jurisdiction in the field of public health. meeting the Health Council reached There is a new Directorate General for political agreement on a common position Health and Consumer Protection and there for a programme of community action in will be an “increasing involvement of public health. The programme budget is European Union institutions in health currently A280m. Owen Metcalfe policy including direct involvement on public health and health protection”.1 Initial reaction to the EU Programme There is also an aspiration that the The initial proposed health strategy Commission has a stance on the overall received a broad welcome from member approach to health across different policy states, the European Parliament, and many “Improved collection areas. The aim is to ensure that the impact other stakeholders. The European Public of a public health programme is reinforced Health Alliance (EPHA) stated that “the and dissemination of by policies and actions in areas having an Commission’s health strategy document effect on health and health systems. As part health information and action programme provides a solid of this changing landscape the Commission framework for EU health policy”2 The prepared a health strategy document and Catalonian Health Minister, said that “the and knowledge is of proposal for a programme of community new health strategy represents a qualitative action in the field of public health. This vital importance” leap in European health policy and points article provides an overview of reactions very clearly to an increasingly important and details a process used on the island of role for health in the construction of the Ireland to explore implications of this European Union”.3 Dr. Tapani Piha called programme. the proposal “very interesting and There had been a general perception that profound, and the first overall approach to those in the Republic were more informed health across different policy areas in the Owen Metcalfe is Associate about European developments than their community”4 The Institute of Public Director, Institute of Public Northern counterparts. In Northern Health in Ireland’s Director said “the new Health in Ireland. Ireland many involved in public health EU Programme offers us a wonderful E-mail: thought EU health developments had not opportunity to take action together to tackle [email protected] made a significant impact. The newly the causes of ill health”,5 while the

eurohealth Vol 8 No 3 Summer 2002 38 HEALTH POLICY

“Increased interest and European Network of Health Promotion that the proposed programme is cautious, Agencies (ENHPA) welcomed “the seeking to consolidate previously success- commitment could be emphasis and importance given to a more ful areas. strategic approach to the impact on health achieved with the of other EU policies and the broader The Irish response 6 establishment of desig- content of health within EU policies”. Apathy had previously caused one commentator to state, “it is striking to note Although the proposal was welcomed as a how little attention has been paid by public nated international deepening and focusing of the health professionals to debates on public Community’s approach to public health health.”8 Thus the Institute wished to and European portfo- many commentators had concerns. The ensure that the public health community ENHPA felt that the budget was not ade- lios within public were not ignorant or apathetic to this quate, and as the programme would only important European development. Debate fund 50% of project costs, many innovative health organisations.” about the programme was stimulated with organisations would not participate. the aim of developing clear recommenda- Funding is small compared to other issues tions and actions that would, firstly allow such as EU subsidies on tobacco. The for a strengthening of links for public EPHA commented generally that many health on the whole island and with the rest strategic questions and operational issues of the EU, and secondly maximise the remained unresolved.7 potential for public health development One innovative feature of the programme offered by the programme. is the establishment of a forum to promote A combination of focus group work, wide consultation and participation. It is didactic information sessions and work- difficult though to see how representation shops were used to arrive at agreed can be achieved in the forum, the diversity recommendations on how to move forward of interests in public health will make and maximise the potential of public health. consensus often impossible. Thus despite (See Figure 1). Focus group methodology this innovation, the overall impression is allowed the identification of key issues without requiring a large group of partici- Figure 1 pants. Focus groups consisted of senior PROCESS USED TO DEVELOP RECOMMENDATIONS management from public health, health promotion and community development. FOCUS GROUP WORK After reading the proposed EU Programme Participants Key public health representatives and discussing crucial priority areas in public health, this group identified four key Actions Supply key representatives with essential information areas to be addressed to strengthen public health links within Ireland and with the Ask key representatives what are the issues? what are the priorities? rest of Europe: – Improving the collection and dissemination of health information and knowl- Use of outcomes of focus edge in Ireland, North and South and in group work to inform seminar Europe. – Strategic development of public health policy in Ireland, North and South and SEMINAR INCLUDING PLENARY PRESENTATIONS AND WORKSHOPS in Europe. Participants Invited audience of senior people involved in public health, – Clarifying and defining responsibilities, North and South roles and structures in Ireland and Actions Provide information Europe. – Integrating health into other policy areas Address focus group priorities in Ireland and in Europe. Ask critical questions A seminar was then held by the Institute; Develop recommendations European Public Health – The Irish Connection. Over 100 individuals partici- pated and were provided with information Use of outcomes of seminar on the programme by Commissioner to develop recommendations Byrne, as well as an assessment of programme contents by relevant experts. Seminar participants took part in separate Production and dissemination of report workshops addressing the four themes “IMPLICATIONS OF EUROPEAN PUBLIC HEALTH” previously identified by focus groups. Key

39 eurohealth Vol 8 No 3 Summer 2002 HEALTH POLICY recommendations and actions arising that public health in member states and at would strengthen public health in Ireland European level. The Institute is certain that and Europe in the four groups are sum- if these recommendations are followed, the marised below. More detailed information impact and effectiveness of the programme is available elsewhere.9 will be greatly enhanced. Prioritisation is difficult, but the Institute learnt that To improve the collection and dissemination improved collection and dissemination of of health information and knowledge: con- health information and knowledge, and the duct an information audit on the current requirement for public health to tackle availability of health information and data REFERENCES social and economic inequalities are of vital sets; additional data are required in areas importance. 1. Dargie C. Policy Futures for where deficits exist, particularly for UK Health. London: Nuffield determinants of health and inequalities; These recommendations can be addressed Trust, 2000. standardisation is required of data collec- within the EU stated aspiration of improv- tion, management, analysis and reporting ing health information, knowledge and 2. European Public Health Alliance. Future health strate- procedures; information systems should addressing health determinants. The gy: Sharing ideas on how to incorporate components for analysis, Institute believes that all its recommenda- move EU Health Policy for- reporting and communication of informa- tions can be implemented, but sustained ward. Update 2000;52(supp. tion. commitment will be necessary to achieve September/October). For strategic development of public health this. It calls on the Commission, the 3. Rins Pey E. The new EU policy in Ireland, North and South: Council and Parliament to allocate suffi- Health strategy and the public health must be defined on a multi- cient resources to ensure implementation. regions. Eurohealth disciplinary and multi-sectoral basis; the The changes in the programme whereby 2000;6(4):10. consultation process in public health policy 70% of project costs may be available, development is crucial; structures allowing compared to 50% outlined initially are 4.Piha T. The new EU health for easy, effective communication to take welcome, but the Institute remains very strategy: Moving forward place at local, regional, national and concerned that the Health Council meeting through communication and A international level need to be established; assigned only 280m to this programme. debate. Eurohealth 2000;6(4):7. structures and consultative processes need It is also concerned that many in public 5. Wilde J. Public Health in adequate financial and personnel resources; health, not just in Ireland, but elsewhere, Europe – The Irish all health strategies and policies should are unaware of and uninterested in Connection. Dublin: Institute have as a core aim the reduction of social European developments. This apathy is not of Public Health in Ireland, and health inequalities. good for public health. The proposed EU Press Release, November 2000. To clarify and define responsibilities, roles forum for health, if operated inclusively, 6. European Network of and structures in Ireland and Europe: con- can attract participation and interest from a Health Promoting Agencies. duct an audit of roles, responsibilities and wide range of stakeholders and assist in The Response of the ENPHA structures for public health; given health overcoming apathy and increasing interest. to the EU Communication on issues are not considered important by This increased interest and commitment the Health Strategy of the many outside the health sector, responsibil- could be achieved with the establishment of European Community and the ities must be allocated across Government designated international and European Proposal for Adopting a departments, and commitment to the portfolios within public health organisa- Programme of Community health agenda obtained at senior level; a tions. The recommendations highlight Action in the Field of Public health forum is a useful mechanism for the necessity for increased contact and Health (2001–2006). ENHPA, achieving collaboration on health. communication between public health November 2000. organisations throughout Europe. To integrate health into other policy areas 7. Hayes A. Update in Ireland and Europe: a wider awareness This programme has the potential to make a 2000;52(supp. of influences on health is important in pro- significant impact on public health in September/October). European Public Health moting public health considerations; cross Europe. The degree to which member states Alliance. sectoral working is essential for effective engage with the programme will be critical public health; all relevant policies must be to success. This is a two way process, 8. Brodin M, Weil O, McKee health proofed, health impact assessment is progress in European public health will M, Oberlé D. Preface. In: one tool for this; strategic and protected depend on member state and Commission Priorities for Public Health budgeting is critical in ensuring health commitment. Arrangements for the man- Action in the European Union. integration into other policy areas; strong agement and implementation of the Weil O, McKee M, Brodin M, determined leadership is needed to secure programme are critical and must include Oberlé D (eds). Vandoeuvre- political support for integration. appropriate member state representation. If les-Nancy: Société Francaise the Commission addresses the recommen- de Santé Publique, 1999. Conclusions dations outlined here, the Institute believes 9. Metcalfe O. Implications of This process resulted in very clear there are major opportunities for a bright European Public Health. recommendations about how this exciting future for European public health in the Dublin: Institute of Public development can be used to strengthen first decade of the century. Health in Ireland, 2001.

eurohealth Vol 8 No 3 Summer 2002 40 EUnewsCOMPILED BY EHMA, ENHPA & HDA

EUROPEAN HEALTH FORUM DISCUSSES EU ENLARGEMENT AND RESEARCH

TheEuropeanHealthPolicyForummetinBrusselsonJune20todiscussHealthandEUEnlargementandthenewSixthFrameworkResearchProgramme. Representativesofsome40stakeholdergroupswerepresent.

Health and Enlargement appointed Director of ‘Life Sciences: Future Priorities Dr Magdalene Rosenmoller present- Research for Health’, discussion In concluding discussions, speakers ed the health service challenges of highlighted the absence of ring including Clive Needle of the enlargement on behalf of the fenced research funding to imple- European Network of Health European Health Management ment the policy priorities of DG Promotion Agencies (ENHPA) Association (EHMA). She stressed Health’s new EU public health pro- stressed that the role of the Forum that EU accession negotiations have gramme and the lack of any defined must be to provide input into policy not adequately addressed health focus for health services research discussions at an early stage rather systems. While negotiations have within the new programme struc- than simply reacting after the event. focused on implementing the very ture. However, Fernand Sauer, Pressing issues for future discussion narrow public health dimension of Director of the Commission’s Public include health aspects of the EU legislation (the ‘Acquis’), poli- Health Directorate, expressed confi- Intergovernmental Conference and cies supporting health system devel- dence that the new public health Treaty reform, which will be taken opment in accession states are frag- programme would benefit from up at the next meeting in November. mented. greater resources available from FP6.

Draft recommendations presented at Further information on the meeting is available at: http://forum.europa.eu.int/ the meeting called on the Public/irc/sanco/ehf/library?l=/policy_2002_brussels Directorate-General for Health to take the lead in launching a new joined up strategy or ‘coordinating centre’. This would bring together 6TH RESEARCH FRAMEWORK PROGRAMME ADOPTED all DGs to address pressing public health and health infrastructure defi- On15May,theEuropeanParliamentapprovedtheCommission’sproposalforthenewEUResearch ciencies and provide a central infor- andDevelopmentFrameworkProgramme(FP6).TheEmploymentandSocialCouncilformallyadopted mation point for accession countries FP6onJune3. on all EU health related issues. Such a development would clearly require The new programme will run until ecosystems, and citizens and gover- additional resources for the Public 2006, with a budget of A17.5 billion, nance. FP6 will also introduce new Health Directorate. a 17% increase on FP5. This repre- instruments, such as networks of This call for a coordinating office sents a substantial EU financial and excellence and integrated projects to providing information for accession policy effort to upgrade European help pool financial and intellectual countries was also echoed by Louise scientific knowledge, quality and resources, Sarch from the European Heart competitiveness. Some 34 amend- The sensitive issue of ethics in the Network (EHN). She also ments were made to the final text programme was not adopted, due to highlighted the challenges of by Parliament on expenditure divisions between Member States. communicable disease (tuberculosis, breakdown, reflecting Parliament’s The Commission will append a dec- hepatitis, HIV/AIDS, other sexually concern that emphasis be placed on laration stating that it will not transmitted diseases and diphtheria), tackling serious diseases such as finance research programs involving non-communicable disease (cardio- cancer and those that affect chil- genetic manipulation, human vascular diseases, cancer and dren. cloning or the creation of embryos injuries) and the need to develop Amongst the priorities covered by for research purposes. The first call civil society and public health FP6 are life sciences, genomics and for proposals is expected in autumn infrastructures. biotechnology for health, informa- 2002. tion science technologies, new pro- EU Research Further information is available at: duction processes and devices, food Following a presentation of the Sixth http://europa.eu.int/comm/research quality and safety, sustainable Framework Programme (FP6) /fp6/index_en.html development, global change to by Octavi Quintana, the newly

41 eurohealth Vol 8 No 3 Summer 2002 EU HEALTH COUNCIL: PATIENT MOBILITY AND HEALTH CARE DEVELOPMENT

HealthMinistersmetintheEUHealthCouncil(27June2002)toagreeasetofconclusionsonpatientmobilityandhealthcar edevelopmentsintheEU.They alsoreviewedthecurrentstateofplayofEUtobaccocontrol,preventionofdrugdependence,reformofEUpharmaceuticallegi slation,qualitystandardsfor humancellsandtissues,andresultsoftheG10Medicineshigh-levelgroup.

It was recognised that although healthcare and care for the elderly together with, inter alia, the new there is a wide range of issues linked being carried out by the Social research and telematics programmes to patient mobility and health care Protection Committee and the provide a framework to pursue a in the European Internal Market, no Economic Policy Committee on the number of issues in relation to forum exists for hosting these dis- basis of the conclusions of succes- mobility of patients, in particular cussions. Therefore, EU Health sive European Councils. It also aspects relating to information and Commissioner Byrne announced notes the work being undertaken on exchanges of experience. the establishment of a ‘high-level the reform and modernisation of 6. In the light of these considera- process of reflection’ to resolve this Regulation 1408/71 which should tions, the Council and Member issue and take discussion forward. provide a simplified framework to States’ representatives consider that support, inter alia, patient mobility. The Council’s Conclusions on It underlines the necessity to take there is a need to strengthen co- Patient Mobility and Healthcare are health concerns and patients’ inter- operation in order to promote the reproduced below: ests fully into account in this process greatest opportunities for access to health care of high quality while 1. The Council and the representa- in which the delivery of care shall be maintaining the financial sustain- tives of the Member States meeting another main concern together with ability of healthcare systems in the in the Council recognise that health the administrative issues. The rele- EU. The imminent enlargement of care systems in the EU share com- vant instances of the Community the EU makes this even more mon principles of solidarity, equity and its Member States should be imperative. and universality, despite their diver- fully involved regarding the implica- sity. They also recognise the emerg- tions of this process. In particular, 7. To this end the Council and the ing interaction between health sys- the Ministers of Health should be representatives of the Member tems within the EU particularly as a fully involved in this process. States meeting in the Council: result of the free movement of citi- 4. With regard to developing cross- – recognise that there would be zens, and their desire to have access border cooperation, the Council value in the Commission pursuing to high quality health services. and Member States’ representatives in close cooperation with the 2. The Council recalls that accord- recognise that bilateral or regional Council and all the Member States – ing to Article 152 of the Treaty, arrangements, which respect the particularly health ministers and Community action in the field of competence of Member States to other key stakeholders – a high level public health must fully respect the organise their health care systems process of reflection. This process responsibilities of the Member and which are in accordance with should be closely coordinated with States for the organisation and relevant Community legislation, can relevant work ongoing in different delivery of health services and med- play an important role, and they fora, including action already initi- ical care. However, it recognises underline the importance of sharing ated in the context of the Lisbon that other developments, such as information about such initiatives. process. This high-level process of those relating to the single market, They emphasise that patient mobili- reflection, about which they wish to ty, especially concerned with have an impact on health systems. be kept regularly informed, should tourism or long-term residence The Council is concerned that these aim at developing timely conclu- abroad, presents particular chal- should be consistent with the sions for possible further action. lenges in terms of the need to Member States’ health policy objec- exchange clinical and other informa- – welcome the Commission’s inten- tives, and the common principles tion, in order to ensure proper fol- tion to take forward work in this outlined above. It therefore consid- low-up and continuity of care. They field, inter alia by including relevant ers that there is added value in recognise the importance of cooper- actions in its work plan for the pro- examining certain health issues from ation, inter alia, to examine the ben- gramme of Community action in a perspective that goes beyond efit of reference centres, in order to the field of public health. national borders. In this context it facilitate the most effective treat- welcomes the debate at the seminar 8. The Council and Member States’ ment for those diseases requiring of health ministers held in Malaga in representatives will return to this specialist interventions. February 2002 which sets out a issue at the next meeting of the number of priority issues for further 5. The Council recognises that the Health Council, taking into account cooperation and takes note of the new programme of Community the developments of the reflection expert discussions on this subject. action in the field of public health process mentioned above. 3. The Council takes note of the A full report of the meeting is available at: http://europa.eu.int/rapid/start/cgi/ ongoing work on the future of guesten.ksh?p_action.gettxt=gt&doc=MEMO/02/155|0|RAPID&lg=EN

eurohealth Vol 8 No 3 Summer 2002 42 EUROPEAN PARLIAMENT APPROVES ‘FOOD HYGIENE PACKAGE’ The Commission and WHO join forces to tackle health OnMay15Parliamentapprovedinafirstreading(withmanyamendments)Commissionproposals threats ona‘foodhygienepackage’originallyadoptedbytheCommissioninJuly2000. Last year, WHO and the European The package includes proposals on to decide what safety measures to Commission explored the possibil- general food hygiene, hygiene of take, rather than prescribing them ity of establishing a new partner- food of animal origin, and animal in great detail. Amendments adopt- ship and a framework for coopera- health rules. The new regulations ed by Parliament included making tion. Subsequently, a series of high- will merge, harmonise and simplify exceptions for traditional local spe- level consultations were held in complex hygiene requirements cialties. The package will be dis- Brussels in June to advance joint previously scattered over 17 direc- cussed in the European Council and efforts to tackle health threats tives. They require food operators adopted through the co-decision throughout the world. Public to bear full responsibility for the procedure. Health Commissioner Byrne, safety of the food they produce, Trade Commissioner Lamy, General information about the ini- with the help of programmes of Research Commissioner Busquin tiative is available at: www.europa. self-regulation and modern hazard and Development Commissioner eu.int/rapid/start/cgi/guesten. control techniques. Legislation sets Nielson as well as senior officials ksh?p_action.gettxt=gt&doc=IP/02/ objectives, leaving national govern- from DG Environment and WHO 719|0|RAPID&lg=EN ments and businesses the flexibility Director General, Dr Gro Harlem Brundtland, discussed joint strategies to address a wide range of health related issues, including RESEARCH SHOWS THE LINK BETWEEN UNEMPLOYMENT AND smoking, communicable diseases, HEALTH health research, access to medicines, the environment and health, A new study Unemployment and In addition, a new study by Anneke nutrition and food safety. Public Health, led by Professor M Goudswaard and Frank Andreis The meeting reviewed ongoing Harvey Brenner from the Technical from the TNO Research and successful cooperation University, Berlin, and sponsored by Organisation prepared for the between the EU and WHO on a the European Commission reports a European Foundation for the variety of different initiatives, such direct link between ill health, life Improvement of Living and as the Programme for Action on expectancy and long periods of Working Conditions indicates that Communicable Diseases in unemployment. According to the temporary staff across the EU Developing Countries and the study, those who work usually live continue to experience poorer work- development of new international longer and enjoy better health. ing conditions than their permanent public/private partnerships, such as Active labour market policies, which colleagues. They perform less skilled the Global Fund, which has com- result in increased employment, jobs, receive lower incomes and have mitted funds to more than 40 improve the health of individuals. less access to training. developing countries to fight The Interim Report is available at: The report is available at: AIDS, Tuberculosis and Malaria. www.europa.eu. int/comm/ www.eurofound.ie/publications/ They decided to work towards employment_social/news/2002/may/ file/EF0208EN.pdf increasing the amount of Official unempl_en.html Development Assistance (ODA) targeted towards health (currently at 7.4%) and agreed on major trade related issues to improve access to PARLIAMENT SUPPORTS COMMISSION PROPOSAL FOR AN medicines. Future priority areas for AMENDMENT TO THE FOOD LABELLING DIRECTIVE cooperation include strengthening the existing partnership on tobacco OnJune12,theEuropeanParliamentapprovedaCommissionproposaltoamendthefood-labelling issues and health information as Directive. well as exploring ways for cooperation in new areas such as health This is intended to ensure that all consumers are informed of the complete con- aspects of EU enlargement, the link tents of foodstuffs, enabling consumers with allergies to identify any allergenic between poverty and health, and ingredients present. The proposal means that all ingredients added will have to child health. be included on the label and will abolish the ‘25% rule’ which is currently in place and holds that it is not obligatory to label components of compound The Commission Press Release is ingredients that make up less than 25% of the final product. The proposal will available at: www.europa.eu.int/ also establish a list of ingredients liable to cause allergies, including alcoholic rapid/start/cgi/guesten.ksh?p_ beverages if they contain an ingredient on the allergen list. The Council is action.gettxt=gt&doc=IP/02/830|0| expected to adopt a common position in November 2002. RAPID&lg=EN

43 eurohealth Vol 8 No 3 Summer 2002 News in Brief

Commission funded public health Initiative on access to drugs for European Health Insurance Card projects low-income countries The Employment and Social Policy The Commission has released The EU has unveiled a plan to Council (June 3, 2002) adopted a further details of projects funded ensure that low-income countries resolution giving further momentum in 2001. These are available at: with no domestic drug production to the implementation of the can obtain affordable supplies of Commission’s Action Plan for Skills AIDS essential medicines. The plan is set and Mobility, including the up- http://europa.eu.int/comm/health/ out in a communication to the Trade coming European Health Insurance ph/programmes/aids/2001indx.htm Related Intellectual Property Rights Card. The Council agreed on a Rare Diseases (TRIPS) Council at the World Trade proposal to step up protection of http://europa.eu.int/comm/health/ Organisation in Geneva and follows workers against the risks relating to ph/programmes/rare/fundproj2001_ on from a Declaration made in Doha asbestos exposure, and also list.htm last November on TRIPS and Public approved the Community strategy Health. The plan would enable a on health and safety at work for the Health Monitoring foreign supplier to fill orders on the period 2002–2006. http://europa.eu.int/comm/health/ basis of a compulsory licence to ph/programmes/monitor/proj01indx address the specific public health Danish EU Presidency Priorities _en.htm needs of another WTO member In a speech to the European Parliament on July 3, Prime Commission doubles research state. Minister, Anders Fogh outlined the spending on pharmaceuticals The full text of the EU priorities of the Danish Presidency. Speaking at the annual assembly of Communication to the TRIPS The programme will be based on the the European Federation of Council is available at: theme One Europe with the princi- Pharmaceutical Industries http://europa.eu.int/comm/trade/ ple aim of completing enlargement Associations (EFPIA) in Bruges in miti/intell/intel3.htm negotiations in Copenhagen at the June, Research Commissioner More information on access to end of the year. The Danish EU Busquin committed at least essential medicines is available at: Presidency website stresses continu- A2 billion to pharmaceutical research http://europa.eu.int/comm/trade/csc/ ity rather than bringing forward within the sixth framework pro- med.htm major new initiatives in the health gramme, with a particular priority field. “In the health field, it will be on genomics and biotechnology for Directive on products used to test very important for the Danish health. This compares with A1 bil- the safety of blood Presidency to follow up the present lion under the fifth framework. He The Commission has approved a debate on the future shape of called for greater research spending new Directive that establishes EU European co-operation. Work on in future to improve the internation- wide technical specifications for the proposed Directive on tobacco al competitiveness of the EU products used to test the safety of advertising and negotiations on the pharmaceutical industry. blood and organ donations. These WHO international convention on Further information is available at: common technical specifications tobacco control also constitute high- http://europa.eu.int/rapid/start/cgi/ (CTS) replace existing national rules priority health issues. Considerable guesten.ksh?p_action.gettxt=gt&doc for products used to ascertain blood priority is attached lastly to pressing =IP/02/920|0|RAPID&lg=EN groups and test for infectious agents ahead with discussions on reform of such as HIV and Hepatitis. EU pharmaceutical legislation.” Commission to invest in Manufacturers are expected to com- nanotechnology research ply with these specifications unless Further information on the Danish Machines no bigger than a molecule they have appropriate reasons for EU Presidency programme is will one day surf our bloodstream, doing otherwise and can offer a available at: www.eu2002.dk/ search and destroy infected tissue solution that is at least equally safe. programme/ and heal our wounds. This is just one application of nanotechnology. ENHPA, EHMA and HDA can be contacted at the following addresses: On June 14, the EU Research Commissioner chaired an informa- European Network of Health Promotion Agencies, tion day on Nanotech New Frontiers 6 Philippe Le Bon, Brussels Tel: 00.322.235.0320 in Grenoble, France. Research is still Fax: 00.322.235.0339 Email: [email protected] in its infancy and will be more effective if coordinated and supported at European European Health Management Association Health EU level. The Commission will Management 4 Rue de la Science, Brussels 1000 therefore allocate A700 million to Association Email: [email protected] research within the 6th Framework. More information on Health Development Agency nanotechnologies is available at Holborn Gate, 330 High Holborn, London WC1V 7BA www.cordis.lu/nanotechnology Email: [email protected]

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