Eurohealth
RESEARCH • DEBATE • POLICY • NEWS Volume 13 Number 3, 2007
Making the economic case for mental health in Europe
France: Health promotion for migrants
Intergovernmental relations in Italian health care
Health inequalities in the decentralised Spanish health care system
Migration of Flemish doctors to the Netherlands • Romania: Pharmaceutical pricing and reimbursement Austria: Electronic health record development • Institutional and community care for older people in Turkey Eurohealth A timely opportunity for Europe LSE Health, London School of Economics and Political The European Commission has just published its new Science, Houghton Street, London WC2A 2AE, United Kingdom C Health Strategy ‘Together for Health: A Strategic fax: +44 (0)20 7955 6090 Approach for the EU 2008–2013’. Building on current www.lse.ac.uk/LSEHealth
work, this Strategy aims to provide, for the first time, Editorial Team an overarching strategic framework spanning core EDITOR: issues in health, as well as in ‘health in all policies’ David McDaid: +44 (0)20 7955 6381 and global health issues. email: [email protected] O FOUNDING EDITOR: Elias Mossialos: +44 (0)20 7955 7564 The explicit inclusion of the promotion of mental, as email: [email protected] well as physical, health is a timely reminder of the DEPUTY EDITORS: importance of looking at health holistically. Poor Sherry Merkur: +44 (0)20 7955 6194 mental health affects more than 130 million Europeans email: [email protected] Philipa Mladovsky: +44 (0)20 7955 7298 M at a cost to every European household of more than email: [email protected] € 2,000 per annum. Despite the high personal, social EDITORIAL BOARD: and economic costs too often mental health has been Reinhard Busse, Josep Figueras, Walter Holland, marginalised within public health policy. Julian Le Grand, Martin McKee, Elias Mossialos SENIOR EDITORIAL ADVISER: Paul Belcher: +44 (0)7970 098 940 M In this issue of Eurohealth we report on the work of email: [email protected] the Mental Health Economics European Network DESIGN EDITOR: (MHEEN). With a wide ranging remit, MHEEN has Sarah Moncrieff: +44 (0)20 7834 3444 been collating evidence to support the case for email: [email protected] investment in the promotion of mental well-being and SUBSCRIPTIONS MANAGER Champa Heidbrink: +44 (0)20 7955 6840 prevention of mental health problems. Findings email: [email protected] suggest that investment in effective interventions in E Advisory Board different setting and across different stages of the life Anders Anell; Rita Baeten; Nick Boyd; Johan Calltorp; course can be highly cost effective; it is also consistent Antonio Correia de Campos; Mia Defever; Nick Fahy; with EU goals of increasing economic productivity Giovanni Fattore; Armin Fidler; Unto Häkkinen; Maria Höfmarcher; David Hunter; Egon Jonsson; Meri Koivusalo; and enhancing social inclusion. Allan Krasnik; John Lavis; Kevin McCarthy; Nata Menabde; Bernard Merkel; Stipe Oreskovic; Josef Probst; N Tessa Richards; Richard Saltman; Igor Sheiman; Aris Tackling health inequalities remains a key objective of Sissouras; Hans Stein; Jeffrey L Sturchio; Ken Thorpe; EC policy and we feature several articles concerned Miriam Wiley
with this theme. Marc Wluczka describes new Article Submission Guidelines mechanisms put in place in France to help promote the see: www.lse.ac.uk/collections/LSEHealth/documents/ health of new migrants, while Cristina Hernández eurohealth.htm Quevedo looks at decentralisation in Spain and its Published by LSE Health and the European Observatory T on Health Systems and Policies, with the financial support implication for health inequalities. The financial and organisational relationships between central and of Merck & Co and the European Observatory on Health Systems and Policies. regional government form the background to analysis Eurohealth is a quarterly publication that provides a forum by George France of attempts in Italy to eliminate for researchers, experts and policymakers to express their marked variations in the financial solvency of health views on health policy issues and so contribute to a constructive debate on health policy in Europe. services across the country. The EU Health Strategy The views expressed in Eurohealth are those of the authors also highlights demographic change and ageing as an alone and not necessarily those of LSE Health, Merck & Co important concern; an example of the challenges now or the European Observatory on Health Systems and Policies. being confronted in Turkey is also featured. The European Observatory on Health Systems and Policies is a partnership between the World Health Organization The publication of the Health Strategy, with its myriad Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the of goals to be achieved in partnership with Member Veneto Region of Italy, the European Investment Bank, the States is welcome; monitoring mechanisms and hard Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School targets are still needed to judge progress in of Hygiene & Tropical Medicine. implementation. © LSE Health 2007. No part of this publication may be copied, reproduced, stored in a retrieval system or transmitted David McDaid Editor in any form without prior permission from LSE Health. Philipa Mladovsky Deputy Editor Design and Production: Westminster European email: [email protected]
Printing: Optichrome Ltd
ISSN 1356-1030 Contents Eurohealth Volume 13 Number 3
Mental Health Economics Jan De Maeseneer is Professor at Vakgroep 1 Mental health and economics in Europe: Findings from the MHEEN Huisartsgeneeskunde en Eerstelijnsgezond- group heidszorg, University of Ghent, Belgium. David McDaid, Martin Knapp, Helena Medeiros and the MHEEN George France is Senior Researcher, Institute group for the Study of Regionalism, Federalism and Self-Government, Italian National Research Council, Rome. Public Health Perspectives Bogdan Grigore is EU Affairs Advisor (Phar- 7 From disease control to health promotion for migrants in France maceuticals), Romanian Ministry of Public Marc Wluczka Health, Bucharest. 9 Health inequalities in the decentralised Spanish health care system Irina Haivas was studying for an MSc in Inter- Cristina Hernández Quevedo national Health Policy, LSE Health, London School of Economics and Political Science.
Health Policy Developments Cristina Hernández Quevedo is Research Officer, European Observatory on Health 12 The migration of Flemish doctors to the Netherlands Systems and Policies, London School of Jos van den Heuvel, Jan De Maeseneer and Lud van der Velden Economics and Political Science.
16 Seeking a better balance: Developments in intergovernmental Martin Knapp is Professor, Personal Social relations in Italian health care Services Research Unit, London School of George France Economics and Political Science and Centre for the Economics of Mental Health, Institute of Psychiatry, King’s College London. 20 Institutional and community care for older people in Turkey Ömer Saka and Nebibe Varol Helena Medeiros is Research Officer, Personal Social Services Research Unit, London School of Economics and Political European Snapshots Science. 23 Electronic Health Record development in Austria David McDaid is Research Fellow, LSE Health Theresa Philippi and European Observatory on Health Systems and Policies, London School of 24 Pharmaceutical pricing and reimbursement in Romania Economics and Political Science. Irina Haivas and Bodgan Grigore Theresa Philippi is Deputy Programme Manager of the task force implementing elec- Evidence-informed Decision Making tronic health records (Arge ELGA), Austria.
26 “Bandolier” How good are we with numbers? Omer Saka is based at the Division of Health and Social Care Research, King’s College 28 “Risk in Perspective” The cost of improving health by reducing London. emissions from public transit buses Jos van den Heuvel is Researcher at NIVEL, the Netherlands Institute for Health Services Research, The Netherlands
Monitor Lud van der Velden is Researcher at NIVEL, the Netherlands Institute for Health Services 31 Book Review Research, The Netherlands. Screening: Evidence and Practice Nebibe Varol is reading for a PhD, LSE by Angela Raffle and JA Muir Gray Health, London School of Economics and Review by Walter Holland Political Science. Marc Wluczka is Public Health Director, 32 Publications Agence Nationale de l’accueil des étrangers et des Migrations, Paris. 33 Web Watch Walter Holland is Emeritus Professor of Public 34 News from around Europe Health, LSE Health, London School of Economics and Political Science MENTAL HEALTH ECONOMICS Mental health and economics in Europe: Findings from the MHEEN group
David McDaid, Martin Knapp, Helena Medeiros and the MHEEN group
Summary: Mental health has become an increasingly important issue both at national and European levels. Working across thirty two countries, the Mental Health Economics European Network has been undertaking comparative analysis grouped around a number of themes including organisational structures and service provision, employment and the health/social care interface. In this article we highlight some of the findings in respect of funding, look at how economic incentives can influence the balance between institutional and community based care, and consider the merits of the economic case for promoting mental health and wellbeing.
Keywords: Mental Health; Economics; Financing; Prevention; Balance of Care
Mental health and economics in Europe reliance in many countries on the old and pockets of individuals and families. Mental health has moved up the political discredited asylums; the difficulties of Decision makers want to know if expen- agenda in many European countries in developing good community-based care to diture on treatment strategies might later recent years, whether in terms of replace them; the perennial and contro- be compensated by reductions in the promoting the general mental well being of versial issue of compulsory treatment; the future costs of inaction. New drugs the population, or addressing the needs of challenge of coordinating activity across invariably look more expensive than old people who have a mental illness. The health, social care, housing, criminal drugs, and delivering psychological European Commission has added its justice, employment and other systems; therapy to more people requires weight to this trend with publication of its the search for effective treatments and appointment of more staff, so questions widely discussed Green Paper in 2005,1 support services; the question of how to are inevitably asked about whether such while the World Health Organization prevent mental health problems arising in expenditure is ‘worth it’. Decision makers brought together all 52 of Europe’s health the first place; and the huge problems of also want to know whether spending more ministries earlier that same year to endorse stigma and discrimination. money in the mental health area represents an ambitious plan for the region.2 a better investment in health improvement None of these concerns is ‘economic’, but and quality of life enhancement than, say, Common concerns any actions taken to address them will have spending the same amount on cancer economic implications. Increasingly, There are many common concerns across services. In other words, they are inter- therefore, politicians, managers and care Europe. Among the most prevalent are: ested in cost-effectiveness. professionals across Europe have been human rights abuses; the continued seeking economic evidence and insights to There are other demands for economic inform and support their decisions. information – for example, on how best to pay for mental health services to ensure Demands for economics fair access, which is an especially chal- David McDaid is Research Fellow, LSE What are they looking for? What are the lenging topic given that long-term mental Health and European Observatory on ‘demands’ or needs for economics in the illness can impoverish someone, leaving Health Systems and Policies, and Helena mental health field? Some needs relate to them unable to afford to pay for their own Medeiros is Research Officer, Personal Social Services Research Unit both at the the costs – often following recognition that treatment. There is the related question of London School of Economics and Political many mental health problems generate equity, and how to design resource allo- Science. Martin Knapp is Professor, substantial and wide-ranging costs that fall cation arrangements to support the most Personal Social Services Research Unit, on many agency budgets and also hit the vulnerable people in society. Economic London School of Economics and Political Science and Centre for the Economics of Mental Health, Institute of Psychiatry, The authors would like to acknowledge the financial support of the European King’s College London. Commission, Directorate General for Health and Consumer Protection. The views here Email: [email protected] are those of the authors alone and not those of the European Commission.
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of key individuals and organisations so as Box 1: Questions addressed in MHEEN Phase II to encourage them to pay more attention to mental health needs. How are mental health systems financed, and how much public expenditure is committed to the area? Supplying the answers These are just some of the questions posed What are the barriers and incentives to improve mental health care, with particular focus on the by decision makers that have an economic balance of care (and especially the reliance on institutional models of care) and employment? flavour, but not many answers have been forthcoming. It was against this back- What mechanisms and strategies are in place for mental health promotion and to prevent the onset ground that the Mental Health Economics of mental health-related problems, and particularly what is known about the cost-effectiveness of European Network (MHEEN), estab- such strategies? lished in 2002 with the support of the European Commission, has been collating Can the European Service Mapping Schedule be refined so as to assess mental health service information, initially across seventeen, but utilisation and costs within small catchment areas? now thirty-two European countries. Jointly coordinated by the Personal Social Finally, is there a commitment to build capacity across Europe in mental health economics? Services Research Unit (www.pssru.ac.uk) at the London School of Economics and the Brussels-based non-governmental organisation, Mental Health Europe, the Figure 1: Mental health expenditure as a percentage of GDP (latest available year) aim has been to develop a network of representatives, at least one from each country, with expertise and/or experience of health economics and with personal work or commitment to the economics of mental health (see www.mheen.org for MHEEN partners). Activities in the first phase of work were grouped around a number of themes: financing; expenditure and costs; provision, services and workforce; employment; and the capacity for economic evaluation. In the second phase (2005–2007), and following expansion to a larger group of countries, the overarching aim remained the same, but the specific topics changed slightly (See Box 1). In this article we highlight some of the findings in respect of funding for mental health, look at how economic incentives can influence the balance between institutional and community based care and consider the merits of the economic case for promoting mental health and wellbeing (A series of policy briefs prepared by MHEEN dealing with these and other aspects of MHEEN work are available at www.mheen.org).
I. What public expenditure commitment is made to mental health? Do services and initiatives that aim to meet mental health needs get their fair share of available health system funding? When we look across the countries of the Network, mental health care generally looks to be data can help to smooth the often-difficult problems, employment and social considerably under-funded. Despite the process of agreeing joint action between exclusion, and hence growing mutual high prevalence, substantial contribution different government departments or other interest among government ministries to the global burden of disability, strong bodies, given that mental health problems responsible for employment, social association between deprivation and can have such wide-ranging impacts. security and finance. Finally, there is the mental illness, and the growing body of Nowadays, there is better awareness of the question of economic incentives and cost-effectiveness evidence, the proportion interconnections between mental health whether they can influence the behaviour of total public expenditure allocated to
Eurohealth Vol 13 No 3 2 MENTAL HEALTH ECONOMICS mental health care is often modest. Only social care system, for example, financing electro-convulsive therapy without anaes- four countries have committed as much as difficulties might arise because there might thesia or muscle relaxants. While these are 0.75 of 1% of Gross Domestic Product not be the same commitment to the prin- undoubtedly exceptions, such practices are (See Figure 1), yet poor mental health may ciples of universality and solidarity; means common enough to warrant urgent action. cost national economies four times this testing is more common, for instance. Charting the exact balance of mental health amount. We do, however, need to be a little Resource allocation care across thirty two countries was obvi- cautious about these figures because it is ously beyond the resources of MHEEN, difficult to make robust comparisons With few exceptions, across MHEEN but we were able to look at a number of between countries when accounting proce- countries that employ tax-based financing important features. First, we asked dures differ, and particularly when the systems annual budgets tend to be deter- Network partners to describe the general boundaries around what is a ‘health mined through some combination of direction of movement, if indeed there had service’ can be drawn in different ways. historical precedent and political pref- been any, in the provision of institution- erence. Few report having an allocation This last point has added significance based services. For example, we asked mechanism objectively based on measures because it has been quite common across about increases in provision or admission of population health need. One conse- Europe for the boundaries between health, rates. Second, we were interested in the quence is that resources are unlikely to be social care and other service systems to be economic barriers to changes in the well targeted to areas where they have the fluid.3 This has been partly a response to balance of care, and in the economic incen- greatest chance of being effective or where the shifting balance of care away from tives that had been found to support they can tackle inequities. Even when institutions and towards systems that are movement away from reliance on institu- budgets are supposedly earmarked for more community-focused. Moving the tional services. mental health services, there are few safe- locus of care to the community creates guards in some countries to ensure that What is clear are that shifts in the balance many new and welcome opportunities, but resources are not actually spent on non- of care away from institutions towards also raises challenges, including the diffi- mental health services. community based support (where appro- culties of coordinating services across priate), vary markedly across Europe organisational and budgetary boundaries, One possible way to improve the allo- according to resources, financial incentives and different eligibility criteria for support cation of resources is through the use of and national traditions. In western Europe, and for exemptions from payment. tariffs linked to specific procedures or over a thirty-five year period, bed numbers needs, such as diagnosis-related groups How are mental health services funded? have fallen sharply (Figure 2). Individuals (DRGs). These tariffs reimburse providers have been transferred to other settings The routes for funding mental health care, of mental health services – in both social such as general hospitals or various forms at first glance, do not appear to differ very insurance and tax-dominated countries – of community-based supported living much between countries. Funding relies on the basis of some pre-set amount. But establishment. In central and eastern largely on taxation or social insurance, using DRGs has generated some diffi- Europe the picture is more opaque – there respecting long-held principles of soli- culties: DRG tariffs have not always taken appears to be significant progress in the darity and universality. But this does not full account of the costs associated with Baltic States in particular; but little change necessarily mean that such systems operate chronic mental health problems and their in countries such as Romania, Slovakia and equitably. Systems where there is high use remains limited. Slovenia (see Figure 3). These data may reliance on out-of-pocket payments at the present a better picture than the situation point of need (such as in Portugal) are II. Shifting the balance of care from merits as they do not take into account the likely to be inequitable. Out-of-pocket hospitals to the community number of people transferred to the large, payments may be particularly inappro- One of the greatest barriers to achieving isolated and poor quality social care homes priate for people with mental health social inclusion of people with mental operated outside the health system. problems, who may already be unwilling health problems and improving the quality to come into contact with services because of care in a number of countries is the The MHEEN group identified a number of fears of being stigmatised, and who are continued use of institutional care, as of barriers to change. Funding may be already disadvantaged economically by the exemplified by the old psychiatric locked in long stay institutions, so service consequences of chronic illness. asylums, dispensaries and ‘social care providers may actually have incentives to homes’ of many countries in central and maintain a high rate of occupancy in order Supplemental voluntary insurance (often Eastern Europe. to ensure that their budgets are not called private insurance) continues to play ratcheted down. Moreover, isolated large a minimal role in providing coverage for It is important to distinguish between the institutions may often be a major source of mental health services in most western large, long-stay, social care homes in some jobs in a locality, meaning that resistance European countries, but its role is more of these countries, where provision is of a to any reform may be substantial. The legal significant in eastern Europe. Evidence low standard, and human rights are often guardians of people with mental health from the US, where the private health overlooked, and the social care facilities problems may also have perverse incen- insurance market is most well developed, that accommodate many thousands of tives to place their relatives in a long stay illustrates the difficulty that mental health people in countries such as the UK, where institutions, as they many be able to retain can have in achieving parity with physical standards are much higher. There are well- the disability pensions of these individuals. health, leading to unequal access to documented accounts of individuals insurance coverage for mental health admitted to institutions being kept in There also remains a shortfall in the treatment. Of course, as responsibilities ‘caged beds’ or solitary confinement, expe- provision of community services in many shift out of the health system and into the riencing physical or sexual abuse, or countries, particularly in southern (where
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Figure 2: Trends in availability of psychiatric beds in western Europe family support is significant), central and eastern Europe. As countries continue to rebalance care they must be aware of the risks of closing beds before adequate community care is developed and funded. For a period of time there needs to be parallel funding of community and insti- tution based services; in situations where resources are scarce this additional investment may be difficult to make. Thus there is a constant concern that bed reduc- tions always precede the development of comprehensive and well-developed community-based services, leaving both hospitals and community services under- resourced. This can reduce public confidence in the appropriateness of community based care. Flexible funding arrangements are one way of overcoming some of these barriers. For instance, joint budgeting arrangements, for example, between health, social care and employment departments in Sweden have been used to tackle the problem of frag- mented funding, while in Flanders money notionally intended for the provision of beds can actually be used to foster inde- pendent living. Mergers between institu- tions and ambulatory services in the Netherlands were an important first step in rebalancing care.4 Effective planning for Source: WHO Health For All Database, 2007. the alternative use of buildings, as well as retraining and economic regeneration of Figure 3: Trends in availability of psychiatric beds in eastern Europe local communities dependent on institu- tions for jobs, can also help promote change. Another important development historically was increased access to social welfare benefits, giving individuals a safety net for supporting themselves in the community. More recently a growing number of countries in western Europe have begun introducing individual budgets, whereby people with mental health problems receive a budget which they can freely spend on services that best meet their needs.
III. The economic case for promotion and prevention MHEEN has not just focused on those with mental health problems, but has examined many issues from a public health perspective. There are many reasons for promoting positive mental health and for seeking to prevent the emergence of problems in the first place. At the core of all of this is a desire to improve the quality of life of a population. But decision makers are also very aware of the costs of not acting appropriately or early enough. Source: WHO Health For All Database, 2007. For example, the total cost of depression
Eurohealth Vol 13 No 3 4 MENTAL HEALTH ECONOMICS in Sweden in 2005 was estimated at €3.5 accumulation of evidence that behavioural competitiveness, and obviously also has billion5 while the cost of schizophrenia in and emotional problems in childhood, if implications for the sustainability of social England in the same year was estimated at not adequately addressed by mental health, welfare systems. Total disability benefit €10.4 billion.6 These cost estimates are education and social work services, can payments in England, Scotland and Wales indicative of a familiar pattern across have enormous adverse consequences in alone in 2007 amounted to €3.9 billion, Europe: the contribution of many different adulthood. For instance, analyses of group with the largest contribution (40%) budgets. For instance, the total economic based parenting interventions suggest that, attributed to ‘mental and behavioural impact of depression in Sweden is even if only very modest quality of life disorders’. absolutely dwarfed by the cost of lost benefits can be gained, these interventions Many national governments have now productivity because so many people with have the potential to be highly cost turned their attention to the employment depression experience absences from work effective.9 The majority of this work is difficulties experienced by people with or long-term unemployment. Similarly, the though from the US, where a range of very common mental health problems, costs of schizophrenia in England fall to a long-term economic benefits from a including stress and depression, and also host of budgets, and not just to the health variety of intervention programmes for encouraging greater awareness among care system. There have also been studies children and young people have been iden- employers as to their workplace responsi- which have pointed to the average cost of tified.10 The extent to which these inter- bilities for promoting better mental well- a completed suicide: €2.04 million in ventions can be adapted to differing being and reducing worker stress. Ireland and €1.88 million in Scotland.7 contexts in Europe still needs careful Evidence on the effectiveness of various Each of these, and many other examples consideration. workplace based programmes, mental could be given, is a substantial amount. health problems is growing. There may Again the costs of a completed suicide are well be substantial scope for economic not just for health or police or other “suicide prevention strategies benefits, such as increased productivity agencies, but include lost productivity and and a reduced need to pay disability the various intangible costs, including the potentially are highly cost benefits, through investment in the work- pain and grief experienced by relatives and effective” place. But there are major caveats on what the lost opportunity for individuals who we know: most evidence again comes from complete suicide to have future opportu- the US and is often generated by nities for life experiences. Remarkably, despite considerable attention given to suicide in policy discussions companies, and not subject to rigorous While even the most optimistic of advo- across Europe, evidence on the cost effec- peer-review. Nevertheless, there are some cates would never imagine that all tiveness of suicide prevention strategies is tantalisingly interesting insights. instances of depression could be sparse. Yet potentially this may be highly For example, evaluation of London prevented, or all psychoses avoided, or all cost effective: work in Scotland suggests Underground’s stress reduction suicides averted, it is surely possible for that if just 1% of suicides could be avoided programme suggests that in its first two European societies to prevent some of then the national programme would years there was a reduction in absenteeism these distressing and often devastating 7 actually be cost saving. Looking at costs of €705,000. This is eight times events occurring? Potentially this might be training interventions, economic analysis greater than the cost of the scheme. In a highly cost effective use of resources. of STORM (Skills-based Training on Risk addition, improved productivity and some MHEEN partners have thus been trawling Management) in England indicated that a positive healthy lifestyle changes were through electronic databases and the ‘grey’ 2.5% decrease in the suicide rate would observed.12 One stress management literature of policy and advocacy bodies, as generate a cost per life year saved of just programme in a Belgian pharmaceutical well as corporate documents, to find out €5,500, a value considered to be highly cost company achieved a reduction in absen- just what is known about the cost- effective.11 The use of taxation instruments teeism of just 1%, but still avoided costs of effectiveness of such initiatives. This has to influence behaviours, for example, to €600,000 because the economic impact of complemented a systematic literature reduce the over-consumption of alcohol, stress-related absenteeism was so review undertaken by MHEEN ranging and subsequent alcohol related addictive substantial.13 over many areas, including schools, work- behaviours, can also be much more cost Mental health promoting interventions can places, primary health care settings and the effective than other alcohol control 8 also be cost effective in helping those who community. policies. are out of work and thus at greater risk of What do we know? developing mental health problems. One IV. Employment It remains the case that economic analysis US programme, designed to help indi- Employment is a fundamental component is rare, but its use is increasing and some viduals take more control when seeking of, or contributor to quality of life, the examples are given here. Perhaps most employment and cope with difficulties and main source of income for most people, strikingly, most of this evidence focuses on disappointments, both increased reem- commonly a major influence on someone’s preventive actions rather than on measures ployment and generated a positive return social network, and also a defining feature to improve mental well-being. This reflects on investment.14 It has subsequently been of social status. The interconnections current challenges being grappled with in implemented, with some success, else- between mental health problems and Europe on how to accurately measure where including Finland, the Netherlands employment are many and various. As well-being. and Ireland. well as the link with individual well-being, The area where most work is available employment is a major contributor to While the economic case is encouraging, relates to children. This builds on the national and European productivity and there are a number of key challenges to
5 Eurohealth Vol 13 No 3 MENTAL HEALTH ECONOMICS meet in strengthening the evidence base on the ground is far from easy; activities like towards an integrative approach. workplace health promotion. Evaluation those undertaken by MHEEN can help International Journal of Integrated Care in the workplace is clearly a sensitive issue; strengthen the economic case for action 2006;6:1–11. both employers and employees may be and identify economic levers and incen- 5. Sobocki P, Lekander I, Borgström F, reluctant to participate. Caution must also tives to promote change. Ström O, Runeson B. The economic be exercised over the results of evaluations: burden of depression in Sweden from 1997 MHEEN members have also been active interventions reported to have significant to 2005. European Psychiatry in raising awareness of the relevance of net benefits may be produced by organisa- 2007;22(3):146–52. economics within mental health discourse tions that stand to gain commercially from in national, international and supra- 6. Mangalore R, Knapp M. Cost of their use. national contexts and have helped to schizophrenia in England. Journal of develop local capacity and interest in Mental Health Policy and Economics economics and mental health. Because 2007;10(1):23–41. “the highest levels of workplace mental health has impacts on many 7. McDaid D, Halliday E, Mackenzie M, et al. Issues in the economic evaluation of stress may well appear in public different non-health sectors, a continuing challenge for MHEEN and others will be suicide prevention strategies: practical and sector organisations” to engage with these sectors and provide methodological challenges. London: economic evidence that encompasses both Personal Social Services Research Unit, inputs from and impacts on the social care, London School of Economics, Discussion Paper 2407, 2007. Recognition of the economic impact of housing, education employment and poor workplace mental health at national criminal justice systems. 8. Zechmeister I, Kilian R, McDaid D. Is it and EU levels does however provide an worth investing in mental health opportunity for action. Policy makers may In particular, a major gap in knowledge promotion and prevention of mental wish to carefully consider providing that MHEEN has addressed is the illness? A systematic review of the evidence financial support for the evaluation of economic case for investment in from economic evaluations. BMC Public workplace based mental health interven- promotion and prevention activities; this is Health 2007 (forthcoming). vital to the better incorporation of mental tions. Already there are some positive 9. Dretzke J, Frew E, Davenport C, et al. health within public health policy. While signs: a number of ongoing and planned The effectiveness and cost-effectiveness of economic evaluations have already been the work of MHEEN indicates that this parent training/education programmes for evidence is still modest, where evaluations identified by MHEEN. One pragmatic the treatment of conduct disorder, have taken place the economic case often approach may be to retrospectively add an including oppositional defiant disorder, in is very strong. To increase this knowledge economic dimension to existing studies of children. Health Technology Assessment one priority should be to incorporate the effectiveness of interventions. More 2005;9:50. economics into more prospective evalua- partnership work between employers in 10. Aos S, Lieb R, Mayfield J, Miller M, tions, but another complementary the private and public sectors is also well Pennucci A. 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Eurohealth Vol 13 No 3 6 PUBLIC HEALTH PERSPECTIVES From disease control to health promotion for migrants in France
Marc Wluczka
Summary: Every year the Public Health Department of the French National Agency for the Reception of Foreigners and Migration (Agence Nationale de l’accueil des Etrangers et des Migrations – ANAEM) conducts a survey of medical examinations given to new immigrants. Obesity, type II diabetes, cardiovascular disease, visual impairments and tuberculosis continue to be highly prevalent. Excess poor health in women is found in migrants from every continent except the Americas. Individuals in poor health, as well as those in high risk groups, have been appropriately referred on to health care services. While some conditions are difficult to identify, for example, mental health problems, nonetheless, these medical examinations have proved to be valuable both as a public health tool and as an aid to integration for first time migrants to France.
Keywords: Public health, Non-EU immigrants, France, Health Screening, Integration Policy
The organisation of medical examinations Table 1: Gender and geographical distribution of 2006 survey sample or checkups for first time non-EU immi- grants is one of the key tasks of the Agence Geographical Origin Men % Women % Nationale de l’accueil des étrangers et des Migrations (ANAEM). Originally, this Europe 441 10.9 486 12.6 examination had two purposes: the first Asia 746 18.3 912 23.6 was to carry out an evaluation of a migrant's capacity and ability to work, Sub-Saharan Africa 764 18.7 749 19.4 while the second focused on the prevention of global and personal health Maghreb 1,692 41.5 1,114 28.9 risks. There is now a third overarching concept: a decree on 11 January 2006 Americas 409 10 527 13.5 placed this medical examination within a public health context where promoting the Others 24 0.6 44 1.1 health of migrants is the key aim. This Total 4,076 3,832 evolution came about as a result of the establishment of ANAEM as a public service in 2005, bringing together the func- refugees. Since 2001, an epidemiological risk factors have changed over time. survey has been conducted to assess their tions of the Office of International In 2006, 7,938 records were examined, of health status.* This takes the form of a Migration and the Social Services which 51% were men.1 Individuals from cross-sectional survey, with data collected Assistance for Emigrants association. the Maghreb (Morocco, Algeria, Tunisia, from a random sample of clients who Libya and Egypt) made up the largest attended a medical checkup service on two A comprehensive overview of migrants’ group in the study sample (Table 1). health concerns different weeks of the year [one in May There are approximately 200,000 new and one in November]. 1,339 medical records indicated the presence of at least one clearly identified immigrants to France every year. They can The survey provides detailed socio- disease, equivalent to a morbidity rate of be broken down into four principle cate- demographic and medical information on 16.4%. This is the highest rate recorded gories: workers, families, students and approximately 8,000 individuals. This since 2001 but may, in part, be due to makes it possible to draw up a picture of improvements in data collection. 1,555 the health of first time migrants and different diseases were identified (12.2% Marc Wluczka is Public Health Director, measure how the prevalence of diseases or Agence Nationale de l’accueil des étrangers et des Migrations, Paris. Email : [email protected] * Available on the French public health database: www.bdsp.tm.fr
7 Eurohealth Vol 13 No 3 PUBLIC HEALTH PERSPECTIVES were diagnosed as having two diseases Table 2: Referrals from 2006 study sample while a further 2.5% had more than two co-morbid conditions). Excess female Referral status Number Percentage morbidity was found in migrants from all continents except the Americas. No referral 4,374 55.1
By far the most frequent disease identified Vaccination centre 2,153 27.1 was malaria (498 cases), although this was almost entirely from migrants from sub- General Practitioner 1,041 13.1 Saharan Africa. Thyroid diseases were also surprisingly numerous. The analysis also Independent specialist 288 3.6 indicates that non-specific diseases, for Public dispensary 57 0.7 example, dermatological, ear-nose-throat or those of the digestive tract, are also Hospital 25 0.3 frequent and deserve more thorough analysis, in particular parasitic disease and cell disease, will be tracked, following an strong under-reporting, alcoholism was the effects of the stresses of immigration. evaluation of specific tools planned for this observed in 2.5% of individuals, while year.3 18.5% were smokers. Targeted continuous monitoring The 2006 report justified the practice of Screening for tuberculosis also continues Referrals following medical examination monitoring certain targeted conditions to be a major issue. Quite apart from the Over the past six years, there has been a such as type II diabetes. In 2003, the high impact on the individuals affected, the shift from a concept of ‘control’ to one of frequency of obesity persuaded the ANAEM medical examination plays a key ‘prevention’. This has been accompanied authorities to make the monitoring of type strategic role in tuberculosis screening by an immense effort to form partnerships II diabetes compulsory. This is carried out owing to its high degree of contact with with different health sectors, whether in on the basis of age (>45) and Body Mass new migrant populations: it is the the field of treatment or prevention, Index (BMI) (> 29). 551 individuals (6.9%) mandatory point of transit and dispersal delivered by public, private or charitable had a BMI greater than 29 and were for some 200,000 of these most vulnerable organisations, or linked to general practice. considered obese. It is particularly high individuals every year. As part of this, a key objective of these among women, especially those from sub- Chest X-ray is the most effective screening medical examinations is to refer individuals Saharan Africa. It is estimated that at the method. It is carried out prior to, or requiring further medical assistance to current rate of medical examinations, more during, the medical examination. Sixty appropriate health care services. Improve- than 6,500 cases of diabetes in individuals cases were identified leading to an esti- previously not aware that they had the ments in the health of migrants as a result mated prevalence rate in the study popu- condition would be identified. It also high- of these referrals demonstrate the value of lation of 755 per 100,000. The distribution lights nearly 60,000 people who are at risk this medical screening process. The medical of tuberculosis cases by country of origin of developing diabetes.2 examinations at ANAEM reception is in line with previous studies. Sub- centres also provide a unique opportunity Other diseases are also linked to the same Saharan Africa dominates (though only for confidential dialogue, which can reveal risk factors, for example, arterial hyper- 19.1% of the study population compared social problems and lead to referrals to tension and cardiovascular diseases. As a with 28.3% worldwide) along with the social services for help and support. result, preventive actions are targeted at Maghreb (35.3% of the study population, those identified as being at greatest risk by 28.3% worldwide). 20% of cases are found In total 3,564 (45%) of the 2006 study the survey: sub-Saharan African women in Asian migrants, 10% in those from the sample were referred for further treatment. between 19 and 40 years of age. Americas, similar to their proportion of (Table 2). It should be borne in mind the study sample, while Europeans however, that referrals were not made Monitoring the prevalence of visual accounted for 6.7% whilst making up solely on the grounds of identifiable impairments is more problematic, particu- 11.7% of the study population. Most cases disease (only 16.4% of sample), but on the larly if individuals are illiterate; it can of tuberculosis are found in the 30–39 age- basis of identified risk factors (positive require much time and the use of group (19 cases), followed by the 20–29 diabetes test, obesity or smoking) or the specialised hardware. However, by identi- age-group (15 cases). need for observation (pregnancy, fying visual impairments, it is often newborns). These also included 2,302 Of the 1,594 women of childbearing age possible to detect congenital visual disabil- referrals for compulsory combined diph- (15–50) 281 (15%) were pregnant, of these ities which are linked to limited pre-natal theria/tetanus/poliomyelitis vaccination 44.8% were from the Maghreb and 23.3% care in low income countries. when vaccination status was unknown. from sub-Saharan Africa. Forty-eight cases One limitation remains the lack of of disability were identified, a prevalence Most individuals identified as having a adaptable tools or techniques to identify rate of 0.6% in the study population. disease were referred to general practi- mental health problems. This undoubtedly Thirty-three of these forty-eight cases tioners or independent specialists, while the leads to an underestimation of the preva- (68.75%) were from the Maghreb and sub- sixty cases of tuberculosis were sent to lence of these problems. Saharan African countries. In contrast to public dispensaries, hospitals or medical In the future, other conditions that are the situation seen in France, there were specialists (chest and tuberculosis highly prevalent in sub-Saharan and high rates of sensory disability (16 cases) specialists). Another finding from this Caribbean populations, including sickle- and motor disability (18 cases). Despite analysis therefore, is that the medical
Eurohealth Vol 13 No 3 8 PUBLIC HEALTH PERSPECTIVES examination appears to result in appro- are refugees. An evaluation of their needs priate referrals to other services when in terms of social services, knowledge of REFERENCES required. French, and adhesion to France's repub- 1. Wluczka M, Debska E. The Health of lican values is provided at the same time as First Generation Migrants in 2006. Paris: The work of ANAEM is complemented the medical evaluation. Then they are Agence nationale de l’accueil des étrangers by that undertaken within accommodation given the CAI. It places an obligation on and des migrations, 2006. Available at centres for asylum applicants that are run them towards the French state, while http://www.anaem.fr/IMG/pdf/FIRST_ by CADA under ANAEM supervision.4 ensuring access to health and social GENERATION_MIGRANTS_HEALTH Here again, epidemiological investigations services, French language lessons, and _TEXT.pdf are undertaken. Monitoring procedures, information about the civic basis of the 2. Wluczka M, Haddou H, Farozi A-M. like those used for type II diabetes, allow republic.* Contribution to Knowledge of the Oral immigrants to assume personal responsi- and Dental Health of First-generation bility for their own health when medical ANAEM’s public health activity has Migrants. Paris: Agence nationale de conditions are at a less advanced stage. undergone a true ‘silent revolution’ during l’accueil des étrangers and des migrations, Results can still be improved and the last six years. It has become instru- 2005. Available at http://www.anaem.fr/ constitute good practice examples for mental in relaying, emphasising and imple- IMG/pdf/Study_about_dental_health.pdf other vulnerable populations. menting public health policies. It has 3. Wluczka M. Sickle cell disease. Epidemi- engendered a culture of partnership ological Elements Based on a Sample Popu- Obligations and benefits extending beyond the ANAEM medical lation. Paris: Agence nationale de l’accueil Since 2005 each accommodation service of departments to administrative and social des étrangers and des migrations, 2003. ANAEM (23 in France) has also proposed departments. It has successfully promoted Available at http://www.anaem.fr/IMG/ a ‘contract of accommodation and inte- the primary objectives of ANAEM in pdf/sickle_celle_disease_register_part_1.pdf gration’ (CAI) to migrants coming for relation to the integration of migrants in and http://www.anaem.fr/IMG/pdf/sickle_ family or long-term work reasons, or who France. celle_disease_register_part_2.pdf 4. Debska E, Wluczka M. Health of * Knowledge of the ‘republican values’ (valeurs républicaines) has been regarded as part of Asylum-seekers and Refugees Housed in French national identity and is referred in the most recent laws dedicated to immigration Accommodation Centres in 2004, 2005 & and integration. Non-EU legal migrants are requested to become familiar with them, 2006. Paris: Agence nationale de l’accueil candidates for French nationality are required to accept them. des étrangers and des migrations, 2006.
Health inequalities in the decentralised Spanish health care system
Cristina Hernández Quevedo
Summary: Despite the optimistic health outcomes that the Spanish population enjoy, there are still disparities in health between different socioeconomic groups in the different Autonomous Communities. Given the process of decentralisation in the Spanish health care system and the lack of a national programme to reduce inequalities in health, initiatives at regional level are particularly relevant. However, not all regions include this target in their health plans, with the exception of the Basque Country. The balance between diversity at regional level and social cohesion remains a challenge in the Spanish health care system.
Keywords: Socioeconomic Inequalities, Health status, Health Plans, Spain, Decentralisation
Cristina Hernández Quevedo is Research Officer, European As the European Union continues to expand, conomic factors such as education, income and Observatory on Health Systems disparities in the health of the European popu- job status.1 Spain is no exception. The Spanish and Policies, London School of lation, both within and between countries, are health care system is decentralised, with health Economics and Political Science. increasingly a cause for concern. Several studies being the responsibility of the seventeen Email: quantifying health inequalities at the European Autonomous Communities (ACs) that make up [email protected] level have shown that they are related to socioe- the country. However, devolution has not been
9 Eurohealth Vol 13 No 3 PUBLIC HEALTH PERSPECTIVES homogenous as health care responsibilities ranking varies according to the source Variability in life expectancy can be found were transferred at different rates to all the considered. The World Health Report at AC level, with the highest figures found ACs. This has negatively affected the prin- 2000, which focused on health systems in Navarra (81.51 years), Madrid (81.39), cipal objective to guarantee the system’s performance, ranked the Spanish health Castilla-León (81.28) and La Rioja (81.18), equity and quality. care system sixth in the world. However, while the autonomous city of Ceuta this result has been challenged. Recently, a (78.62), Andalucía (78.83) and the Canaries Organisation and performance of the report by Health Consumer Powerhouse, (79.16) have the lowest rates.4 There are Spanish health care system a private consultancy collecting consumer also variations in how individuals perceive The Spanish health care system is publicly information on health care at EU level, their health. Citizens from northern ACs, funded and has a regional organisational ranked the Spanish health care system including La Rioja, Aragón, Navarra and structure resulting from a process of devo- fourteenth among twenty-nine countries Cantabria, are the most satisfied with their lution. Population coverage under the studied.3 Although Spain was three places health, while those from the south of Spanish National Health System (NHS) is up compared to its 2006 ranking, waiting Spain, including the Canaries and almost universal (99.5%), including low- lists and the lack of information for Extremadura report the worst levels of income populations, immigrant adults and patients were still considered weak points perceived health. children, hence providing a benefits in this report. package to all inhabitants independently of Socioeconomic inequalities in health This classification has already been criti- their ability to pay. It is a health system within Spain cised by the Spanish government which financed mainly by general taxation, which Regional and gender-based health inequal- has argued that the focus on consumer is intended to favour financial sustain- ities persist in Spain, as in most other information does not permit a fair evalu- ability.2 European countries. By age group, ation of the universality of the Spanish inequalities in health increase with age The central government is responsible for system. Furthermore, the ranking is not in until age 45–54; after 64 years of age they strengthening coordination and cooper- line with others such as the European tend to decrease. Furthermore, studies ation in the health sector, guaranteeing the Union Barometer, where Spain occupies have shown that these inequalities in health quality of all services and equity in access seventh place. Nonetheless, despite the are related to socioeconomic factors. The to health care throughout the national different rankings reported, there is a prevalence of chronic illness and disability territory. In particular, the Spanish common consensus that waiting lists and is greater among those at the bottom of the Ministry of Health assumes responsibility waiting times, despite the efforts to tackle income distribution. Inequalities in self- for general coordination and basic health them made to date, remain important assessed health (SAH) status between legislation, foreign health, international policy issues in Spain. social classes have been reported, as well as relations, undergraduate and postgraduate education-related inequalities in SAH and education, together with research and Spanish health outcomes in the European chronic diseases. high-level inspection. context As with other high income countries, These inequalities also apply to other At the regional level, the seventeen ACs Spain has experienced a significant health outcomes such as obesity and have the power to establish their own improvement in health during the last smoking. The socioeconomic inequalities health plans and to organise their own twenty years. According to recent statistics in the prevalence of obesity are largely health services. These competencies were provided by the Instituto Nacional de explained by education and demographic transferred over the past twenty years, Estadística (INE – Spanish National characteristics. Education and income although this process did not take place Institute of Statistics), life expectancy at characteristics have been found to be simultaneously. While several regions birth increased between 1995 to 2005 by strong predictors of smoking. These obtained responsibility for health many more than two years and now is 80.23 socioeconomic differences in smoking years ago (Catalonia in 1981, Andalucía in years. Furthermore, mortality data in behaviour in turn influence inequality in 1984, Basque Country and Valencia in Spain reflect a decrease both in mortality lung cancer and total mortality. 1988, Galicia and Navarra in 1991 and the rates and in the probability of death within Canaries in 1994), the devolution of health According to the 2003 National Health each age group. care responsibilities nationwide was only Survey, most Spanish ACs have significant completed in 2002. According to Eurostat, life expectancy at differences in self-assessed health status by birth in Spain ranks ninth in Europe. social class. In the Canaries and Galicia, To promote the cohesion of the NHS, the Spanish female life expectancy is second 40% of men and 50% of women from the Inter-territorial Council of the NHS was only to that in France. However, life working class have the highest levels of bad created in 1987, consisting of health repre- expectancy for men from Sweden, Ireland, health, while in contrast Aragón and La sentatives from central and regional Holland, Italy and the United Kingdom is Rioja have very small differences according governments. It is defined as an institution higher than that observed in Spain. These to social class.5 Moreover, there is evidence facilitating the permanent coordination, generally optimistic figures on life to suggest that those ACs with the highest cooperation, communication and exchange expectancy at birth and mortality rates in levels of income-related health inequality of information on health care services Spain are linked to the increase in the are also likely to display low levels in across the ACs and with the state adminis- number of older people; these now average health status. Using data from the tration, thus helping to guarantee the account for approximately 15% of the Spanish National Health Survey for 2001, rights of citizens across all of Spain. population. Furthermore, it is projected García and López observed that the In terms of the performance of the Spanish that by 2010 40% of the Spanish popu- Basque Country, Navarra and La Rioja health care system, the international lation will be more sixty years of age. had the highest levels of average health
Eurohealth Vol 13 No 3 10 PUBLIC HEALTH PERSPECTIVES status and present the lowest degree of 2002 to 34% by 2010.8 Elsewhere, while reducing regional inequalities in health and income-related health inequality.6 At the Galicia and the Canaries do not include a improving coordination mechanisms other extreme, Murcia’s population reports description of health status by SES, they between the central and regional levels, so one of the lowest levels of average health do include some targets in respect of as to link evidence to policymaking. These status and suffers the greatest degree of reducing inequalities in health by SES in equity challenges for the NHS should be income-related health inequality, rein- their health plans. addressed within the context of the forced by the effects of education. broader goal of achieving a balance In terms of regional inequalities, the Compared to the Basque Country, other between diversity and social cohesion central government is focussed on ACs presenting high income-related health within the country. improving equity in access to the health inequality include Madrid, the Balearic care system. The current Minister of Islands and Catalonia. Health recently expressed an interest in REFERENCES guaranteeing geographical equity in access Policies to reduce inequalities in health to the health care system, meaning an 1. Hernández-Quevedo C, Jones AM, The number of countries and international equivalent level of benefits for all citizens López-Nicolás Á, Rice N. Socioeconomic organisations acknowledging the need to provided independently of the place they inequalities in health: a comparative longitudinal analysis using the European reduce inequalities in health is increasing. live. For this purpose, one of the objectives Community Household Panel. Social Most of these countries follow the equity of the current Minister of Health is to Science and Medicine 2006; 63:1246–61 principles and values of the World Health strengthen the role of the Inter-territorial Organization and as such are explicitly Council of the NHS in order to enhance 2. Durán A, Lara JL, van Waveren M. concerned with the socioeconomic territorial cohesion. Spain: Health system review. Health dimension of health inequalities. However, Systems in Transition 2006;8(4). Some initiatives developed by the central there is considerable diversity in the public 3. Health Consumer Powerhouse. Euro government target particular health care policy goals and targets that aim to address Health Consumer Index 2007 Report. health inequalities across different services or segments of the Spanish popu- Brussels: Health Consumer Powerhouse, European countries. lation with the intention of improving October 2007. health. For example, as access to dental 4. INE. Mortality Tables 1992 – 2005. In Spain, there is relatively little evidence care varies throughout Spain, one central Madrid: Instituto Nacional de Estadística, of national policies to tackle socioeco- government objective has been to address 2007. nomic inequalities in health, but there are a this issue head on and assure equity in few examples of important regional or access to dentists for all children. Recently, 5. García Altés A, Rodríguez-Sanz M, local initiatives. The different Spanish ACs it announced that it will become Pérez G, Borrell C. Desigualdades en salud specify their health policies in regional mandatory for all Spanish children y en la utilización y el desempeño de los health plans, including principles and between seven and eight years of age to servicios sanitarios en las Comunidades Autónomas. [Inequalities in health and in values, objectives, strategies and interven- have access to dentists free of charge from the utilisation of health care services in the tions to achieve certain goals over a specific 2008. These treatments will be financed time period. Borrell and colleagues Autonomous Communities] Cuadernos equally by the Ministry of Health in Económicos de ICE (in press). undertook a systematic review of the Madrid and the ACs. Access will then be health plans of the different ACs in Spain, expanded over the ensuing five years, with 6. García-Gómez, P, López-Nicolás Á. excluding Madrid, Asturias and the goal of coverage for all children Regional Differences in Socioeconomic 7 Health Inequalities in Spain. Bilbao: Cantabria. They found that the regional between seven and fifteen years of age by Fundación BBVA, Working Paper 09, health plans tend to include a description 2012. of health areas by socioeconomic status 2007. Available at http://w3.grupobbva.com/TLFB/dat/dt9_ (SES) rather than including specific Final comments 07_regional_differences%20.pdf policies to reduce inequalities in health by Although there has been an increase in the SES. understanding of socioeconomic inequal- 7. Borrell C, Peiró R, Ramón N, et al. Desigualdades socioeconómicas y planes ities in health within Spain in recent Exceptions include the health plans from de salud en las comunidades autónomas decades, this has not impacted sufficiently the Basque Country and Extremadura, del Estado español [Socioeconomic on the policy agenda. At regional level, where descriptions of health by socioeco- inequalities and the health plans of the nomic characteristics were made and the little attention is paid to inequalities in Autonomous Communities in Spain] reduction of inequalities by SES were health by socioeconomic status in AC Gaceta Sanitaria, 2005;19(4):277–85. included in their key plan objectives. health plans. Few ACs take them into account, but even then not all areas are 8. Judge K, Platt S, Costongs C, Jurczak K. However, it was only in the Basque Health Inequalities: A Challenge for covered. The importance given in the liter- Country that specific policies linked to Europe. London: UK Presidency of the ature to the effect of socioeconomic factors SES could be found. In particular, the EU, 2006. Available at on individual health appears to be in Basque Country health plan adopted http://www.dh.gov.uk/prod_consum_dh/ contradiction to the lack of reference to specific quantitative targets such as groups/dh_digitalassets/@dh/@en/ this issue in health plans elaborated at reducing social class differences in documents/digitalasset/dh_4121583.pdf regional level. There is also a lack of a mortality from diseases of the circulatory national strategy to tackle health inequal- system by 25% from 39% in 2002 to 30% ities related to socioeconomic factors such by 2010. It also set a target to reduce social as education, job status or level of income. class differences in mortality from cardio- vascular diseases by 25% from 45% in Thus there appears to be more to do in
11 Eurohealth Vol 13 No 3 HEALTH POLICY DEVELOPMENTS The migration of Flemish doctors to the Netherlands
Jos van den Heuvel, Jan De Maeseneer and Lud van der Velden
Summary: The cross border migration of Flemish general practitioners (GPs) to the Netherlands was examined. In the recent past Belgium experienced a surplus in GPs, while in the Netherlands a shortage was observed. Despite the availability of potential incentives in respect of income and professional practice, surprisingly very few Belgian GPs have moved to practices in the Netherlands. Most probably considerations with regard to social-cultural factors are the most important elements in individual decisions on whether or not to migrate.
Keywords: International Labour Migration, Health Care, General Practitioners, Belgium, Netherlands
In the Netherlands, there was a shortage of Methods migrate. In the scientific literature these general practitioners (GPs) in the recent Data on the number of Flemish doctors conditions are often called push and pull past.1,2 By contrast, over the same period a who have settled in the Netherlands were factors.4 Not all commonly presented surplus was observed in the neighbouring obtained from the GP database of the factors have the same relevance within the country of Belgium.3 As there are no Netherlands Institute for Health Services context of the Flemish/Dutch situation. language barriers between the Netherlands Research (NIVEL). This database provides Several factors were considered most and Flanders (the Dutch speaking part of a complete picture of the work status of all pertinent and thus studied in more depth: Belgium) and no formal obstacles with GPs in the Netherlands, from their initial professional opportunities; working regard to the recognition of the profes- entry into the system until retirement. conditions; income; educational opportu- sional qualifications, it would not have This database was thus used to help nities and culture. been surprising if these conditions had determine migration patterns of GPs Professional opportunities resulted in significant inward migration working in the Netherlands. Data from flows of Flemish doctors to the Nether- Statistics Netherlands on population and In general, professional opportunities lands. the number of contacts with GPs per depend on the position within the health care system, the workforce situation and From the perspective of potential labour inhabitant were also used. Similar data on job responsibilities. In this regard, a migration within the European Union, it the number of GPs, population and comparison between the two regions is of interest to explore whether these number of GP contacts were also gathered yielded a number of findings. Firstly, the conditions did indeed lead to significant for Belgium as a whole, and Flanders in most prominent difference between the migration. Therefore, a study was set up to particular, from the Belgian Federal examine firstly, how many Flemish Organisation of Public Health Insurance, two countries is illustrated by the ‘gate doctors settled in general practice in the RIZIV (Rijksinstituut voor Ziekte- en keeper’ function the Dutch GPs play in the Netherlands, and secondly, to determine if Invaliditeits-Verzekering) and Statistics health care system, which is in contrast to it was possible to identify plausible expla- Belgium. Furthermore, an examination the position of their Flemish colleagues. nations for these migration movements. was made of relevant literature, while key Referral by a GP to a specialist is required informants from both the Netherlands and for the coverage of specialist treatment in Belgium were interviewed in order to the Netherlands, whereas in Belgium Jos van den Heuvel and Lud van der obtain a more qualitative insight into patients are allowed to visit a specialist Velden are researchers at NIVEL, the possible explanations for the migration without such a referral. Moreover, the Netherlands Institute for Health Services pattern observed. health insurance system in the Netherlands Research, The Netherlands. Jan De requires the registration of patients with a Maeseneer is Professor at Vakgroep Push and pull factors: selected drivers specific GP (patient-list), again something Huisartsgeneeskunde en Eerstelijnsge- and obstacles that does not apply in Belgium. As a zondheidszorg, University of Ghent, Social and psychological conditions, as consequence, Dutch GPs have a signifi- Belgium. well as professional opportunities, can cantly stronger position as doctors of first Email: [email protected] influence an individual’s decision to contact for patients.
Eurohealth Vol 13 No 3 12 HEALTH POLICY DEVELOPMENTS
Table 1: Key figures on GP and specialist care in the Netherlands, Belgium and Flanders
Netherlands Belgium Flanders
2005 Source 2004 Source 2004 Source
Number of registered GPs 10,061 a 14,050 c 7,061 c
Number of professionally active GPs 8,850 a 10,359 c 5,718 c
Percentage of professionally active GPs 88% 74% 81%
Number of full time equivalents (FTE) of GPs 7,129 a 7,655 c 4,528 c
Mean number of FTE per GP 0.81 0.74 0.79
Number of inhabitants (in thousands) 16,257 b 10,396 d 6,066 d
Mean number of GPs per 1.000 inhabitants 0.54 1 0.94
Mean number of inhabitants per GP 1,837 1,004 1,061
Mean number of inhabitants per FTE GP 2,280 1,358 1,340
Number of professionally active medical specialists (MSs) 14,283 a 17,048 c 8,561 c
Mean number of MSs per 1.000 inhabitants 0.88 1.64 1.41
Mean number of inhabitants per MS 1,138 610 709
Mean number of MS per GP 1.61 1.65 1.5
Mean number of contacts per year with a GP per inhabitant 3.6 b 4.6 d 4.6 d
Mean number of contacts per year per GP 6,613 4,616 4,880
Mean number of contacts per year with a MS per inhabitant 1.8 b 2.3 d 2.0 d
Mean number of contacts per year per MS 2,049 1,403 1,417
Sources: a. NIVEL; b. Statistics Netherlands; c. RIZIV; d. Statistics Belgium.
The Netherlands has 5.4 GPs per 10,000 Support from auxiliary health profes- Regarding these differences, the way in inhabitants (see Table 1). In Belgium there sionals also influences workforce capacity. which the workforce is regulated should are 10.0 GPs per 10,000 inhabitants, with Working with a practice assistant allows be considered. In the Netherlands, the a similar supply of 9.4 GPs per 10,000 for the delegation of tasks, resulting in a number of GPs is regulated in two ways: inhabitants in Flanders. Therefore, there higher number of patients that a doctor can firstly, through a legally set ‘numerus fixus’ are almost twice as many GPs in both care for. In the Netherlands, each GP has for undergraduate education; secondly, by Belgium and Flanders as in the Nether- roughly one practice assistant; in Belgium, a limited number of positions for the post- lands. However, for a more appropriate the use of such professionals is rare. Differ- graduate vocational education scheme. In comparison, working time equivalents ences in the number of medical specialists Flanders, by contrast, the only limitation should be taken into account. Based on a might also shed light on the difference in to the intake of undergraduate students is crude comparison, more GPs in Belgium the number of GPs. The number of an admission examination, which has only and Flanders seem to work on a part-time medical specialists per 1,000 inhabitants in been in existence since 1997. Moreover, it basis than is seen in the Netherlands. The the Netherlands is low compared with the was only in 2004 that any restrictions were average GP in the Netherlands works 0.81 situation seen in Belgium. As with GPs, introduced on the number of positions of a Full Time Equivalent (FTE), while the Belgium has almost twice as many medical available in the postgraduate vocational average Belgian GP works only about 0.74 specialists. On the other hand, in the education scheme. FTE. This leads to an estimated 4.4 FTE Netherlands about 1,100 specialised In general, no substantial differences GPs and 7.4 FTE GPs per 10,000 inhabi- ‘nursing home physicians’ provide care for between the two countries exist regarding tants in the Netherlands and Belgium patients in nursing homes and similar insti- job responsibilities of GPs. Consultation, respectively; which is still a remarkable 1.7 tutions. This type of specialist does not diagnosis, prevention, treatment, referral times more in Belgium compared to the exist in Belgium where GPs must also to a specialist or allied health professional Netherlands. provide care for nursing home residents. and prescription of medicines are the
13 Eurohealth Vol 13 No 3 HEALTH POLICY DEVELOPMENTS common elements of a position which is have not finished formal specialist training. they are also commonly used as a crucial in the continuity of health care In this sense, more than 17,000 Belgium benchmark for ‘professional standards’. provision. doctors are considered to be ’general Belgian doctors, on the other hand, while physicians’. However, the number of naturally taking into account available Working conditions professionally active GPs is less, at about scientific evidence, tend to include more In Belgium, most GPs work in single- 10,000, or 14,000 if we count those doctors ‘soft’ considerations. In Belgium, medicine handed practices, without practice auxil- who are accredited GPs and perform at is still considered more of an art, in French iaries. In contrast, many Dutch GPs are least 1,250 patient contacts according to expressed as ‘l’art de guérir’, or in Dutch members of group-practices consisting not the RIZIV. As a consequence, when as ‘geneeskunst’. Potentially, this only of several GPs, but also allied health dividing the cost of GP care by 10,000 difference in attitude could be a driver for professionals and practice auxiliaries. The instead of 17,000, one arrives at a gross migration of doctors who feel more benefits for these doctors of working in a average income for Belgian GPs that does attracted to the other approach. structured collaboration like group- not differ much from that of their Dutch In addition to these professional factors, practice are less working hours per week counterparts. Secondly, the average income social differences can also play a very figures for GPs in the OECD data reflect and working days per year. important role. These can include educa- the gross income of doctors. To fully Workloads are dependent on the number tional opportunities for children, including interpret these figures, differences in of patients per GP and patient appeal to the quality of secondary education, labour taxation and post-retirement provisions the GP. The difference in the relative opportunities for partners and, last but not for doctors have to be taken into account, least, family and friends. number of GPs per 10,000 inhabitants in order to reach a judgement on actual indicates that one GP in the Netherlands disposable income. has to deliver care to approximately 1,840 Facts on cross border migration of GPs inhabitants. In Belgium this population to Continuing professional development between the two regions4 Before 1999, about two Belgian born (and GP ratio is 1,004:1 and in Flanders 1,061:1. Continuing professional development probably Flemish) GPs entered the Dutch In addition, individuals in the Netherlands (CPD) is crucial in terms of quality GP workforce each year. Compared to the on average visit a GP 3.6 times a year per assurance in health care. Until recently, no total inflow of GPs with foreign GP inhabitant. In Belgium and Flanders the formal obligation for CPD existed for training, these Belgian/Flemish GPs only number of GP-contacts per inhabitant is Belgian GPs, but CPD contributed to accounted for 7% of the total during this 28% higher at 4.6 times a year. On average, ‘accreditation’ by health insurance period. Furthermore, compared to the each GP has about 6,600 contacts with a companies, including access to higher rates total inflow of some 250 GPs per year with patient per year in the Netherlands, fee-for-service. In 2006 some quality Dutch GP training, the Belgian/Flemish compared with about 4,600 in Belgium and criteria were introduced in order to retain inflow was almost negligible. 4,900 in Flanders. So, compared to the qualifications. In the Netherlands, the average Belgian or Flemish GP, Dutch GPs system of a legally protected title is tied to From 1999 until 2003, the inflow of have to deal with 43% or 36% more a system of periodical re-licensing. Prac- Flemish GPs was eleven per year, about contacts per year. ticing Dutch GPs can be re-licensed if they one quarter of all foreign trained GPs who Time per contact also varies.5 In the can prove that they have been involved in entered the Dutch workforce. Compared Netherlands, the average patient contact in CPD activities above a certain minimum to the total number of Dutch trained GPs a GP practice lasts about ten minutes while level. Recently, the Belgian Minister of in this period (300 per year), the inflow in Flanders, this is about 15 minutes. Health approved legislation aiming to from Belgium remained marginal. develop a future system of mandatory Moreover in Belgium as a whole, 31% of In 2004, only seven Flemish GPs entered CPD activities for Belgian GPs.6 all contacts are house-calls, compared with the Dutch GP workforce and in 2005 only less than 10% of contacts in the Nether- Culture five. So, while the inflow was relatively lands. This again will result in differences high in 2000, it has been declining in recent Flanders and the Netherlands are neigh- in workload. years. bouring geographical areas where the same Income language is spoken. In this respect, from a Interestingly, most GPs with foreign GP Recent OECD data3 indicates that the distance it may look as if both societies are training who entered the Dutch GP work- average income of Dutch GPs was twice very similar. However, this is not really the force are in fact Dutch born GPs who the average of Belgian GPs in 2002: case. The general feeling in both countries went abroad for their vocational is that there are significant cultural differ- €100,000 vs. €50,000. A number of caveats education. This was due to the restrictions ences which are reflected also in the overall must however be applied. First of all, the on the number of vocational education attitudes of doctors. The prevailing positions in the Netherlands. Most went to definition of ‘GP’ is not the same in both attitude of Dutch physicians is aimed at Belgium and returned after a few years to countries. In the Netherlands, the title of transparency in medical practice and the Netherlands. A few went to England, ‘huisarts’ (Dutch for GP) is legally professional accountability: the science of others to Germany. protected and allowed to be used only by medicine, or in Dutch ‘geneeskunde’. This those doctors who have successfully The number of Dutch GPs who settle in is illustrated in the development of various followed the post-graduate vocational Belgium, is less than one per year. The total professional guidelines that are ‘evidence training scheme and who have been regis- number of GPs who are going to work based’. tered on the formal register for GPs. In outside the Netherlands is about 5 per Belgium, however, the title of ‘general These guidelines play not only an year. They move worldwide, to work in physician’ can be used by all doctors who important role in everyday practice, but any country. From these data it can be
Eurohealth Vol 13 No 3 14 HEALTH POLICY DEVELOPMENTS concluded that very few GPs migrated Box: Case study interviews between Flanders and the Netherlands during the last decade. In general, Belgian Two Flemish general practitioners shared their experiences to illustrate the individual dimen- GPs do not tend to settle in practice sions of international labour migration. One doctor had migrated, the other had not, despite abroad frequently. Over the last decade on previously planning to do so. average 15 GPs per year migrated to France. The estimated numbers of migrant Belgian GP practising in the Netherlands; Dr A GPs to Germany or the United Kingdom were even smaller. At the end of the 1990s, Dr A was not happy in his GP practice in Flanders. Too little income, too heavy a workload and the humble position of Flemish GPs within the health care system, Shortage or surplus? made him think of moving to the Netherlands. After a period of exploration of the opportunities Based on the facts presented on the and disadvantages, including serious deliberations within his family, he became a GP in a available workforce and workload in deprived area in one of the big cities in the Netherlands in 1999. After the decision to migrate, Belgium and the Netherlands, it is very he and his family had to go through a mountain of administrative procedures, not only with difficult to state objectively that in one regard to the recognition of his professional qualifications, but also with regard to practical situation a shortage existed and in the aspects of cross-border migration, like residence permits and insurance. Despite these other a surplus. Waiting lists are often obstacles, the positive expectations for the future remained unbroken. Positive expectations of mentioned as a yardstick for a shortage in a more challenging and more rewarding professional life overrode the insecurities of a profes- provision; unemployment for a surplus. It sional and family life in an unfamiliar environment. should however be noted, that shortfalls based on need can co-exist with the unem- After seven years practicing in a non-native country, Dr A is able to state that his expectations ployment of health workers, due to local have been met. He feels really at home in the Dutch health care system, considering the position market conditions. of the GP and the organisation of GP care. In addition, he is very active in professional debates on the changing scene of health care provision in the Netherlands. In this survey, no structural problems with regard to the accessibility of GP care in the Belgian GP not practising in the Netherlands; Dr B Netherlands, nor to the unemployment of Belgian GPs, were observed. Therefore, In 1999 Dr B considered migrating to the Netherlands due to low income resulting from insuf- the question remains unanswered as to ficient patient visits to his general practice in Flanders. At that time, meetings were organised whether the workforce mismatch in both in Antwerp, the main city of Flanders, in order to recruit Flemish GPs to work in the Nether- countries, as experienced by many indi- lands. Dr B attended one meeting. This was followed by visits to two locations in the Nether- viduals, reflected a real misbalance lands, where more GPs were needed and which were potentially interesting work environs. One between demand and supply for care. of these places was in the deprived area of a large city, the other in a small town close to the Moreover, it can be stated that, method- Belgian border. Dr B was very much interested in this nearby town, but, so were some twenty ologically, there are no gold standards for Dutch GPs. He considered his chances and the needs and desires of his family (a son with assessing sufficiency of the workforce in severe disabilities, social environment, and housebound wife), and he decided to stay in 7 health care. Belgium.
Discussion and conclusions Dr B made the following general remark. The income differential between Belgian and Dutch The facts in respect of cross-border GPs, found in almost all international comparative studies, does not reflect the real difference migration of GPs between Flanders and in disposable income. In his view disposable income during working life is about the same in the Netherlands show that, despite poten- both countries due to differences in taxation. However, pension provisions in Belgium are very tially stimulating factors with regard to poor and require additional payments during working life in order to achieve a reasonable income and professional practice, surpris- income post retirement. ingly very few Belgian GPs have settled in the Netherlands. The small number of cations played a role. It can also be easy as that observed for more ‘technical’ migrants and the fact that no sound scien- concluded that individual considerations disciplines such as anaesthesiology or tific explanatory model for migration with regard to social-cultural conditions surgery. flows is available, do not allow for any are the most prominent in the process of general conclusions on the reasons for deciding whether or not to emigrate in international migration between two these two western European countries. REFERENCES neighbouring countries. Consequently, the development of any 1. Van der Velden L, Hingstman L. The scientific model that might help to explain Considering the potential drivers and supply of general practitioners in the objectively the reasons for individual obstacles described in the literature, it can Netherlands. In: Wester FP, Jabaaij L, migration does not seem to be realistic; the be concluded that significant differences Schellevis FG (eds). Morbidity, multitude of potential influences can have Performance and Quality in Primary Care between professional opportunities, quite different values for different indi- – Dutch General Practice on Stage. Oxford, working conditions, income, educational viduals (See Box). Radcliffe Medical Publishing, 2006. opportunities and cultural values, have not stimulated many of the Flemish to go In addition to the push and pull factors 2. Ontwikkeling capaciteit huisartsenzorg abroad; even though ‘abroad’ is nearby and described above, it might be the case that [Development of GP Care Capacity], no general obstacles, like foreign language for disciplines like ‘family medicine’ with a 2000–2004–2012. Capaciteitsorgaan, 2004. or the recognition of professional qualifi- high contextual ‘load’, migration is not as 3. Simoens S, Hurst J. The Supply of
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Physician Services in OECD Countries. 5. Deveugele M, Derese J, van den Brink- ‘emotie’ naar ‘evidence’. [Manpower- Paris: OECD, Working Paper 21, 2006. Muinen A, Bensing J, De Maeseneer J. planning in family medicine in Belgium: 4. Buchan J, Parkin T, Sochalski J. Interna- Consultation length in general practice: from ‘emotion’ towards ‘evidence’. tional Nurse Mobility: Trends and Policy cross sectional study in six European Tijdschrift voor Geneeskunde 2006;62(22). Implications. Geneva: Royal College of countries. British Medical Journal 7. World Health Organization. The world Nursing/World Health Organization/ 2002;325:472–77. Health Report 2006 – Working Together International Council of Nurses, 2003. 6. De Maeseneer J. Manpowerplanning in for Health. Geneva: WHO, 2006. de huisartsgeneeskunde in België: van
Seeking a better balance: Developments in intergovernmental relations in Italian health care
George France
Summary: Health care policymaking in Italy takes place at both central government and regional levels. The latter have significant freedom on expenditure, but have relied heavily on central funding. This asymmetry has caused accountability problems manifested in chronic regional deficits. Deficit spending runs counter to the external hard budget constraint – a condition of membership of the European Monetary Union. Over the last seven years, central government has developed a two-pronged strategy: use of central spending power and intergovernmental negotiation and cooperation. Regions are offered financial help provided they respect conditions – some extremely severe – on budgetary management and health service provision. The conditions, negotiated between the State and the regions, are part of a series of accords, bricks for the construction of a framework for intergovernmental co- operation. The strategy appears to be producing results, although it is too early to tell if the structural problems causing the deficits will be amenable to rapid resolution.
Key Words: Italy; Health Care; Finance; Cooperation.
In elections held in Italy in June 2006, the policy, however, may be due to the tlement (Livelli Essenziali di Assistenza – centre-left coalition headed by Romano persistence of certain structural problems LEA), that is services which are guaranteed Prodi was victorious over Silvio in the Italian health care system. to all citizens regardless of place of resi- Berlusconi’s centre-right formation which dence. As a result of an amendment to the had governed Italy since 2001. The transfer Bipolarism in health policymaking Constitution in 2001, the State was of power has been marked by some Italy has a constitutionally based system of required to make sure that the LEA is changes in health care policy, but on the regionalism. There are twenty regions with guaranteed to all citizens and to ensure, via whole there has been continuity. This may elected governors and legislative assem- equalisation grants, that all regions have come as a surprise given the gulf which blies. Regional autonomy is most advanced the financial means to do this. separates the two political groupings in and visible in the health care sector where The constitutional jurisprudence has for most policy areas. Continuity in health responsibility is shared between central government and the regions. The State is long held that the regions have virtually responsible for setting health policy in complete autonomy in the organisation George France is Senior Researcher, broad terms and for promoting and and administration of the regional health Institute for the Study of Regionalism, protecting the national interest in health services. Until the early 1990s the regions Federalism and Self-Government care. This national interest takes concrete were mainly concerned with the detailed (ISSiRFA), Italian National Research form in the tax-financed National Health design and implementation of centrally set Council, Rome. Service (Servizio Sanitario Nazionale – policies such as market oriented reforms, Email: [email protected] SSN) and in the national health care enti- public management, Diagnosis Related
Eurohealth Vol 13 No 3 16 HEALTH POLICY DEVELOPMENTS
Grouping (DRG) based hospital financing Repeated measures to make the regions afford per capita spending levels similar, and provider accreditation. More recently, responsible for their deficits foundered for example, to those in Germany, France they have become more active policy because of their lack of revenue raising or the UK, unless it cuts expenditure else- makers and less policy takers and have powers. From the mid 1990s, the State where or increases tax levels. In addition, been innovating across the entire health granted the regions important taxes, in as a condition of membership of the policy sphere. For example, they have been particular a ‘piggy-back’ tax on the European Monetary Union, Italy had to active in: setting guidelines and standards national personal income tax, a regional undertake to maintain an overall balance in (for the delivery of specific health services, business tax and a motor vehicle tax. A few the public budget and to substantially accreditation of centres for assisted repro- regions have become completely self- reduce its public debt. Living with such a ductive therapy and transplant units, etc); sufficient, but most still rely to some hard budget constraint means rigorous setting up programmes for immigrant degree on central financing, some very central planning of aggregate public expen- health care, improving the diets of school heavily so. This in part reflects wide diture levels; chronic divergence between children and women’s health, as well as disparities in regional tax bases: Using planned and actual spending cannot be providing additional services not specified Gross Domestic Product (GDP) per capita permitted, especially in a sector as large as in the LEA. as an appropriate measure of regional tax health care. Meantime, economic and take, in the northern Lombardia region political considerations rule out the option Groups of regions have agreed on proce- this was 28% higher than the national of increased national taxation. dures for regulating cross-border flows of average, compared with the southern patients. Regions have also organised region of Calabria where it was 35% lower Changing the balance schemes for centralised purchasing of than the national average. The need to impose a hard budget services and equipment and have experi- constraint in public health care was all the mented with complex accounting systems. These differences in tax bases, combined in greater because of the approval by refer- Finally, some regions are funding medical some regions with weak administrative endum of the constitutional amendment in and health services research. The constitu- and technical capacity and set in a context October 2001. This, among other things, tional amendment of 2001 then formalised of substantial regional autonomy, meant consolidated the autonomy of the regions this autonomy which the regions had that over time there was a growing diver- and placed an obligation on the State to begun to accumulate on an ad hoc basis gence in the character of health care guarantee that the regions had sufficient over the years. Health policymaking in available in the individual regions. The fear resources to deliver the LEA. The outcome Italy has therefore two distinct loci – the was that the integrated SSN risked being of the referendum had already been antic- State and the region. replaced by a loose-knit federation of ipated by the Berlusconi government heterogeneous regional health systems, elected in May of that year. Foreseeing the Asymmetry and the problem of regional placing in serious jeopardy the national need for a re-adjustment in the inter- accountability interest in health care. Moreover, year after governmental balance of power, they In contrast with the thrust of the regions year, the regions continued to report negotiated an accord with the regions for power, the State in the second half of deficits, accumulating over time a barely three months later.3 the 1990s seemed to be gradually with- mountain of debt, some of this dating back drawing from proactive health care policy as far as 1994. Something had to be done. This accord of 8 August 2001 provided for making with the important exception of central aid to the regions to help them health care financing and expenditure The external budget constraint eliminate their accumulated deficits, but control. The irony is that, contrary to what the only on condition that they demonstrated chronic deficits in the SSN might suggest, concretely how they planned to avoid The SSN has been plagued virtually from public spending on health care spending in future deficits, including resorting to its birth by a lack of regional accounta- Italy was, and continues to be, relatively increased regional tax rates, patient co- bility due to asymmetry between spending low by international standards: 6.4% of payments, property sales and steps to and revenue raising responsibilities. GDP in 2004 compared with the OECD- reduce unnecessary and inappropriate care Taxation had been centralised in Italy in Europe average of 6.6%. Expenditure per and labour costs. An important innovation 1971; when the SSN was set up in 1978 it head in 2004, at purchasing power parity, was the imposition of rules on allocating was believed that the national interest in was $1,828 compared with an OECD- the blame between the State and the health care required central financing. The European average of $1,942.1 The problem regions for deficits and, therefore, respon- regions in consequence lacked any signif- lies elsewhere. Italy has built up a large sibility for funding them. For example, a icant own-source revenues. At the same public debt over time, currently equivalent distinction would be drawn between time, constitutional limitations on central to 107% of GDP. This has heavily increased expenditure due to a higher wage intervention in the running of the SSN constrained spending options. To illustrate bill as a results of nationally negotiated meant that the State had very limited the magnitude of this debt, if this could be labour contracts and new expenditure influence over how the regions used their halved, €35 billion per annum in interest stemming from regions providing services grants. Inevitably, the regions failed to live payments could be avoided.2 not included in the LEA. within the means provided to them and ran up deficits. The State tried to contain This opportunity costs of servicing the Seen in retrospect, the 2001 accord was a aggregate spending with a policy of delib- public debt include foregone expenditure watershed in intergovernmental relations erate under-financing, in the hope that on health care and other public services, in health care. Cooperation replaced fiscal stress would induce the regions to reduced investment in infrastructure and confrontation. However, the accord on its economise and rationalise their spending. limited scope to reduce taxes. It has meant own proved insufficient to put a stop to Instead, this tended to aggravate deficits. that for public health care Italy cannot regional deficits. Over the period
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2002–2005, a total deficit of €20,851 renegotiated with creditors; the State prepared to accept severe limitations on million was accumulated. Using the new helped to lighten the annual burden to a their freedom of action. This exercise of rules, almost 84% of this sum was attrib- region of debt repayment by making it a central spending power represents a utable to the regions.4 long term loan repayable in thirty annual dramatic break with the period pre-2001 instalments. when state financing was granted virtually On March 23 2005, another State-region unconditionally. Central grants had tended accord was signed under which, in return The Plan had to include measures aimed at to be seen as going to finance expenditure for help in eliminating the deficits accu- resolving the problem of structural budg- considered to be essentially rigid in the mulated in the period 2001–2005 and any etary imbalance, including further short to medium term. Moreover, these remaining debt incurred before 2001, the increases in regional tax rates. These grants were intended to help finance the regions accepted considerably tougher measures were to be designed by each LEA which the State and regions were conditions.3 As with the 2001 accord, they region working closely with a team of constitutionally obliged to guarantee. had to prepare detailed proposals for experts nominated by, and reporting balancing their future budgets, plus directly to, the Ministry of Economy and Finally, there was a tendency in Italy to see describing how they intended to cover any Finance. In addition, each region was regional autonomy as a situation whereby deficits that should occur. The regions had expected to enter into a ‘partnership’ with there would be minimal central inter- also to agree to transmit detailed infor- a region in budgetary balance, with a view ference on how funds from the centre were mation to the central authorities on the to facilitating the procurement of know- spent. This meant that central government operation of their health services; this how and experience. The seven regions in Italy lacked the instruments to influence information had to conform with defini- were subject to strict data reporting regional policy in health care to any signif- tions set by the New System for Health requirements, continuous monitoring, as icant degree. Italy had differed here from Information (NSIS) operated by the well as quarterly and annual in-depth other countries with decentralised systems Ministry of Health. Additionally, they appraisals. Regions receiving aid under of government, such as Australia, Canada were required to introduce in all facilities these terms were in effect under special and the USA, where the federal govern- detailed accounting systems based on cost surveillance. ments have always made heavy use of the centres. Other conditions included action power of the purse – spending power – to The Prodi government, which took office being taken to rationalise the hospital condition the health policies of sub-central in June 2006, continued this policy and set sector, in particular reducing the bed stock governments. itself the target of regional budgetary and creating alternatives to inpatient care balance by 2009. A State-region accord, Now, under the State-region accords such as day hospitals, ambulatory surgery, called A Pact for Health and signed in described above, the central government is domiciliary health care and extra-hospital September 2006, laid out the strategy to be trying to do just this – use its spending residential and semi-residential care. followed.6 The Prodi government power to condition regional budgetary Heavy emphasis was given to the need to increased the resources going to the SSN policies. And it is going further. The integrate these delivery options to secure for fiscal years 2006 (via supplementary Berlusconi government saw a window of seamless care. State financial help in funding) and 2007. The proportion of the opportunity and used the weakened tackling their budget imbalance would be state grant to be retained until the central bargaining power of the regions stemming granted only after external appraisal of the authorities are satisfied that the conditions from their precarious finances to impose regions’ actions. 5% of the annual state have been met was however reduced to 3% additional conditions aimed at influencing funding to a region to finance the LEA for 2007. regional policies on the provision of health entitlement would be withheld until the services. There seem to have been several A Transition Fund has been set up to central authorities were satisfied that the motivations for this. First, there was provide additional aid to the regions with conditions contained in the accord had concern that, with the imperative to serious deficits, provided of course they been met. balance their budgets, the regions might meet the conditions included in the various evade their constitutional obligation to A survey of regional health policy in 2005- accords. Those running a deficit in 2006 provide the LEA. Second, as noted earlier, 2006 found that the bulk of the regions equal to or more than 7% of planned regional autonomy plus differences in tax 5 spending have been classed as “regions in were trying hard to meet these conditions. bases and administrative capacity risked In the closing months of the Berlusconi difficulty”. Three such regions accounted creating excessive geographical hetero- government in 2006, the financial screws for 75% of the total national deficit in 2006 geneity in the SSN and damaging the were turned ever tighter on those regions (Lazio, where Rome is located, Campania, national interest in health care. Third, the still running serious deficits. The bulk of including Naples, and Sicily), while central government may have been trying the deficits (64.4%) were run up by just another four (Abruzzo, Molise, Liguria, to re-assert the constitutional power to set seven regions.4 Eligibility for state aid to Sardinia) also meet the 7% criterion. The the broad direction of health care policy these regions was made dependent on their State signed bilateral accords with five of that had been placed in question by the preparing a Budgetary Balance Plan (Piano these regions in February 2007 and with regions’ thrust for autonomy during the di Rientro) which would serve as the basis the remaining two in July. 1990s. for a bilateral accord between the indi- vidual region and the State. This Plan had Wielding the spending power Thus, the 2005 accord required, as an addi- to provide as precise an estimate as Central strategies to rein in regional tional condition for receiving supple- possible of the region’s indebtedness, deficits have heavily conditioned regional mentary funding and the 5% retention, calculated with the help of an Advisor options on the financial plane. The seven that the regions design programmes to Bank nominated by the Ministry of the ‘regions in difficulty’ are in such dire implement national plans for prevention, Economy and Finance. Debt had to be financial straits that they have been training and revalidating SSN staff and
Eurohealth Vol 13 No 3 18 HEALTH POLICY DEVELOPMENTS reducing waiting lists. Additional state signed agreements for the promotion of to the ‘regions in difficulty’ via the Tran- funding was available for this, provided the population health with voluntary associa- sition Fund, complaining that this is tanta- regions also met part of the cost. tions, patient groups and consumer mount to rewarding improvidence. organisations. Finally, it has set up a broad Further subsidies of this kind could be The regions have responded positively swath of ministerial commissions and opposed. here. For example, all regions had working parties involving the health care announced measures to cut waiting lists by Using spending power to influence the professions, with briefs to make recom- March 20077 and most had published provision of health services may also be mendations regarding, for example, AIDS strategies on prevention by the end of problematical. The regions do seem to policy, doping in sport, appropriateness of 2006.5 In addition, as already noted, the have responded positively and are setting medical prescriptions, pain therapy and 2005 accord contained requirements up programmes to implement national palliative care, immigrant health care, stem regarding the rationalisation of the hospital policies for prevention, waiting lists, inte- cell research, women’s health and vacci- sector and the integration of health care grated care processes, etc., but it is one nation policy.8 delivery options. The regions continue to thing to prepare programmes, it is another have wide discretion in the design and to implement them actively. It also remains Prospects administration of programmes, but it is a to be seen if these programmes will Continuity in national health care policy measure of the effectiveness of the centre’s produce the desired results, including since the early 2000s reflects the spending power that they have accepted containing costs. In any case, it is persistence of imbalance in regional health policy directives from the centre which inevitable that there will be inter-regional care budgets, particularly for the ‘regions only a few years ago would have been differences here. But at least central poli- in difficulty’. It also derives from the immediately contested in the Constitu- cymakers do seem to have learned, albeit search for compatibility between the tional Court or possibly just ignored. belatedly, a basic law governing policy- pursuit of the national interest in health Another likely reason for regional making in systems of decentralised care and strong regional autonomy. compliance is that the national strategies government. This is, if it is to attain its Finally, continuity is the result of the need have been negotiated by the State and goals, a central government needs the for national government to respect the regions and included in the accords as hard external budget constraint accompa- cooperation of subcentral government just annexes. nying membership of the European as much as subcentral government need its The Prodi government has continued the Monetary Union. funding. strategy of using central spending power An important development has been the to influence health care service provision use of central spending power to influence REFERENCES by the regions. Regions are required to regional policies, but what may prove to submit to regular appraisals and moni- 1. Organisation for Economic be equally significant is the emergence of a toring by teams attached to the Ministry of Co-operation and Development. Health form of ‘cooperative regionalism’. The two Health with the specific purpose of veri- Data 2006. Paris: OECD, 2006. are corollaries: the bitter pill for the fying that the regions are meeting their regions of the exercise of central spending 2. Camera dei Deputati. Documento di LEA obligations. Programmazione Economico-Finanziaria power may be made easier to swallow by Relativo alla Manovra di Finanza Pubblica Over and above requiring continued intergovernmental negotiation and co- per gli Anni 2008–2011. Rome: Camera dei regional action in the specific fields operation in policy design and implemen- Deputati, 2007, p 7. targeted by the Berlusconi government, tation. This would represent a break with the Prodi government has created an ad a past characterised by State-region 3. Available at ISSiRFA website (section La hoc fund for the co-financing of projects conflict and mutual incomprehension Cooperazione Interistituzionale), in other fields, for example women’s regarding the adequacy of central funding. www.issirfa.cnr.it health, rare diseases and spinal units. 4. Istituto di Studi e Analisi Economica. The strategies developed over the past six Rapporto ISAE: Finanza Pubblica e The new government has also continued to years may now be producing results. The Istituzioni. Rome: Istituto di Studi e encourage intergovernmental cooperation majority of the regions appear to have their Analisi Economica, 2007. and has taken it further. It called for “a new financial situation under control and the form of shared government” and urged a ‘regions in difficulty’ are under strict 5. Camera dei Deputati. Rapporto 2007 sul la Legislazione tra Stato, Regioni e Unione “cooperative and consultative approach”. surveillance. It remains to be seen if it is Europea. Rome: Camera dei Deputati, One of its first initiatives was the presen- possible to modify markedly the structural Osservatorio sulla Legislazione, 2007, Part tation in Parliament in July 2006 of A New factors contributing to large deficits, at II, chapter 5. Deal for Health [Un New Deal della least within the short time frame set by the Salute].5 This strategy went beyond state- Prodi government. It is also an open 6. Available at www.ministerosalute.it regional cooperation (addressed in the Pact question as to how long the ‘regions in 7. Ministero della Salute. Riepilogo Piani for Health) and covered all the stake- difficulty’, particularly those with lower Regionali – Liste d’Attesa al 30 Marzo holders in the health care system. As part than average tax bases, can sustain the 2007. Rome: Ministero della Salute, of the New Deal, the Ministry of Health is higher than average tax levels which they Dipartimento della Qualità, Ufficio III, cooperating with other ministries in have had to include in their Budgetary 2007. investment programmes in health care in Balance Plans. The other side of the coin is 8. Ministero della Salute. Diario delle southern Italy, financed in part with that some of the ‘virtuous’ regions which Attività e delle Iniziative del Ministro European Union funds, and in initiatives have attained budgetary balance are Livia Turco, Giugno 2006 – Maggio 2007. to promote population health. It has also unhappy with the special treatment given Rome: Ministero della Salute, 2007.
19 Eurohealth Vol 13 No 3 HEALTH POLICY DEVELOPMENTS Institutional and community care for older people in Turkey
Ömer Saka and Nebibe Varol
Summary: Turkey still has a young population in respect to most other European countries, although the proportion of the population comprising older people is expected to increase in future years. This will necessitate a change in the perception and provision of health and social care services. Current services are already insufficient to meet the needs of the older population. The government and other institutions in Turkey need to be ready to meet these ever increasing needs and enhance the quality of existing services in order to improve the health and living conditions of older people in the country.
Keywords: Institutional Care, Social Care, Older People, Turkey
International awareness of health issues people lived independently in their own The largest single provider of social care relating to ageing populations has been homes, 36% resided with their children services for older people is the General increasing in recent years as populations and just 1% lived with other relatives or Directorate for Social Services and Child age. The rate of increase in population within a residential care facility.6 Protection Agency (Sosyal Hizmetler ve growth in Turkey slowed from 1.41% to Çocuk Esirgeme Kurumu – SHCEK). Although traditionally in Turkey, as in 1.26% between 2000 and 2005. During the Operating nationwide, services include many other Mediterranean countries, older same period, the percentage of the popu- residential care homes (‘huzurevleri’), people in need have often lived with other lation aged 65 years old and above home-care services, day centres and reha- family members, the situation is beginning increased from 5.4% to 5.9% and is bilitation services.3 Other service to change. The demand for access to expected to rise further to 7.75% by 20201 providers include municipalities, voluntary formal care services has expanded due to a and to reach 17.6% by 2050.2 Older people sector organisations (‘vakifs’) and the account for a even higher share of the myriad of factors. These include migration private sector. population in rural areas, 9% compared to by children from rural areas to urban areas; Publicly funded places in residential care just 6% in urban settings.3 90% of all those the increase in the number of women in homes are primarily for those demon- over 65 have to live with chronic health employment; changing culture and strated to be destitute through an problems. This ageing of the population, increasingly divergent values between assessment of means, rather than those coupled with a change in family structures young and old generations; and social and 7 with severe health care needs.3 Indeed, to away from the extended family to the economic deprivation. gain admission an individual must be smaller nuclear family will increase the healthy enough to undertake activities of need for formal services for older people.4 Access to formal support services The 1985 Law on Agency for Social daily living independently, have no serious disability or illness requiring continuous Living arrangements for older people Services and Child Protection, set out the medical care, no drug or alcohol abuse While 65 years of age has traditionally conditions under which support and care problems and demonstrate social and/or been seen as the beginning of old age in could be provided to various groups of the economic destitution through a social many high income countries, individuals population including older people, analysis report. above 60 have been defined as being of old children and people with disabilities.8 age in Turkey.5 This is also the cut-off There are two principal types of support: As Table 1 indicates the size of residential point for admission into residential long access to financial support and secondly care home varies substantially, with more term care facilities. In 2003, according to access to support services. Social security than 20,000 beds available in total. As of one survey carried out by the State benefits are available to clients of the October 2007, SHCEK operated 69 homes Planning Agency (DPT), 63% of older Retirement Fund (Emekli Sandigi), the with 7,504 beds.9 There are no charges Social Insurance Association (SSK) and the levied on residents, who in addition have Omer Saka is based at the Division of Social Insurance Association for all their health care needs, including Health and Social Care Research, King’s Tradesmen and Craftsmen (BAG-KUR). medications and access to prosthetics College London. Nebibe Varol is reading Since 1976, some provision has also existed covered. A further 25 homes with 4,432 for a PhD, LSE Health, London School of for “a monthly salary for indigent, beds are provided elsewhere by the public Economics and Political Science. destitute and homeless Turkish citizens sector. More than 7,000 beds are also Email: [email protected] over 65”.3 provided in 143 residential homes by other
Eurohealth Vol 13 No 3 20 HEALTH POLICY DEVELOPMENTS
Table 1: Residential care home places in Turkey Challenges The principal problem that older peoples’ Residential care home service provider Number of homes Number of beds services face today is the lack of institu- tional capacity, which is far below popu- SHCEK 69 7,504 lation need, as Tables 1 and 2 indicate. The Other government ministries 6 2,442 Ninth Development Plan aims to support home-care services for older people and Municipalities 19 1,990 improve both the capacity and quality of residential care centres. It has been noted Total public sector 94 11,936 that “inadequate conditions in these facil- ities and the incompetence of the staff are the two foremost problems encountered”.7 Voluntary sector (including vakifs) 33 2,360 Professor Zerrin Soylemez from Minority group organisations 7 991 Gaziantep University, who is currently undertaking analysis of the situation in Private sector 103 4,478 Turkey, also notes that other important issues include the lack of social and Total voluntary and private sectors 143 7,829 cultural programmes to support the social needs of residents of these institutions and the absence of special programmes on Total 237 19,765 geriatrics at departments of nursing; these are only to be found in departments of 2 Table 2: Membership of day (solidarity) centres in Turkey, October 2007 psychiatry and public health.7
Day Centres Men Women Total A study conducted in Izmir in the west of the country, indicated that older people Ankara Emek 31 174 205 living in a family environment had higher Ankara Mamak 2 2 4 levels of self-assessed quality of life compared to those living in institutions.12 Canakkale 23 163 186 The study suggested that it was difficult for health care services to meet the needs Izmir Nebahat Dolman 79 375 454 of older people by building residential care Eskisehir 57 13 70 home or geriatric hospitals as in high income countries. Another study in a semi Total Members 192 727 919 rural province concluded that living with family members results in higher levels of public and private sector organisations2 maintain psychological well-being and life satisfaction for older people.14 Given (See Table 1). Legislation on private homes stave off illness. The centres also provide the deficiencies in these institutions, home passed in 1997 states that individuals advice on health, psychological and social care services have an important role to play accepted into private homes must be above needs. Older people also act as volunteers in resolving this problem. It is important 55 years of age and require institutional in these centres helping their peers. There to encourage individuals to remain at care due to social and/or economic need. is a need to expand both the number of home by giving priority to organisations centres available, while also widening their such as ‘Care at Home’ and ‘Daytime Care Those in need of nursing and medical care appeal within the male population as the Homes’. and without mental health problems may overwhelming majority of members are be admitted to rehabilitation and care Another study analysed the situation faced women. Additionally, SHCEK runs one centres. Those with little income, as well by older people using data on 1106 indi- day care centre for people with as all who have been awarded state military viduals aged 65 plus from the 1998 Turkey Alzheimer’s Disease in order to provide honours (‘Istiklal Madalyasi’), are Demographic and Health Survey.13 some respite to family carers, reduce the admitted free of charge. Everyone else Socioeconomic variables relating to indi- risks of staying at home alone and avoid must pay a charge.10 vidual, household and community-level overcrowding in nursing houses.11 factors were selected and the study then Community day centres In 1994, SHCEK started a project training looked at housing, heating, source of Five community day centres for older home-carers. Families whose older rela- drinking water and the type of toilet facil- people (known locally as ‘solidarity tives are in need of care can accept help ities, which are important factors centres’) fall under the remit of legislation from these carers after completion of impacting on daily life. It reported that enacted in 2001. The centres (including one training. The project, which is carried out 87.5% of older people owned their own with just four participants) provide an by the Provincial Social Service homes, while the remaining 12.5% lived in opportunity for mobile older people to Management (Sosyal Hizmetler İl rented accommodation. 82.7% were using expand their social networks, enjoy enter- Müdürlüg˘ü) and implemented solely in stoves for heating, 45.8% lived in houses tainments and improve the use of their Ankara, Istanbul and Izmir is anticipated with a pit or other type of toilet difficult to leisure time; these activities, by reducing to become widespread. use, 1% were using rivers/streams as a social isolation, can help individuals source of drinking water, while 35.9%
21 Eurohealth Vol 13 No 3 HEALTH POLICY DEVELOPMENTS were living in houses with earth or for social and health care has to be 6. Atalay B, Kontas YM, Beyazıt S, wooden floors. When these figures and the increased. Preventive care services to Madenoglu K. Turk Aile Yapısı Araştırmas. declining sensory and physical abilities of maintain physical and mental health and An Investigation of Turkish Family older people are taken into account, it can advisory services on health and personal Structure. Ankara: State Planning Agency be safely assumed that the risk of hip frac- care needs have to be developed. Projects Publications,1992. tures due to the physical danger of living and programs to enable the social, cultural, 7. Soylemez Z. Elderly Care and Elderly in such conditions can be very high. economic and political involvement of Structures in Turkey. Wuppertal: First Turkey needs to improve the living condi- older people should also be supported.7 Transnational Conference, 2006. Available tions and quality of housing to decrease at http://www1.gantep.edu.tr/~gukamer/ Turkey also needs more research to map the risk of domestic hazards and improve docs/Wup2.ppt#256,1,Elderly Care & and profile the older population, in order quality of life. Elderly Structures in Turkey to identify their expectations and service This study also suggested that 25.2% of needs and appropriate social policies. The 8. Secretariat General for EU Affairs. EU Accession Negotiations. Screening Chapter older people live in poverty without any EU can also help in this respect. One such 23: Judiciary and Fundamental Rights. regular income. This situation is particu- research initiative now underway involves Ankara: Secretariat General for EU Affairs, larly acute in the rural areas of the country, the Contemporary Women and Youth 2006. although it is complex because of cultural Foundation, Gaziantep University and ş factors such as the understatement of the Gaziantep Social Services Directorate. This 9. SHECK. Ya li bakim hizmetleri dairesi ş ğ need for regular income, good food and international project is carried out with ba kanli inin görev ve yetkileri [Services access to health care services. While the partners in four other European countries for the care of older people] Ankara: SHCEK, 2006. Available at government pays a quarterly salary to under the coordination of the Paritatische http://www.shcek.gov.tr/hizmetler/yasli/Y older people over 65, this is insufficient to Akademie in Germany.17 Entitled Compe- asli_Bakim_Hizmetleri.asp meet needs. Despite free access to public tency Profile of Trainers for Domiciliary transportation, the majority of older Care of Older People, the project runs for 10. SHECK. Huzurevleri ile Huzurevleri people in Turkey do not have access to two years until October 2008 within the Yasli Bakim ve Rehabilitasyon Merkezleri health and geriatric service; geriatrics scope of the EU Leonardo da Vinci [Residential Care Homes and Rehabilitation Service Centres]. Ankara: services in particular are scarce and programme. Activities include data 14 SHCEK, 2006. unevenly distributed across the country. collection on care; quality management ğ Malnourishment and depression are also education for older person care and on 11. SHECK. Ümitköy huzurevi müdürlü ü ş significant problems. One recent study assessment of the need for education in this Alzheimer hastası ya lılar gündüzlü bakım merkezi [Day care centres for older people suggested that up to 5.4% of older people area; and the organisation of a National with Alzheimer’s disease] Ankara: living alone, 2.4% in residential care homes Conference in March 2008 in order to SHCEK, 2006. Available at and 0.4% living with families could be discuss findings with social partners. http://www.shcek.gov.tr/hizmetler/yasli/ regarded as malnourished.15 In a much Alzheimer.asp older study from 1991, the prevalence of depression, assessed using the Hamilton REFERENCES 12. Ozer M. A study on the life satisfaction of elderly individuals living in family Rating Scale was 35% (33% for men, 37% 1. Turkish Statistical Institute. Population environment and nursing homes. Turkish for women) for the total population, 41% Statistics and Projections. Turkish Statistical Journal of Geriatrics 2004;7(1):33–36. (40% for men, 42% for women) for those Institute: Ankara, 2007. Available at living in an institution and 29% (24% for http://www.turkstat.gov.tr 13. Ayranci U, Ozdag N. Old age and its related problems considered from an men, 33% for women) for those living at 2. Social Security High Advisory 16 elderly perspective in a group of Turkish home. Commission. Dokuzuncu Kalkinma Plani elderly. The Internet Journal of Geriatrics [Ninth Development Plan]. Ankara: and Gerontology 2005;2(1). Reflections SSHAC, 2006. Available at The increasing proportion of older people http://plan9.dpt.gov.tr/oik11_ 14. Senol Celink S, Celik Y. Ageing in in the population and their unmet need for sosyalguvenlik/sosyalgu.pdf Turkey. Perspectives 2001;4. Available at care and support is a challenge that Turkey, http://aabss.org/journal2001/Celik2001. 3. Research and Application Centre of jmm.html a developing and changing society, now Women Issues (GUKAMER). Elderly care must face. Living conditions and access to in Turkey. Gaziantep: Gaziantep 15. Bekaroğlu M, Uluutku N, Tanrıöver S, health care are in need of revision and University, 2006. Available at Kırpınar I. Depression in an elderly improvement. As the Ninth Development www1.gantep.edu.tr/~gukamer/eng/ population in Turkey. Acta Psychiatrica Plan indicated, policies to encourage and eldery.htm Scandinavica 1991;84(2):174–78. support care for older people within their 4. Yavuz S. Changing Household and 16. Şanlıer N, Yabancı N. Mini nutritional own homes have to be adopted. Solutions Family Compositions in Turkey: A Demo- assessment in the elderly: living alone, with need to be adapted to account for differing graphic Evaluation for 1968–1998 Period. family and nursing home in Turkey. circumstances in rural and urban areas. Hacetteppe University: Ankara, 2004. Nutrition & Food Science 2006;36(1):50–58. Both the capacity and the quality of the Available at http://www.sdergi.hacettepe. 17. Research and Application Centre of residential care institutions have to be edu.tr/sutaymakale.htm Women Issues (GUKAMER). Gaziantep: improved. This must include those resi- 5. SHCEK. Yaşliliğa Genel Bakiş Ankara: Gaziantep University, 2006. Basin dences that cater for older people with SHCEK, 2006. Available at duyurusu. Available online at disabilities and chronic health problems. http://www.shcek.gov.tr/hizmetler/yasli/ http://www1.gantep.edu.tr/~gukamer/ The number of qualified personnel both Yasliliga_Genel_Bakis.asp 2006.12.07.htm
Eurohealth Vol 13 No 3 22 HEALTH POLICY DEVELOPMENTS Electronic Health Record development in Austria
Theresa Philippi
The Electronic Health Record (EHR) or cists. Nevertheless, being a strongly tech- Elektronische Gesundheitsakte (ELGA) nology driven process, its introduction Box 1: Basic components of ELGA aims to integrate the various but isolated might prompt some scepticism, for systems of information technology (IT) instance in respect of data confidentiality Nationwide master patient index based health data management that exist in and privacy issues, as well as concerns Health service provider index Austria. The new ELGA, it is anticipated, about a potential increase in bureaucracy Document registry providing links to docu- will help promote the implementation of required to operate the new system. integrated care, in particular, through ments Thus, a broad and in depth process of enabling better cooperation between the Authorisation system information and communication with all secondary/acute care sectors and the stakeholders has been an essential prereq- Internet portal providing high quality health primary/community care (extramural) uisite to implementation. The dossier information as well as individual and secure sectors.1 Outlook on the first implementation phase access to personal data Currently, hospitals are the leaders in of ELGA in Austria was the subject of a information communication technology broad consultation process prior to accessibility of their individual data. (ICT) based data management and storage. approval by the Federal Health Some have already implemented local Commission in May 2007. Consequently, Integrated care in a federal state EHR solutions allowing both individual representatives of the principal stake- Austria’s constitution as a federal state, units within and clusters of hospitals to holders, as well as legal and data protection consisting of nine provinces (Länder) and gain access to specific health data. Doctors experts, have been integrated into the a federal entity (Bund), provides a special are, however, more reluctant to use IT in subsequent creation of the ‘masterplan’ for challenge when it comes to the implemen- the management of patient data. The aim IT architecture completed in autumn 2007. tation of this new EHR system. Legislative now is to place all health care providers on Further features of ELGA will be shaped competence is shared between the Bund the same technological level playing field and implemented by six project teams, and the Länder, whereas the vast majority through ELGA. Data will originate from consisting of the key representatives from of hospitals in Austria are run solely by the health care providers, as well as patients, the principal players in the health system, Länder. Furthermore, although social and will be stored at the individual health i.e. doctors, pharmacists, social care, social security is state funded it is organised inde- care provider’s facilities or hospital. security and the federal and regional pendently. In this environment it is crucial The use of ELGA obviously should administrations. Additionally, an analysis to create interfaces to facilitate integrated increase the amount of information of the costs and benefits of the system will care and encourage communication in available to doctors, patients, nurses and be conducted. order to avoid redundant investments. pharmacists. At the same time the elec- Consequently, the task force for the imple- tronic health record will have an impact on IT-Architecture mentation of ELGA (Arge ELGA), established forms of cooperation and The ELGA-IT-Architecture will be built created in July 2006 consists of represen- communication in the health care system. on an international framework of health tatives from the Bund, Länder and social The highest levels of data security and data related IT-standards, the so-called ‘Inte- security system. Step by step implemen- protection are indispensable preconditions grating the Health Care Enterprise’ (IHE) tation of the new system is dependent on to successful implementation. Access to standards. The basic components of this regular consultation between all these data will thus be restricted to authorised Architecture are set out in Box 1. Core system partners, in addition to decisions taken by the Federal Health Commission. individuals. Initially these will include applications of the first implementation health care providers working in hospitals, phase consist of the electronic discharge Legal matters as well as doctors, laboratory and pharma- summary, e-Report laboratory, e-Report radiology and an e-Medication tool. Implementation also has a number of legal implications, first and foremost in respect The architecture also contains crucial Theresa Philippi is Deputy Programme of privacy laws. Notwithstanding the elements for data security. A special audit Manager of the task force implementing provisions of the Austrian Data Protection layer allows for the full control of electronic health records (Arge ELGA) in Act, the EU Data Protection Directive retrievals, as well as the detection of abuse. Austria and also responsible for legal and 95/46 EC (most notably Articles 6 and 8) Another important tool is the so-called public affairs. is the principal instrument to comply ‘Basic Patient Privacy Consent Register’ Email: [email protected] More with.2 The challenge for legislators will be information in German at which is designed to allow for the opt-in to establish a balance between the right to http://www.arge-elga.at and opt-out of patients with regard to the
23 Eurohealth Vol 13 No 3 HEALTH POLICY DEVELOPMENTS privacy and the right to patient infor- mation. Long established legal acts already Pharmaceutical pricing and oblige doctors and hospitals to file patient documentation. More recently, the Health Telematics Act has provided rules on the reimbursement in Romania electronic exchange of health data and respective information management. Initially under the new system electronic health records will only be accessible to Irina Haivas and Bodgan Grigore authorised health professionals, thus leading to impacts on relevant health system legislation. One way of addressing legal questions over patient identification Overview of pharmaceutical funding Republic, Bulgaria and Hungary). If data (which is also a precondition for data and expenditure from these three countries are lacking or protection) might be to take the data The Romanian health care system is based contradictory, Poland, Slovakia, Austria, processing rules of the E-Government Act on social health insurance, operating Belgium, Italy, Denmark and the UK are as a role model. through a single National Health then used. Insurance House (NHIH). Within the Potential for greater patient focus framework of social health insurance, the Pharmaceutical reimbursement The new ELGA clearly has much potential insuree benefits from access to medicines Insurance coverage for medicines is based to improve information for patients and listed in the Medicines List. In 2007, the on the National Medicines List. This is a enhance patient empowerment. It is Romanian government allocated 4.2% of positive list compiled by a speciality tech- destined to give doctors and patients faster Gross Domestic Product (GDP) to health nical committee called the Therapeutic access to more and better quality infor- care, the largest budget as a proportion of Strategy Committee and then subject to a mation on their health status. With all GDP since 1990;1 80% of pharmaceutical debate by a National Transparency relevant data readily retrievable, delays can expenditure is funded by the NHIH. Committee which includes representatives be reduced and therapy commenced However, per capita consumption is still of NHIH. Finally, it is approved through earlier. Redundant checks which are often low, at an average of €75 per annum, an official government decision. The Ther- burdensome for the patient (and at the despite significant market growth of over apeutic Strategy Committee is formed same time costly for the health system) 20% per year in recent years. The value of mostly of key opinion leaders in the might be reduced or avoided. the Romanian pharmaceutical market in medical field, generally heads of Speciality € Health care providers are also expected to 2006 was 1.55 billion, with prescription Committees. It also includes representa- benefit from the comfort of the ‘full medicines accounting for approximately tives of the NHIH, the Ministry of Health, € picture’ of a patient’s condition, as well as 1.3 billion. and observers from trade and industry. from higher quality communication with The list is organised into three sublists Pharmaceutical pricing their colleagues and improved data according to the level of reimbursement Pricing decisions are taken separately from management. In the long run, it is and cost sharing: 90% reimbursement reimbursement decisions. The National envisaged that the patient will be able to (sublist A), 50% reimbursement (sublist B) Catalogue of Medicine Prices sets the access his or her own record and feed data and 100% reimbursement (sublist C). The maximum retail prices, inclusive of VAT into the system by means of a personalised latter includes medicines for ambulatory for prescription medicines, both imported internet portal. Thus patient information care for a group of diseases (category C1); and locally produced. The catalogue is will be enhanced. In this regard, patient medicines for patients included in national published by the Ministry of Health and groups have already been contacted by the health programmes for diabetes, cancer every three months updated and adjusted ELGA team in order to integrate their and post-transplantation care (category for inflation. These updates are available needs in the design of ELGA’s functional- C2); and medicines for people aged 18 and online free of charge.2 ities as much as possible. younger. Other groups covered include Prices for original medicines and generics students and apprentices aged 18–26 if are set through an external reference they have no income, as well as expectant REFERENCES pricing mechanism, using the minimum and new mothers.3 price from three selected countries (Czech 1. Kodner D. Integrated care: meaning, The level of reimbursement refers to the logic, applications and implications – a cheapest medicine within a cluster of discussion paper. International Journal of medicines with the same International Integrated Care 2002; Oct–Dec(2):e12. Irina Haivas was studying for an MSc in Nonproprietary Name (INN), strength 2. Commission of the European International Health Policy, LSE Health, and pharmaceutical form.3 The price is the Communities. Working Document on the London School of Economics and Political reference price from the National Cata- processing of personal data relating to Science. logue of Medicines Prices. Patients have to health in electronic health records (EHR). Bogdan Grigore is EU Affairs Advisor cover any additional costs if the medicine Brussels: Directorate General Justice, (Pharmaceuticals), Romanian Ministry of used is not the cheapest in a cluster, or if it Freedom and Security, 2007. Available at Public Health, Bucharest. is not fully reimbursed. http://ec.europa.eu/justice_home/fsj/privac y/docs/wpdocs/2007/wp131_en.pdf Email: [email protected] The current Medicines List has been
Eurohealth Vol 13 No 3 24 HEALTH POLICY DEVELOPMENTS
Box: Criteria for the National Medicines List5 inequalities widening over time; it may also reduce competition between phar- Inclusion criteria macies. This threshold is often reached before the end of the month, and thus no pharmacy in any county may be able to 1. New INN, with new therapeutic indication and a major clinical benefit. dispense medicines on a reimbursement 2. Existing INN, with new therapeutic indication and a major clinical benefit. basis, even if a patient presents a prescription for a medicine that would 3. INN with superior clinical efficacy compared to INNs in the same therapeutic cluster, as normally be reimbursed. demonstrated by controlled clinical trials. While one possible reason for this is insuf- 4. INN with superior clinical safety compared to INNs in the same therapeutic cluster, according to ficient pharmaceutical expenditure, the data presented by the authorisation owner within the marketing authorisation process. another cause may relate to prescribing practices. With a lack of incentives for 5. INN or associations of INNs, from the same therapeutic group, with the same therapeutic good prescribing practices, feedback from indication as the existing products for a certain disease, if this brings a cost reduction (the cost of a defined daily dose). prescribing doctors to the NHIH is usually delayed for four to five weeks. A strategy to implement a national infor- Non-inclusion criteria mation technology network has been drafted with a goal to improve feedback 1. INN not intended for outpatient treatment. and efficiency in measuring prescribing patterns. 2. OTCs (over-the-counter medicines). Another issue is that the pharmaceutical 3. INN that brings no benefit, is not safer or cheaper than medicines already on the list. budget is distributed between local agencies of NHIH (one for each county), Exclusion criteria based on crude population levels, but without using other resource allocation 1. INN therapeutically obsolete. formula or risk adjustment mechanisms. Such adjustments may merit future consid- 2. INN for which the benefit/cost ratio (according to national pharmacovigilance regulations) has eration, alongside any increase in the changed in favour of risk. percentage of GDP allocated to health care 3. INN that can be replaced with another approved medication with a better cost/efficacy based in general and pharmaceutical care in on daily therapeutic dose. particular.
4. INN that changed status to OTC medicine. REFERENCES 5. INN with expired marketing authorisation. 1. Parlamentul Romanâniei. Meeting of Commission for Health and Family. produced in line with the World Health generic manufacturers try to get prices Bucharest: Romanian Parliament, 26 October 2006. Available at www.cdep.ro/ Organization recommended process for close to, or below, the current reference comisii/sanatate/pdf/2006/sz102426.pdf. developing clinical practice guidelines and price. This helps to drive prices down. the EU Transparency Directive. The law 2. Pharmaceutical Directorate, Romanian states some broad general criteria Other issues Ministry of Public Health. regarding inclusion, non-inclusion and Pharmaceutical legislation in Romania www.msf-dgf.ro exclusion (See Box).4 Members of the requires further development in terms of 3. Government Ordinance No.1842/2006. Therapeutic Strategy Committee are not complexity, transparency and clarity. A 21 December 2006. Available at accountable for the economic or public new law for medicine pricing is expected http://www.cnas.ro/?id=223 health impact of their decisions. Moreover, by the end of 2007. The Ministry of Health 4. Order of the Ministry of Public Health the process of how the reimbursement expects this to lead to an overall decrease No. 917 27 July 2006. level is assigned to certain medicines is not in retail prices of 15%. Not all prices will fully transparent to the public. be modified by the same percentage and Furthermore, no health technology some might increase, but the exact price assessment criteria are used for setting changes in each category are not yet price and reimbursement, although some known. The law will increase the number interest has been expressed in using these of countries used for reference pricing. in future. Each pharmacy is allocated a monthly There is no formal policy for generics, but budget threshold and must only dispense as patients usually choose the product that reimbursed medicines within this limit. allows the lowest level of cost-sharing, County Health Insurance Houses are medicines whose prices are closest to the responsible for this budget allocation, reference price are the most dispensed; based on historic sales. This may lead to
25 Eurohealth Vol 13 No 3 Evidence-based health care
How Good Are We With Numbers?
Bandolier 103 featured a study that looked at literacy attainments in rheumatoid arthritis patients. Literacy is especially important because these patients often have complicated medication regimens. The study found that one patient in six would, at best, struggle with patient education material, and one in twenty could not read prescription labels. We now have some studies looking at numeracy, both in medical students and patients.
Table 1: Some definitions of health numeracy First we need to have some understanding of what is numeracy. The dictionary definition is one of competence in mathematical skills to allow us to Concept Definition cope with everyday life, but also includes under- standing mathematical terms from graphs, charts, or Health The degree to which individuals have the capacity to tables. Fortunately health numeracy has been numeracy access, process, interpret, communicate, and act on provided with a set of definitions.1 numerical, quantitative, graphical, biostatistical, and prob- abilistic health information needed to make effective health Various levels of health numeracy have been defined decisions (Table 1). The four levels start at the most basic, with statistical numeracy being that degree of Basic Having sufficient skills to identify numbers, and to make numeracy that we would expect from most doctors, numeracy sense of quantitative data requiring no manipulation of and quite a lot of other health professionals. numbers. An example would be identifying the correct number of pills to be taken, data and time of appointments, Numeracy in medical students using a phone book One way of measuring numeracy is to ask a few simple maths questions, and see how many correct answers you get. It does not need to be an intensive Computa- The ability to count, quantify, compute, and otherwise use examination, and one set of questions used in tional simple manipulation of numbers, quantities, items, or visual numeracy elements in a health context so as to function in everyday studies of medical students and patients is shown in 2 situations. An example would be using nutritional labels Table 2. Most of us would expect to get the right correctly answers to these three questions, on simple proba- bility, and converting frequency to percentages and back again. The level is that of basic and computa- Analytical This involves the ability to make sense of information, as numeracy well as higher functions like inference, estimation, propor- tional numeracy in Table 1. tions, percentages, frequencies, and equivalent situations. These questions were answered by 62 first-year Information may be from multiple sources, and an example medical students at the University of North would be determining whether an analytical result was Carolina at Chapel Hill Medical School who within the normal range, or understanding graphs attended a risk-communication seminar. Most students answered all three questions correctly, but Statistical An understanding of basic biostatistics involving proba- 5% (1 in 20) answered only one or none correctly numeracy bility statements, skills to compare different scales (proba- (Figure 1). bility, proportion, percent), to critically analyse quantitative Students were also given information about information like life expectancy or risk, and understanding treatment choices, with results presented in different concepts like randomisation and blinding. An example ways (relative risk reduction, absolute risk would be making choices between treatments based on reduction, number needed to treat, and a combi- standard outcomes of relative or absolute risk nation). Most students (90%) correctly stated which drug worked better (comparative answer), but only 61% could work out the quantitative answer. For Bandolier is an online journal about evidence-based healthcare, written by both, there was a strong relationship with being able Oxford scientists. Articles can be accessed at www.jr2.ox.ac.uk/bandolier to answer the simple maths questions correctly This paper was first published in 2006. © Bandolier, 2006 (Figure 2).
26 Eurohealth Vol 13 No 3 HEALTH POLICY DEVELOPMENTS
Table 2: Three simple questions to test numeracy only 40–60% were able to determine which of two treatments was better, but fewer than 20% (1 in 5) were able to work Question Calculation Correct answer out the quantitative difference.
Imagine that we flip a coin 1000 times. 1000 x 0.5 500 Comments There is not a huge literature on numeracy, What is your best guess about how many times the coin would but it is likely to be important, and at least come up heads? as important as literacy. For instance, a single observational study4 showed that In the lottery, the chance of winning a prize is 1%. 1/100 10/1000 patients older than 50 years attending anti- What is your best guess about how many people would win a = X/1000 coagulation management units had signif- prize if 1000 people each buy a single ticket to the lottery? icantly poorer control of INR when they had low numeracy skills, while low In the publishing sweepstake, the chances of winning a car is 1 1/1000 0.10% literacy made no difference. in 1000. = X/100 But numeracy and literacy have to be What percent of tickets to the sweepstake wins a car? taken together. A detailed paper too difficult to précis5 asked professionals and public about ways of expressing results Figure 1: Numeracy as measured in medical students and patients relating to prenatal diagnosis and chro- mosome abnormalities. There were huge differences in the way people responded to the same information. For instance, when asked which of 5% or 1 in 20 sounded bigger, 81% thought 1 in 20 sounded bigger. That paper is certainly worth a read for anyone teaching communication skills. The bottom line, though, is that on limited information, we can identify that many patients and some professionals have prob- lems with numbers. That puts even more heat on trying to explain those numbers in ways that people can understand.
REFERENCES 1. Golbeck AL, Ahlers-Schmidt CR, Paschal AM, Dismuke SE. A definition Figure 2: Students' interpretation of quantitative information according to their correct and operational framework for health answers to numeracy questions numeracy. American Journal of Preventive Medicine 2005;29:375–76. 2. Sheridan SL, Pignone M. Numeracy and the medical student's ability to interpret data. Effective Clinical Practice 2002;5:35–40. 3. Sheridan SL, Pignone M, Lewis CL. A randomized comparison of patients' understanding of number needed to treat and other common risk reduction formats. Journal of General Internal Medicine 2003;18:884–92. 4. Estrada CA, Martin-Hryniewicz M, Peek BT, Collins C, Byrd JC. Literacy and numeracy skills and anticoagulant control. American Journal of Medical Science 2004;328:88–93. Numeracy in patients numeracy are in Figure 1, and show that 5. Abramsky L, Fletcher O. Interpreting The same research group performed the most patients could answer only one information: what is said, what is heard – same tests in 257 patients aged 50 to 80 (30%) or no (41%) numeracy questions a questionnaire study of health years attending for health care at an correctly. It was also true that whatever professionals and members of the public. internal medicine clinic.3 The results for way information was presented to them, Prenatal Diagnosis 2002;22:1188–94.
Eurohealth Vol 13 No 3 27 Risk in Perspective
THE COST OF IMPROVING HEALTH BY REDUCING EMISSIONS FROM PUBLIC TRANSIT BUSES
Joshua T Cohen, James K Hammitt and Jonathan I Levy
Introduction sions. In particular, we estimate how much Because improvement of outdoor air quality opting for ECD or CNG instead of CD is a key priority for both the federal would reduce the number of quality adjusted government and for some local regulatory life years (QALYs) lost as the result of oper- Improvement of outdoor air agencies, standards limiting tail-pipe emis- ating a fleet of 1,000 buses, with each bus trav- quality is a key priority for sions by motor vehicles in general and urban elling an average of 40,000 miles annually. We transit buses in particular are steadily estimate the additional resource costs for each both the federal becoming more stringent. alternative technology relative to CD, including the cost of vehicle procurement, government and local To address regulatory and public concern over infrastructure improvements, and operations emissions, transit agencies across the United (fuel and maintenance). Emissions from all regulatory agencies States have been investigating the effectiveness three types of buses contribute to global and feasibility of alternative propulsion climate change, and we include the resulting systems for these vehicles. Alternative damages as another monetary cost. Dividing propulsion systems represent various changes the incremental cost by the incremental to engine design, fuel, and exhaust treatment. QALYs saved yields the cost-effectiveness In this issue of Risk in Perspective, we discuss (CE) ratio. A low CE ratio (fewer dollars a recent Harvard Center for Risk Analysis spent per QALY saved) is more favourable (HCRA) study that evaluates two of the most than a high CE ratio (more dollars spent per common alternative technologies now in use QALY saved). for urban transit buses – emission controlled diesel (ECD) and compressed natural gas We define the ECD technology as a new (CNG). For each of these technologies, we conventional diesel bus equipped with both an quantify both the health benefits and resource oxidising catalyst and a continuously regener- costs. We find that CNG has a modest edge ating diesel particulate filter (DPF). A DPF over ECD in terms of its health benefits. traps particles and uses exhaust gases to However, CNG comes at a substantial cost oxidise and eliminate the material. To prevent relative to ECD. The complete study fouling of the DPF, ECD vehicles require fuel appeared in the April 15, 2003 issue of Envi- with lower sulphur content than conventional ronmental Science and Technology. Our diesel fuel. The DPF also requires annual analysis draws on a wide range of information cleaning to remove built-up ash. in the scientific literature, and was guided by CNG burns cleaner than diesel fuel. Because input from an advisory panel that included it is a vapour at ambient temperature, CNG members from academia, industry, and public must be compressed to around 3,000 pounds transit agencies. This article is reproduced with per square inch (psi) to carry sufficient quan- permission and was first published tities onboard, requiring stronger fuel tanks. Alternative propulsion technologies as Risk in Perspective Volume 11, Compression also requires additional energy evaluated Issue 4 by the Harvard Center for and special equipment. Storage, fuelling, and We consider a scenario in which a hypo- Risk Analysis in October 2003. maintenance facilities must be equipped with thetical transit agency purchasing new buses special ventilation and detection equipment to can choose among three propulsion tech- Harvard Center for Risk Analysis, minimise the risk of an explosion if there is a Harvard School of Public Health, nologies – conventional diesel (CD), ECD, gas leak. 718 Huntington Avenue, and CNG. We estimate the health benefits of Boston, Massachusetts, USA. ECD and CNG by comparing the morbidity Buses relying on other propulsion tech- The full series is available at and mortality impacts of their emissions to the nologies could also be considered, including www.hcra.harvard.edu morbidity and mortality impacts of CD emis- electric buses, hybrid buses that have electric
28 Eurohealth Vol 13 No 3 RISK IN PERSPECTIVE power trains and small fossil fuel engines, Figure 1: Annual QALYs lost due to emissions from a fleet of 1,000 buses hydrogen fuel-cell vehicles (which generate electricity from hydrogen without producing harmful combustion byproducts), and more advanced diesel technologies that address other emission components. We chose to compare only the ECD and CNG technologies, for two related reasons. First, these are the most common alternative technologies used by transit authorities. For example, CNG vehicles represent around 60% of all alter- native fuel transit buses purchased and New York City has plans to equip 3,500 vehicles in its diesel fleet with DPFs. Second, because these technologies are the most common, they are the only tech- nologies for which adequate performance data are available. SO2, up stream emissions are for the most ECD, ranging from $15,300 in areas with Because the values of many of the param- part far smaller than corresponding emis- low land costs (range: $4,800 to $26,000) eters in our analysis are uncertain, we sions from vehicle operation. to $20,500 in areas with high land costs estimate how best case and worst case (range: $5,800 to $36,000). Land costs Compared with CD, both ECD and CNG values for these parameters influence our significantly affect overall CNG costs reduce PM emissions by approximately results. We also estimate how risk may because of the need to provide adequate three-fourths. For NOx, CNG reduces change across the US due to geographic ventilation of storage, fuelling, and main- aggregate emissions by around one-third, variation in factors such as population tenance facilities. Transit authorities can while ECD does not reduce NOx emis- density and atmospheric chemistry. address ventilation requirements by sions at all. ECD reduces SO emissions to 2 building single-story facilities, which can a greater extent than does CNG, but the Health effects and emissions take up substantial amounts of land. Alter- baseline emissions are so small that the Our analysis accounts for the health effects natively, they can build multi-story struc- contribution of SO to baseline health associated with emissions of particulate 2 tures to reduce land requirements, but risks is limited. matter (PM), nitrogen oxides (NOx), and must include more sophisticated venti- sulphur dioxide (SO2). PM is thought to Taking all the emissions and their health lation equipment. In low-cost areas, where substantially increase mortality due to impacts into account, our central estimates land is readily available, we estimate the cardiopulmonary factors. In addition, EPA are that a fleet of 1,000 new CD buses amortised incremental cost for infra- and other regulatory agencies judge that would result in a loss of 16 QALYs each structure to be $950 per bus. In high-cost diesel PM may contribute to lung cancer, year. Accounting for uncertainty under- areas, the corresponding annualised whereas it is widely assumed that CNG lying this calculation, we estimate that this estimate is $6,200. PM does not. Although these assumptions loss might be as little as 0.1 QALYs (best In addition, CNG buses themselves are are both controversial, we accept both for case bounding assumptions) or as much as more expensive because of the complexity this analysis, biasing our results in favour 85 QALYs (worst case bounding assump- of the fuel tanks and onboard fuel-distrib- of CNG. tions). Replacing these buses with 1,000 ution system. Amortising these costs NOx is important to health because of the ECD buses would reduce this loss by 6.3 yields an annualised increment of $2,800. chemical reactions it undergoes after QALYs annually (range: 0 to 41 QALYs), Further, based on the experience of large leaving the tailpipe. First, NOx can and replacing them with 1,000 CNG buses transit agencies, we conclude that CNG’s become a ‘secondary particulate’ when it is would reduce the loss by 8.6 QALYs operating costs are higher than CD. converted to nitrate and combined with annually (range: 0.01 to 65 QALYs). Although CNG fuel is less expensive than ammonium, thus adding to PM exposure. Figure 1 summarises these results. diesel (per unit energy content), the lower Second, when it reacts with volatile efficiency of CNG engines means that the organic compounds (VOCs) in the Resource costs annual fuel cost for CNG is around $3,200 presence of sunlight, NOx generates For each bus, the annualised incremental higher than for CD. Data from New York ground-level ozone, a contributor to cost for ECD relative to CD is $1,700 City suggest that the annual maintenance smog. Ozone may contribute to mortality (range: $1,300 to $2,100). The major cost for each CNG bus is $6,000 higher and to the incidence of asthma. Like NOx, components of that difference are the than for each CD bus. (Some transit SO also contributes to the formation of amortised cost of equipping the vehicle 2 agencies have reported that maintenance secondary PM. with the diesel particulate filter and the added cost of ultra-low sulphur fuel. costs decreased when they purchased Our analysis takes into account both emis- Maintenance of the filter contributes a CNG vehicles. However, inspection sions associated with vehicle operation and small amount as well. reveals that these agencies were comparing emissions generated by ‘upstream’ activ- new CNG buses to old diesel buses, or ities – i.e., the extraction, production, and The annualised incremental cost for each that they reported maintenance costs net distribution of fuel. For PM, NOx, and CNG bus is substantially higher than for of those covered under warranty.)
29 Eurohealth Vol 13 No 3 RISK IN PERSPECTIVE
Figure 2: Annual health damages and incremental costs for a fleet of 1,000 buses* Conceivably, the gains of both ECD and CNG may both be too small to justify their costs. Alternatively, it is possible that even though the reduction in health damages achieved by CNG is more expensive than the reduction achieved by ECD, this saving of 2.3 QALYs per year may be worth the added annual cost of $13 million (low land cost areas) to $19 million (high land cost areas). One way to address this issue is to compare these technologies with other investments that improve public health. Doing so suggests that both ECD and CNG are expensive. QALYs can be saved at a lower cost by investments in the medical prevention of coronary heart disease and cancer, reduction of motor-vehicle injury trauma and fatalities, and the prevention of infectious disease. However, CE ratios for public-health investments often differ *Bubble area is proportional to QALYs lost for each technology. Cost for CNG ($15 substantially across domains. For example, million per year) is for areas with low land costs. For areas with high land costs, the an analysis conducted by HCRA in the annual incremental cost is $21 million. 1990s found that the median cost per QALY saved for regulations considered by different agencies were much higher for Finally, the CNG fuelling infrastructure invested). For CNG, the CE ratio ranges EPA ($7.6 million) than for several other (natural gas compressors) must be main- from $70,000 to $2 billion per QALY agencies: Federal Aviation Administration tained, adding another $2,300 in costs saved in low land cost areas, and from ($23,000), National Highway Traffic Safety annually per bus. $90,000 to $3 billion in high land cost ($78,000), Occupational Safety and Health areas. We also find that the CE ratios Both ECD and CNG generate more Administration ($88,000), Consumer depend on local atmospheric conditions greenhouse gas emissions than do CD Product Safety Commission ($68,000). and population patterns, factors that affect vehicles. The incremental monetised population exposure to air pollution. When compared within the domain of damage associated with CNG ($200 per other clean-air policies, investments in year) exceeds the corresponding figure for Interestingly, two issues that garner ECD and CNG do not look as expensive. ECD ($30 per year), but these increments substantial attention – the effect of diesel For example, results from another HCRA are very small compared with the acqui- exhaust on lung cancer and the contri- analysis suggest that controls on stationary sition, infrastructure, and operational costs bution of emissions to climate change - air-pollution sources (for example., power for these technologies. contribute little to our quantitative esti- plants) save lives at a cost ranging from mates. When measured in terms of lost tens of thousands to a million dollars per Cost effectiveness QALYs, the impact of lung cancer, even if life year. Mobile source controls (for Compared with CD, we estimate that it is caused by diesel exhaust, is far less example, motor vehicles) cost from tens of ECD improves health and reduces than the impact of PM on the cardiopul- thousands to four million dollars per life mortality at a cost of $270,000 for each monary mortality rate. As mentioned year saved. For ECD, the return per dollar QALY saved. For CNG, the corre- above, the estimated monetary value of the invested falls within both of these ranges, sponding cost is $1.7 million per QALY in incremental effect of ECD and CNG on while the return for CNG falls within the an area with low land acquisition costs and climate change is small compared with range of CE ratios for mobile-source $2.4 million per QALY in an area with their other costs. Hence, our conclusions programs only, and is towards the high end high land acquisition costs. Directly are not affected by these factors, no matter of this range. comparing the two alternatives we what plausible assumptions we choose. considered, the incremental cost effec- Of course, economic efficiency is not the tiveness of CNG relative to ECD is esti- Discussion only issue that a transit agency must mated as $5.8 million (low land cost) to As illustrated in Figure 2, the reduction in consider in choosing among alternative $8.4 million (high land cost). health damages afforded by CNG propulsion technologies. There are compared with ECD is modest and comes aesthetic considerations (diesel buses are Because of uncertainty about the appro- at a substantial increase in resource costs. often said to be noisy and to generate a priate values of many of the parameters in However, while cost-effectiveness strong, unpleasant odour), and safety our analysis, the ranges of plausible values provides an indication of the relative effi- issues (CNG can explode, while diesel fuel for the ECD and CNG CE ratios are wide. ciency of investing in either of these tech- can cause environmental damage if a spill For ECD, the cost per QALY saved may nologies to improve health, it does not by occurs). Moreover, although aggregate be as small as $30,000 or infinite (i.e., no itself indicate which investment, if either, population risks may be small, individual health benefits per incremental dollar is desirable in an absolute sense. impacts may be comparatively large for
Eurohealth Vol 13 No 3 30 RISK IN PERSPECTIVE those who live or work near locations where buses operate. It must also be kept in mind that our results are imprecise, as indicated by the wide range of plausible Book Review results described earlier. Nonetheless, cost is an important issue. Screening: Evidence and Practice Spending more for each new alternative technology bus may delay the process of replacing older, dirtier buses if a transit Angela Raffle and JA Muir Gray agency's budget is limited. Alternatively, Oxford University Press, Oxford, 2007 if the number of buses to be purchased is fixed, a more expensive technology drives ISBN 978-019921449-5 up the purchase price, potentially taking Paperback, 336 Pages, £24.95 resources from other investments. For example, spending may be reduced for This is very good book with some outstanding chapters. The approach to the other mass transportation priorities, such problem of screening is novel and differs from that of many other authors in as improving or extending service. A this field reflecting their background. Raffle is a practising public health model developed for the American Public physician, who has had responsibility for cervical cancer screening in the Transportation Association suggests that Bristol area for many years. Muir Gray, also a public health physician, has such reductions depress public transit been Programme Director of the UK National Screening Committee for the ridership, as people tend to switch to past eleven years. private vehicles in response to a decrease in the quality of public transit service. Raffle exemplifies the characteristics of what public health physicians should Increased use of private vehicles increases do. With her responsibilities for screening services in a large community in congestion and air pollution and offsets South-West England, she has analysed the necessary characteristics for the intended gains. delivery of quality public health services, undertaken the required measures and been active in the communication of these. Muir Gray brings to the topic The increased use of private vehicles is one wide knowledge and appreciation of the national policy perspective. potential “adverse side effect” of spending on alternative-technology buses. Under- Praise for this work is not limited to this review. Apart from the foreword, by standing whether this and other side the English Chief Medical Officer, there are three endorsements from eminent effects offset the benefit of investing in individuals in Australia, the Netherlands and the USA – a novel initiative. cleaner buses depends on quantifying the The first chapter is intended to give a brief historical account of how technology’s costs and benefits, which is screening began. This concentrates on the history of periodic health examina- the goal of the type of analysis described tions. This, perhaps, is the only major reservation I have of this book. The in this issue of Risk in Perspective. While importance of screening for tuberculosis, and mass miniature radiography, is there are other factors that influence such neglected. A pity – because screening services for disease may not be only decisions, consideration of economic effi- considered in the improvement of health, but also for health protection and ciency – the health return per dollar quarantine. This concentration on chronic conditions such as cancer and invested – is an important part of the cardiovascular disease means that consideration of the issues of screening for discussion. infective conditions such as tuberculosis and HIV are omitted. Subsequent chapters consider the definition of screening and basic principles, ADDITIONAL READING what it does, including the measurement of test performance, how screening Cambridge Systematics Inc. and needs to be implemented, necessary measures for quality control, as well as Economic Development Research Group. the management of screening. Perhaps the best, and most novel chapter, is the Public Transportation and the Nation’s last, which examines in detail the way in which screening policy is formulated Economy: A Quantitative Analysis of at national and local levels. This chapter examines in detail the various Public Transportation’s Economic Impact. pressures such as ethics, values and beliefs as well as the use of evidence. This Underwritten by the American Public chapter has general applicability to all health policy making, not only Transit Association, 1999. Available at: screening, and illustrates the authors’ experiences at national, regional and http://www.edrgroup.com/ local levels. pages/pdf/Public-Transport.pdf. Cohen JT, Hammitt JK, Levy JI. Fuels Each chapter is illuminated by case examples as well as tests that the reader for urban transit buses: a cost-effec- may take to determine his/her appreciation of the chapter. The illustrative tiveness analysis. Environmental Science examples do not stop at description of medical/technical matters but also and Technology 2003;37:1477–84. illustrate legal issues. This book is of particular relevance to public health practitioners responsible for the design and delivery of screening services but US Environmental Protection Agency should also be read by all those involved in decisions on pubic health services. (EPA). Regulatory Impact Analysis: Control of Emissions of Air Pollution from Highway Heavy-duty Engines. Review by Walter Holland, Emeritus Professor of Public Health, LSE Health, EPA420-R-00-010. Office of Air and London School of Economics and Political Science Radiation, 2000.
31 Eurohealth Vol 13 No 3 NEW PUBLICATIONS
Eurohealth aims to provide information on new publications that may be of interest to readers. Contact Philipa Mladovsky at [email protected] if you wish to submit a publication for potential inclusion in a future issue.
Joint Report on Social Protection and The report provides a broad overview of indicators of levels of health across the Social Inclusion: Social inclusion, social protection and inclusion in the Union and at health care spending, health pensions, healthcare and long term care EU, drawing on the material provided by status and inequalities. Member States in their National Reports The second half systematically examines on Social Protection and Social Inclusion, the current systems and policy strategies European Commission, Directorate- as well as analysis provided by inde- relating to social inclusion, health, long- General for Employment, Social Affairs and pendent experts and a set of common term care and pensions of the 27 Member Equal Opportunities Unit E2 (2007) indicators reporting trends. States. It particularly explores how The document is divided into two parts. Member States set out to address The first relates to the common objec- inequalities in access to the resources, tives for promoting social cohesion and rights and services needed for full ensuring effective interplay between the participation in society. Open Method of Coordination and the Contents: EU’s Lisbon and Sustainable Devel- opment Strategies. It begins with an Key messages analysis of the economic and demo- Supporting document: scope and outline graphic context in which measures to of the report combat poverty and exclusion and to Part one: quantitative analysis Freely available at: ensure the adequacy, quality and sustain- Part two: thematic analysis http://ec.europa.eu/employment_social/soci ability of social welfare are being imple- al_inclusion/docs/2006/joint_report_en.pdf mented. It goes on to examine the social Annexes: country profiles situation across the fields of social 418 pages inclusion, pensions, health and long-term ISBN 978-92-79-05561-4 care; the health dimension looking at the
Inequalities in health in Scotland: The report outlines key facts about may produce more aggregate health gain, What are they and what can we do socio-economic inequalities in health in value judgments may have to be made about them? Scotland, presenting mortality and about the relative priority to be given to morbidity data by socioeconomic group. creating aggregate health gain as It goes on to highlight policy issues, such compared to reducing inequalities. Sally Macintyre as distinguishing between upstream and Contents: Occasional Paper Number 17, October downstream interventions, the impor- 2007, MRC Social and Public Health tance of multisectoral interventions and Inequalities in health in Scotland: what Sciences Unit area based approaches. The report also are they and what can we do about them? reviews evidence on the effectiveness of What are inequalities in health, and what policies aiming to reduce health inequal- causes them? ities, pointing out that disadvantaged Social gradients in health and health risks groups tend to be harder to reach and Policy issues and principles find it harder to change behaviour. What do we know about what works to Summarising lessons learnt from research reduce inequalities in health? on how best to reduce inequalities in What do we know about what is likely to health, the paper recommends putting a reduce inequalities in health? high priority on changes in the physical and social environment (for example, Possibly competing goals building and planning regulations, fiscal Appendix 1: chronology of selected 16 pages policies, and reducing price barriers to reports and actions on inequalities in Freely available online at: health-promoting goods and services), health in the UK http://www.sphsu.mrc.ac.uk/files/File/ rather than information-based campaigns References reports/OP017.pdf or interventions which require people to opt in. The report ends by arguing that because targeting the already advantaged
32 Eurohealth Vol 13 No 3 Please contact Philipa Mladovsky at [email protected] to suggest websites WEBwatch for potential inclusion in future issues.
The health programme of the This website contains information on Portuguese Presidency initiatives in the field of health. Portuguese Presidency of the EU It provides information on meetings, publications, technical initiatives, news, reports and other documents, as well as links to other Presidency websites. It also features a newsletter http://www.eu2007.min-saude.pt/PUE/ and a calendar of events. The website is available in Portuguese and English. en/conteudos/programa+da+saude/ presidencys.htm
International Society for ISPOR promotes the science of pharmacoeconomics and outcomes research (the scientific Pharmacoeconomics and discipline that evaluates the effect of health care interventions on patient wellbeing, Outcomes Research (ISPOR) including clinical outcomes, economic outcomes and patient-reported outcomes) and aims to facilitate the translation of this research into useful information for health care decision http://www.ispor.org makers. The English language website provides information on meetings, publications, research and educational courses, as well as information on job opportunities in the phar- maceutical sector.
The European Health Management EHMA is a network of health organisations throughout Europe. Its objective is to improve Association (EHMA) health through better management, partly through advocacy with the European Commission on behalf of members, and partly by providing services on their website. http://www.ehma.org These include: news and events; a monthly bulletin on health-related news; briefings on EU health policy; advice on EU funding opportunities; and publications on EU health policy. Some services are available to members only, but the remainder of the English language website is available to non-members.
Association Internationale de la AIM provides information on developments in the field of social protection and health care Mutualité (AIM) at European and international levels. The website contains information on the members of AIM as well as position papers, a programme of events, reports and links on topics related to http://www.aim-mutual.org social protection and health care. It is available in English, French and German.
The BBVA Foundation The BBVA Foundation undertakes and commissions research in the social sciences, biomedicine and the environment, with priority being given to key challenges and opportu- http://w3.grupobbva.com/TLFB/TLFB nities faced in the new millennium. The website provides access to detailed information on index.htm programmes, including one on biomedicines, health and the health care system and another on demographic change, the family and social integration. Both provide information on current and completed projects and publications. The Foundation also has a working paper series, many of which are on health-related issues. All working papers as well as a regular newsletter are freely downloadable. The website is available in Spanish and English.
The Robert Koch Institute (RKI) The Robert Koch Institute serves the German Federal Ministry of Health as a central scien- http://www.rki.de/EN/Home/ tific institution in the field of biomedicine. Its tasks include protection against infectious homepage__node.html diseases, analysis of the health situation in Germany and safety assessment of genetic engi- neering methods and products. The English language web pages contain selected items from its German language site and are being continually expanded. A few reports are down- loadable in English, but it mostly provides English language abstracts and summaries of German language reports and research projects.
33 Eurohealth Vol 13 No 3 MONITOR
EUROPEAN MONITOR of the population which require Proposed actions include a new strategic approach. support for Member States in managing innovation in health The three strategic themes New EC Health Strategy systems and in the implemen- include demographic changes tation and interoperability of e- launched and population ageing, which health solutions. The Strategy On 23 October the European the Strategy notes are “changing also calls for a Community- Commission adopted a new disease patterns and putting wide framework for safe, high health strategy, ‘Together for pressure on the sustainability of quality and efficient health Health: A Strategic Approach EU health systems. Supporting services, noting that “new for the EU 2008–2013’. Building healthy ageing means both on current work, this strategy promoting health throughout technologies must be evaluated aims to provide, for the first the lifespan, aiming to prevent properly, including for cost- time, an overarching strategic health problems and disabilities effectiveness and equity, and framework spanning core issues from an early age, and tackling health professionals’ training in health, as well as in health in inequities in health linked to and capacity implications must all policies and global health social, economic and environ- be considered. New and unfa- issues. The strategy aims to set mental factors.” Proposed miliar technologies can generate clear objectives to guide future actions include measures to ethical concerns, and issues of work on health at the European promote the health of older citizen’s trust and confidence level, and to put in place an people and the workforce and must be addressed.” implementation mechanism to actions on children’s and young The White Paper and other achieve those objectives, people’s health, as well as devel- background documentation are working in partnership with opment and delivery of actions available at http://ec.europa.eu/ Member States. (in partnership with Member health/ph_overview/strategy/ The strategy focuses on four States) on tobacco, nutrition, health_strategy_en.htm principles and three strategic alcohol, mental health and other themes for improving health in broader environmental and Health Programme 2008–2013 the EU. The principles include: socioeconomic factors affecting With a budget of €321.5 million, health. New guidelines on the Second Programme of – taking a value-driven cancer screening and a commu- Community Action in the Field approach, nication on European action in of Health 2008–2013 will come – recognising the links between the field of rare diseases are into force from 1 January 2008. health and economic prosperity, planned by the Commission, This follows on from the first while there will also be a follow programme (2003–2008) which – integrating health in all up of the Communication on financed over 300 projects and policies, and organ donation and transplan- other actions. There are three News – strengthening the EU’s voice tation. principle objectives: to improve in global health. Major threats to health citizen’s health security; to promote health, including the The strategy notes that the EC’s including pandemics, major reduction of health inequalities; important role in health policy physical and biological inci- and to generate and disseminate has been reaffirmed in the dents, bioterrorism and climate health information and Reform Treaty agreed by EU change are another area of knowledge. Heads of State and Government concern. A core part of the in Lisbon on 19 October 2007, Community’s role in health is to In terms of health security, which proposes to reinforce the coordinate and respond rapidly proposed actions include devel- political importance of health. to health threats globally and to oping strategies and mechanisms enhance the EC’s and third for preventing, exchanging A new overall aim on countries’ capacities to do so. information, on and responding supporting citizens’ wellbeing is Actions will strengthen mecha- to health threats from commu- expected, as well as an encour- nisms for surveillance and nicable and non-communicable agement of cooperation response to health threats, diseases, as well as health threats amongst Member States on including a review of the remit from physical, chemical or health and health services. Work of the European Centre for biological sources, including on health at Community level Disease Prevention and Control Press releases and deliberate release acts; taking adds value to Member States’ and examination of the health other suggested action to ensure high-quality actions, particularly in the area implications of adaptation to information for diagnostic cooperation between of the promotion of quality, and climate change. future inclusion Member States’ laboratories; the launch of a number of can be e-mailed to A third overarching theme is to supporting existing laboratories health-related agencies. the editor support what the Commission carrying out work with rele- David McDaid However, there are several calls ‘dynamic health systems vance to the Community; and [email protected] growing challenges to the health and new technologies’. working on the establishment of
Eurohealth Vol 13 No 3 34 MONITOR a network of Community reference during these workshops included issues repetitive tasks at a higher work pace, laboratories. concerned with nanotechnologies, resulting in a higher prevalence of consumer behaviour, ethical MSDs. Enhanced autonomy over In terms of promoting the safety of consumption and health equity. The working methods, work pace and choice citizens, measures will include help to results of the workshops were then used of breaks is associated with a reduction enhance the safety and quality of organs to draft the ‘Future Challenges’ paper. of MSDs. The risk is lowered where and substances of human origin, blood, there is training provided by employers and blood derivatives; and then Issues that the paper flags up include: and consultation about working condi- promoting their availability, traceability will consumers have confidence in what tions and about organisational factors. and accessibility for medical use, while we purchase in a supermarket? Will respecting Member States’ responsibil- consumers be increasingly looking for MSDs are differently defined in different ities as set out in Article 152(5) of the ethical or local products? Will citizens Member States, making it tricky to Treaty. live longer and healthier? Will investigate their prevalence or to consumers spend even more time on the establish Europe-wide trends. Some To promote health, action will be taken definitions refer to body parts, like on health determinants such as nutrition, internet looking for information or WRULD (work-related upper limb alcohol, tobacco and drug consumption, making a purchase? What are the disorders), while others refer to causes, as well as social and environmental different future scenarios? What does it like RSI (repetitive strain injuries). determinants. There will be measures on mean for us? How should we prepare Moreover, there is a lack of homoge- the prevention of major diseases of ourselves pro-actively? neous data or standards in monitoring particular significance in view of the The paper is now being widely circulated MSDs. Relatively few countries report overall burden of diseases in the inside the Commission and externally on the direct costs of MSDs, like sick Community, and on rare diseases, where and comments may be sent by the end of leave and disability benefits, or indirect Community action, by tackling their December to [email protected] costs like lost productivity. The study determinants, can provide significant outlines good practice of interest to added value to national efforts; reducing The Future Challenges Paper can be policy-makers, employers and workers health inequalities across the EU; and downloaded at alike. actions to increase healthy life years and http://ec.europa.eu/dgs/health_consumer promote healthy ageing. /events/future_challenges_paper.pdf The report and more information on the high-level conference are available on Actions to foster dissemination and Musculoskeletal disorders still the most www.eurofound.europa.eu knowledge exchange will include further widespread work-related diseases development of a sustainable health Musculoskeletal disorders (MSDs) European countries adopt milestone monitoring system with mechanisms for remain the most common work-related declaration on tuberculosis the collection of comparable data and diseases, according to a new comparative In Berlin on October 22 over 300 dele- information, with appropriate report ‘Managing Musculoskeletal gates at the WHO European Ministerial indicators. Disorders’ published by the European Forum ‘All against Tuberculosis’ adopted The text of the decisions adopted jointly Foundation for Living and Working the Berlin Declaration on Tuberculosis, by the European Parliament and the Conditions’ European Working which describes the disease as “an Council of the European Union can be Conditions Observatory (EWCO). The increasing threat to health security in the viewed at http://eur-lex.europa.eu/ results, which constitute the first WHO European Region”. The Decla- LexUriServ/site/en/oj/2007/l_301/l_301 secondary study based on the ration calls for urgent action to halt and 20071120en00030013.pdf Foundation’s fourth European Working reverse the high levels of tuberculosis Conditions Survey, were presented to (TB), including its man-made multi- Commission thinking ahead on health European social policy-makers at a high- drug-resistant (MDR) and extensively challenges level conference, under the auspices of drug-resistant (XDR) strains. In the DG Health and Consumer Protection the Portuguese EU Presidency, in Declaration, Member States and interna- has published a ‘Future Challenges Lisbon on 11–12 October 2007. tional partners commit themselves to paper: 2009–2014’. This paper provides a MSDs, like backache or muscular pain of providing more political support and ‘draft vision’ of the main challenges that the shoulders, neck or limbs, are the resources to control and eventually elim- we may face under the lifespan of the most often reported symptoms of work- inate the disease. next Commission. It is built on the related ill health. The report found that In 2005, there were 445, 000 new cases of views of many Health and Consumer MSDs were associated with strenuous TB and 66,000 TB-related deaths in the Protection officials and the input of a working conditions and physical strain, Region. Of the fifty three countries in number of external experts. such as tiring and painful working posi- the Region, eighteen have a high TB Four drivers of change were identified tions, repetitive movements, carrying burden and thus are of high priority for (governance, consumer confidence, heavy loads and poorly designed work- TB control: Armenia, Azerbaijan, globalisation and changing society) and stations. Work intensification and stress Belarus, Bulgaria, Estonia, Georgia, the scenarios were developed on the lead to increased occurrences of MSDs. Kazakhstan, Kyrgyzstan, Latvia, basis of uncertainties linked to these Surprisingly, job rotation and team Lithuania, the Republic of Moldova, drivers. These scenarios were used working are also associated with a higher Romania, the Russian Federation, Tajik- during internal workshops held between incidence of MSDs. Lean production istan, Turkey, Turkmenistan, Ukraine January and May 2007. Questions raised models require workers to perform and Uzbekistan. The disease is not
35 Eurohealth Vol 13 No 3 MONITOR confined to one part of the Region: even put in place to ensure that the Decla- EU and US harmonise ‘orphan drugs’ in some countries with a relatively low ration is implemented efficiently and approval procedures burden there has been a reversal of the promptly. Progress will be assessed at The European Commission, the previous decline. Moreover TB is the the regional level every second year, European Medicines Agency (EMEA) most prevalent cause of illness and death starting in 2009. and the United States Food and Drug in people living with HIV/AIDS in the The process of developing the Decla- Administration (FDA) adopted on 26 Region, and few countries address ration took over a year. The WHO November 2007 a common application TB/HIV co-infection in a compre- Regional Office for Europe consulted form for drug developers seeking hensive way. countries and partners in devising and approval for orphan medicines on both sides of the Atlantic. Both drug adminis- The Forum, which sought to place TB revising drafts. The consultation in The trations will, however, continue control higher on public health agendas, Hague, Netherlands on 6 July 2007 was conducting independent reviews to attracted health ministers and high-level organised in collaboration with the ensure compliance with their respective decision-makers from forty-nine of the KNCV Tuberculosis Foundation. scientific requirements. fifty-three Member States in the WHO Speaking about the Declaration, Dr European Region, along with represen- Marc Danzon, WHO Regional Director Rare diseases are defined as those tatives from other United Nations for Europe, said “will this Declaration affecting fewer than five in 10,000 people bodies, intergovernmental agencies and make a difference to the more than in the EU and fewer than 200,000 people nongovernmental organisations 445,000 TB patients in the WHO in the USA. Companies are reluctant to (NGOs). The agenda of the Forum European Region? It will if governments spend their resources on the devel- addressed current challenges facing carry out the decisions made in Berlin. opment of drugs for such rare condi- health systems in responding to TB and And we in WHO are committed to tions, as they expect relatively low achieving Target Eight of Millennium helping with programmes that target profits from sales and, in some cases, a Development Goal (MDG) Six: to have areas where we have something financial loss, when the costs of research halted and begun to reverse the substantial to contribute and where we and development of these drugs are incidence of TB by 2015. can make a difference. The good news is taken into account. At present, the European Region is the that many of the challenges that have Some thirty million EU residents and only WHO region other than Africa been pointed out in Berlin can be tackled twenty five million Americans suffer where TB rates are declining too slowly with good political will and from more than six thousand rare to reach Target Eight. The Declaration commitment. The reason we called this diseases. Realising that some potentially sets out several directions to speed up Forum was to draw attention to TB promising orphan medicinal products action, mainly relating to each country’s problems that health systems in our for rare diseases would not be responsibility to strengthen political Member States have to face so that developed, the Orphan Drug Act was will, public health and social services governments can do something about enacted in the USA in 1983 and the systems, human resource capacity, TB them.” European Union adopted its Regulation surveillance and monitoring and inter- Dr Jorge Sampaio, the United Nations on Orphan Medicinal Products in 1999. sectoral collaboration, and to the need Secretary-General’s Special Envoy to These legal frameworks aim to provide for a Region-wide approach to control Stop TB and former President of regulatory and financial incentives, such the disease, which respects no borders. Portugal, added that “European as protocol assistance, and marketing Allocating more funding from appro- ministers are today demonstrating their exclusivity, to sponsors to develop and priate multilateral mechanisms at the commitment to fighting TB through market orphan medicinal products. global and European levels is also their participation in this forum. This To be eligible for receiving orphan important. event is an important step towards incentives, sponsors of orphan medicines While recognising previous achieve- greater international partnership and have had to submit separate applications ments, the Declaration calls for more coordination.” for orphan designation to the EMEA action in specific areas. Some actions, On behalf of the host country, German and to the FDA using different such as investing in and strengthening Federal Minister of Health, Ulla Schmidt submission formats to satisfy the health systems for better TB control, stressed that the “successful fight against respective regulatory requirements. form part of a Region-wide commitment TB is always rooted on two levels: These different formats have imposed an for the first time. Others are well medical progress and support by public additional burden on sponsors. Hence, known: applying the high-quality health policy; one is unthinkable the parties have agreed to harmonise the directly observed treatment, short- without the other. Germany has already application form to simplify part of the course (DOTS) strategy launched by bundled TB-related activities for World orphan medicines designation process. WHO in 1995; addressing MDR-, TB Day this year in March, and run a This common application format will XDR- and HIV-related TB, removing TB symposium. Today’s Ministerial now allow sponsors to apply to both stigma and promoting research into new Forum in Berlin gives the political signal jurisdictions at the same time with one diagnostic methods and tools, drugs and for an enhanced fight against TB.” application. A common format will also vaccines. More information on the Ministerial establish a favourable environment for A mechanism involving the European Forum can be found at the EMEA and FDA to share common Union, other organisations, civil society, http://www.euro.who.int/tuberculosis/ experiences and gain an understanding communities and private sector will be TBForum/20070621_1 of the similarities and differences of the
Eurohealth Vol 13 No 3 36 MONITOR process of obtaining orphan designation the burden of disease that health systems expected to be submitted for adoption in the two regulatory systems. must tackle has changed. Diseases by Member States at the Conference in including heart disease, diabetes and Tallinn. The common application form contains asthma, some mental disorders, cancer, a section for common information Further information on the Tallinn certain disabilities and impairments, as required by both the EMEA and the Conference is available at well as some communicable diseases FDA. It also has sections for require- http://www.euro.who.int/ such as HIV/AIDS, require management ments unique to each agency. A sponsor healthsystems2008 over a period of years or decades. who wants to submit an orphan desig- nation application to EMEA alone may Today health systems that have tradi- also use this form. The EMEA and the tionally dealt with people’s acute, short- ECJ NEWS FDA will still conduct independent term health needs must change and adapt reviews of such submissions to assure to this new reality. As managing chronic the data submitted meet the legal and disease is not about cure but enhancing Commission refers Finland to the scientific requirements of their quality of life and minimising symptoms respective jurisdictions. long term, patients should clearly take European Court of Justice a second time an active role in managing their illness. over tobacco for oral use This initiative follows an agreement On 24 October the European made in June 2007 between the “Patient empowerment is vital for health Commission decided to refer Finland to Commission, EMEA and FDA to systems to be responsive and adapt to the European Court of Justice (ECJ) for expand transatlantic regulatory co- people’s needs. Yet we must also ensure a second time for failing to comply with operation on several issues to reduce that the weakest in society, indeed those an earlier judgement by the European unnecessary differences in regulations who so often require health care most, Court of Justice on 18 May 2006 and associated costs for industry and are not left behind. WHO is committed concerning tobacco for oral use in the consumers. to helping countries find effective ways Åland Islands, an area of Finland which of providing professional care and The European biotech industry has enjoys extensive autonomy over most improving information and self- welcomed the common application form issues, including health matters. management for all patients. I hope that for orphan drugs and awaits further these early discussions on a European The Court’s judgment in this case transatlantic harmonisation in the field. charter on health systems will lead in the (C-343/05) confirmed Finland’s failure Another twenty eight areas for simplifi- right direction,” said Dr Marc Danzon, to comply with Article 8 of Directive cation in the approval and marketing WHO Regional Director for Europe. 2001/37/EC on the manufacture, presen- authorisation of medicines were tation and sale of tobacco products, presented to EU and US authorities by Countries increasingly recognise that which prohibits the placing of tobacco the industry during a transatlantic addressing diseases early reduces the for oral use on the market. This includes workshop on administrative simplifi- pressure on health systems. This shifts “all products for oral use, except those cation in medicines regulation on 28 the focus from treatment to prevention, intended to be smoked or chewed, made November 2007. which also has economic repercussions. wholly or partly of tobacco” and In the United Kingdom, for example, it The common application form is includes ‘snus’ – a form of moist snuff has been estimated that the financial available at http://ec.europa.eu/ used in the Åland Islands. The needs for health care projected for 2022 enterprise/pharmaceuticals/orphanmp/ Commission will ask the Court to will differ by €50 million, depending on doc/annex2_application-form.pdf impose on Finland a lump-sum fine of whether the health of the population €2,029,536 and if Finland fails to comply improves according to the most opti- Countries start negotiating a European before the judgment, a daily penalty mistic or pessimistic estimates. charter on health systems payment of €19,828.80. Experts met in Bled, Slovenia on 19–20 The experts meeting in Bled also Because of their special status, the Åland considered strategies that ensure the November 2007 to discuss how people’s Islands had to adopt their own legis- coordination and continuity of care, increasingly complex health needs lation in order to comply with Directive both of which are central to ensuring the require a change in the balance of 2001/37/EC. In 2002, as the Åland professional and patient involvement in cost-effective and responsive delivery of Islands had not yet transposed Article 8 care. The meeting also provided a forum services. The meeting emphasised the of that Directive, the Commission for discussing a European charter on role of integrating health system services started an infringement procedure. In health systems, currently under devel- in cancer control, and also learnt from 2005, given that the Åland Islands had opment by Member States in the WHO work under way, in preparation for the still taken no measures to comply with European Region. Its objective is to Slovenian presidency of the European their obligations, the Commission provide guidance and a strategic Union in 2008, on fighting against referred the case to the Court. On framework for strengthening health cancer in Europe. 18 May 2006 the Court concluded in its systems throughout the Region. This The findings from the meeting will also judgment in case C-343/05 that by process is led by a charter-drafting group contribute to the agenda of the WHO failing to ensure transposition by Åland of experts from Member States. European Ministerial Conference on of Article 8 of Directive 2001/37/EC and As people live longer and can be treated Health Systems: ‘Health Systems, Health observance on vessels registered in for long-term conditions, but are and Wealth’, to be held in Tallinn, Finland of the prohibition on placing on exposed to modern lifestyle risk factors, Estonia, in June 2008. The charter is also the market of snuff laid down by that
37 Eurohealth Vol 13 No 3 MONITOR provision, the Republic of Finland has COUNTRY NEWS come to smoke cannabis, but this also is failed to fulfil its obligations under the a drain on the emergency services who EC Treaty and Directive 2001/37/EC. have to cope with smokers affected by Netherlands: Availability of medical unusually potent drugs. Border towns Only in January 2007 did the Åland also suffer problems from ‘drug tourists’ Islands, after the opening of a second cannabis for scientific and medical who travel from neighbouring Germany infringement procedure under Article research and Belgium and nearby France to stock 228 EC, adopt new legislation aiming to Since 2003, patients have been able to up on weed. comply with the judgment. However, obtain cannabis on prescription. It is that legislation the EC deems still fails to cultivated under government super- Under the previous conservative implement the above Directive because vision. Ab Klink, Minister of Health, government, Parliament was dissuaded it only prohibits oral tobacco known as Welfare and Sport, wants a five-year from outright legalisation by fears that it ‘snus’ from entering the market, rather extension of the availability of medicinal would lead to a confrontation with the than oral tobacco in general, as foreseen cannabis for scientific and medical European Union. According to data in the EU Directive; and in relation to research. Mr Klink believes that compiled by the Netherlands’ Trimbos the selling of oral tobacco on vessels, the medicinal cannabis should simply be a Institute for Mental Health and law limits its application to vessels oper- registered medicine. His aim in Addiction, after thirty years of the ating within Finnish territorial waters. extending the availability is to give the Dutch tolerance policy, usage rates are This would allow the sale of oral development of cannabis-based medicine above those in Germany and the Scandi- tobacco on vessels registered in the a serious chance of succeeding. Last year navian countries, but below those of Åland Islands, once these vessels exit a Dutch company began work on France, Britain and the United States. Finnish territorial waters. developing such a medication. The work, which will take several years to Finland: Conference reports alcohol The Commission will only be satisfied complete, may provide scientific data responsible for 15% of early deaths in with a ban without restrictions. It has and understanding into the balance EU also stressed that the sales of ‘snus’ on between the effectiveness and safety of Alcohol use increases the risk of several vessels not only affect the 25,000 resi- medicinal cannabis. types of cancer and is a significant cause dents of Åland but also tourists from It will continue to be possible for of premature death in EU countries. The other parts of Finland and other patients to obtain medicinal cannabis hazard it poses to health outstrips any Member States. In addition, both from pharmacies on prescription, for health benefits it may have. Finland and Sweden have signed and example as a painkiller. If a registered ratified the United Nations Framework This is according to Professor Jürgen alternative comes on the market in the Convention on Tobacco Control Rehm, who addressed a conference held coming five years, the minister will (FCTC), and therefore have legal in Espoo, Finland on 15 November that review the need for this supply. To date, obligations under international law to concluded a 2004–2007 alcohol demand for medicinal cannabis has been cooperate in favour of tobacco control. programme run by the government. The low, in part because of the availability of programme sought to cut the harmful Tobacco is the single largest cause of similar products at a third of the price in effects of alcohol use and involved a avoidable death in the European Union, ‘coffee shops’, where it remains illegal wide range of organisations and sectors accounting for over 650,000 deaths each but tolerated if sold in small amounts. of society. year. It is estimated that 25% of all In a letter to Parliament, Mr Klink stated cancer deaths and 15% of all deaths in Professor Rehm said that alcohol use has that “this development track will take the Union could be attributed to clear links to the risk of cancer of the years, but it can yield scientific evidence smoking. Tobacco for oral use contains lips, throat and mouth, larynx, and give insight into the balance between particularly large quantities of oesophagus, liver, small and large safety and effectiveness of medical carcinogenic substances. intestine and, in women, breast cancer. cannabis.” Klink conceded that the He said that although alcohol use was Commenting on this decision, European Bureau for Medical Cannabis, the body increasing among women in EU coun- Health Commissioner Markos that licenses the growing of medical tries, its harm is most apparent among Kyprianou said that “the Commission cannabis, would make a loss this year of men. decision underlines that given the health approximately €200,000 and said he In Central and Eastern Europe it is risks linked to the use of oral tobacco, hoped a drug under development would responsible for 15%, and in other parts the Commission has no tolerance for eventually replace cannabis and the need of the Community 12%, of premature allowing the placing on the market of for official growers. deaths. Rehm said that worldwide that product. We cannot accept that the Pro-cannabis campaigners continue to alcohol use is increasing most in more prohibition of placing of tobacco for call for full legalisation and claim that densely populated countries. It is also oral use on the market is not transposed this would lead to better labelling of the linked to the spread of chronic diseases or implemented by Member States or plant’s chemical contents. Currently the and rising accident rates involving even by parts of Member States. Only ‘coffee shops’ have no way to legally inebriated people. the consistent and continuous source their products. Many are supplied application by all Member States of all Alcohol use in Finland has increased. by mini-plantations hidden in residential Community provisions relating to Per capita consumption of pure alcohol areas, which may be a fire hazard. tobacco can achieve our goals in fighting increased from 6.7 litres in 1996 to 8.2 tobacco.” Amsterdam benefits from tourists who litres in 2005. And yet over the same
Eurohealth Vol 13 No 3 38 MONITOR period time spent on alcohol production £41 million national screening European Medicines Agency (EMEA) and retailing dropped from 29,000 to programme to detect serious illnesses and its access by Member States. 27,000 working years. early. Another measure is a definition of risk £97 million will be provided to phase management which is described as the Scotland: Health and Wellbeing budget out prescription charges over a three “planning of the pharmacovigilance outlined year period, while £134 million will activities to enable the anticipation of Patient-focused services and investment be invested in sport to increase security problems and the introduction aimed at helping Scots live longer and participation and improve sporting of measures that may decrease the healthier lives with reduced inequalities performance, contributing to a range of known risks of medicinal products and are at the heart of the Health and Well- outcomes including better physical and the effective communication of such being spending plans outlined on 14 mental health. activities”. November by Cabinet Secretary for Health and Wellbeing Nicola Sturgeon. Minister Sturgeon also indicated that The Decree also introduces a duty to be “tackling the misuse of alcohol in carried out by pharmaceutical companies The Health and Wellbeing portfolio is to Scotland is a significant challenge, not so as to include a warning (in the shape be responsible for public spending of least because of the tragic effects that of a yellow triangle) during the five year £11.2 billion in 2008–09, or £2,200 for misuse can have in terms of heart and period of commercialisation of a new every person living in Scotland, rising to liver disease, cancer and problems in active substance in communications £12.2 billion in three years time. This families and communities” She added directed to health professionals. There comes amid what the Scottish that “£85m of additional investment will are also improvements in the procedures Government believes to be the tightest fund a radical range of measures to to be taken in case of revocation of the UK spending settlement since devo- reduce alcohol harm as part of a authorisation of a medicinal product. lution. Ms Sturgeon said it was vital to forthcoming long term strategy.” Scotland’s economic future that every Germany: Health insurers’ rebate penny of this funding supported people Reducing health inequalities is also contracts may breach European Compe- in leading longer and healthier lives, important for the Minister, who noted tition Law with a particular focus on areas and that the “spending plans target resources The European Commission initiated the communities with the worst health in particular at communities most at risk first step of treaty violation proceedings records. She acknowledged that the of poor health. They allow us to increase against Germany through publication of priority would be “to focus on measures the supply of good quality, sustainable a letter of intent on 17 October 2007. which improve health and prevent housing, to tackle poverty and The allegation is that rebate contracts illness. There can be no doubt that deprivation at its roots, and to promote under Section 130a(8) of the Social Act reducing alcohol and tobacco abuse equality, as well as strengthening V (Sozialgesetzbuch V – SGB V) leads to healthier lifestyles, so these will primary care health care services in our concluded between the Statutory Health be key spending priorities over the next most deprived areas and expanding early Insurance Funds and individual three years.” years support for those most in need.” companies regarding the delivery of To help achieve a healthier Scotland, the The full text of the Scottish Budget and particular medications without a 2007 spending review includes £350 Spending Review 2007 by Finance and European-wide tender violates million of new money on health Sustainable Development Secretary John European public procurement law. improvement and better public health, Swinney can be accessed at Since the right to negotiate discounts including £85 million over three years to http://www.scotland.gov.uk/News/This- was granted to the Statutory Health reduce harm done by alcohol, £3 million Week/Speeches/spendreview07 Insurance Funds, the insurers have a year on further action to reduce signed about 7,500 rebate contracts with smoking and a £11.5 million a year Spain: Strengthening pharmaco- sixty-two manufacturers covering 20,500 programme on diet and physical activity vigilance of medicinal products medicinal products. At the end of for health and to prevent obesity. There The Council of Ministers has approved a September 2007 the German General is also an injection of £270 million to new Royal Decree on 11 October 2007 Local Health Insurance Fund (Allge- ensure that by the end of 2011, nobody which develops pharmacovigilance of meine Ortskrankenkasse – AOK) started will wait longer than 18 weeks from GP medicinal products for human use. This its second tendering procedure in which referral to treatment for routine condi- Royal Decree develops the Law of 40% of all prescription medicinal tions, and £30 million (£10 million each Guarantees and Rational Use of products purchased would be covered year) to ensure more flexible access to Medicinal Products and Medical Devices by rebate contracts. The German Cartel primary care. of 2006. Although the Royal Decree has Office (Bundeskartellamt – FCO) not yet entered into force, these new Investment in prevention, screening and became involved after Germany’s four measures assure an effective vigilance in early detection of serious illnesses are main industry associations lodged an the provision of medicinal products to also key priorities, with a new immuni- official complaint about the AOK’s patients. sation programme to protect women operations and conducted a hearing with against cervical cancer costing £64 One of the measures adopted by the new the AOK. It is argued that the Public million, a commitment of £53 million to Decree is an electronic notice in case of Procurement Tribunal of the FCO screen people admitted to hospital for possible adverse effects which will should stop this second tendering MRSA and continued action to help enable the creation and maintenance of a procedure as it may violate the prevent the spread of infection, and a European database managed by the provisions of general German public
39 Eurohealth Vol 13 No 3 MONITOR procurement law. However, the AOK was to remove reimbursable products 4 October. As reported by the Russian denied the applicability of the German from the market, but the final wording News and Information Agency – public procurement law, with the adopted by Parliament distinguishes NOVOSTI, “during the first nine argument that Statutory Health between normal and ‘unjustified’ months, 1,933 emergency situations Insurance Funds are not public practices. Moreover, the new provisions were registered in Russia with 3,535 contracting entities. under the Act overlap with existing anti- people being killed,” the ministry said in corruption provisions in the Pharmaceu- its statement. In September 2007 alone, The discussion focuses on whether the tical Law and Penal Code. Even though Russia registered 174 man-made acci- Statutory Health Insurance Funds are the rule is that provisions prohibiting public contracting entities under Section dents, which left 283 dead and 511 certain activities as well as penal provi- 98 No. 2 of the Act Against Restraints of injured, the ministry said. At the same sions should be interpreted narrowly, Competition (Gesetz gegen Wettbe- time, all regions in Russia witnessed a there are opinions supporting a wider, werbsbeschränkungen – GWB) and decline in the number of man-made punitive interpretation. whether rebate contracts are considered emergencies, the ministry said. as public contracts pursuant to Section Art 63c of the Act confirms the general “Compared with the same period last 99(1) GWB. Separately, discussion is rules of competition law. This provision year, the number of man-made incidents continuing as to whether rebate prohibits unequal treatment of declined by 14.9% while the number of contracts are excluded from public competitors at the wholesale level in the people killed in emergencies fell 20%,” tender requirements on the basis of pharmaceutical market. This provision the ministry said. social security legislation (Section 69 does not affect normal commercial activ- Meantime on November 12, NOVOSTI SGB V). If both these issues are ities as stated in article 94(4) of Directive reported that more than 27,000 people answered in the affirmative and public 2001/83. The unclear wording of this had been killed in road accidents in procurement law is considered as super- provision has, however, caused problems Russia since January 2007. In a statement seding social law, discount agreements in the market. It is interpreted by some the Russian Traffic Police said that will have to be publicly tendered on a commentators as a prohibition on all “from January–October 2007, a total of European basis. discounts, even though such an interpre- 27,289 people were killed and 247,770 tation is contrary to Directive 2001/83 The National Health Insurance injured in 194,000 road accidents." This and the EU Constitution. Authority (Bundesversicherungsamt – is a 3.4% increase on the same period in BVA), the supervising authority for Article 63a of the Act supplements the 2006. The majority of accidents were Statutory Health Insurance Funds, prohibition on advertising already caused by violations of road traffic rules. stated in August 2007 that Statutory contained in pharmaceutical regulations. However, tougher punishments for Health Insurance Funds are to be It prohibits the corruption of pharma- driving under the influence of alcohol considered public contracting entities cists, supervisors/managers of wholesale saw a 10% drop in drink-driving under German public procurement law companies or other employees of phar- accidents. The drop in child road deaths and rebate contracts are public contracts macists or wholesalers by offering them saw a similar decrease. under Section 99(1) GWB. Therefore, in benefits in return for increased sales. its view, rebate contracts pursuant to This prohibition appears to apply only Russia: Work on new strategy for health Section 130a(8) SGB V fall under the to private persons. care development. scope of the GWB and should be According to the Russian daily news- Breach of Articles 63a and 63c, or by publicly tendered European-wide. In paper, Kommersant, Russia’s Health and employees of a company as described in addition, the BVA clearly expresses that Social Development Ministry will focus Article 192b-c of the Healthcare Law, public procurement law is not ruled out in 2008 on developing a new Strategy for may result in criminal liability. The by Section 69 SGB V. Health Care Development for the period penalties for a company may include a 2009–2019. The document should detail As the legal jurisprudence regarding the ban on taking part in tenders or a fine of growth in medical expenditure and put use of public procurement law principles up to PLN twenty million. If the regula- forward a programme of health system for rebate contracts is inconsistent, the tions are violated by an employee, it is reforms to be carried out in 2009 situation is unclear. Against this back- possible to avoid punishment if the through 2012. ground, the decision of the FCO and the company proves that the violation was course of the treaty violation the result of unusual behaviour by the Russia’s newly appointed Minister of proceedings of the European employee and that the company acts Health and Social Development, Tatiana Commission against Germany is according to proper rules and exercises Golikova, made the first public awaited. care in selecting and controlling its statement related to the mid-term employees. It is now up to the new strategy of the ministry. “The document Poland: Act on healthcare services government to interpret these shouldn’t be a general slogan, but feature financed from public funds provisions. definite directions for the first three, and On 29 September 2007, the Act on then for the following seven years,” the Healthcare Services Financed from Russia: 30,000 deaths in man-made minister pointed out. It appears the Public Funds (the ‘Healthcare Law’) and road traffic accidents in 2007 Finance Ministry, where Golikova entered into force, incorporating anti- More than 3,500 people have been killed worked prior to her current corruption provisions (Art. 63a-c and in about 2,000 man-made incidents in appointment, will now face a strong Art. 192b-c) with penal sanctions. The Russia since the beginning of 2007, the advocate for greater health system Act is controversial, as its original aim country’s emergencies ministry said on funding. According to Kommersant,
Eurohealth Vol 13 No 3 40 MONITOR sources do however indicate that UNICEF has requested the Government some degree of disrepute in a way, Golikova does not think that funding is to provide additional information on the because you don’t want your lab to be the major concern; more important is conditions of care in other institutions associated with something which is the need to introduce quality control for children with disabilities as part of purporting to have cells which clearly measures in the health system. the review of residential care system. they’re not. And the only way you can deal with this is to be upfront and honest More information in Russian at The statement indicates that key reforms about it and get rid of those cells and http://www.kommersant.ru/doc.aspx?D are still needed to convert existing resi- then re-evaluate everything you’re doing ocsID=822336 dential institutions into a system of in the lab,” Professor Pilkington added. community-based services, thus Bulgaria: UNICEF responds to protecting the right of the child to live in Northam claims that “such contami- intolerable situation in children’s home a family environment. UNICEF is also nation of cell cultures is by no means In Sofia on 19 November, the United committed to helping the government unique. Many laboratories suffer similar Nations Children’s Fund (UNICEF) further expand family support services catastrophes, even with well-established renewed calls for accelerated efforts to for the prevention of abandonment and lines of cells, which are sold all over the improve the child welfare system in help local municipalities in designing world by specialist companies. There’s Bulgaria, particularly the reliance on appropriate interventions and chan- also a lively informal system of exchange institutionalising children without nelling adequate financial resources for in which scientists send each other cell- parental care. deinstitutionalisation of children. lines, blissfully unaware that some have become contaminated and are not what The statement was made in response to a Information on the documentary they purport to be. These mistakes can documentary ‘Bulgaria’s Abandoned ‘Bulgaria’s Abandoned Children’ is go undetected for years – on occasions Children’, first broadcast by the BBC in available at http://www.bbc.co.uk/ even for decades.” September. This documentary depicts bbcfour/documentaries/features/ the intolerable situation at one insti- bulgarias-children.shtml One of the latest examples of scientific tution in Mogilino. It once again empha- research to be affected by this problem is sised that additional and urgent efforts UK: BBC report claims cancer studies a study of oesophageal cancer. have to be channelled towards the ‘wasted millions’ Researcher Dr Chris Tselepis worked prevention of institutionalisation and An investigation by the BBC has with an international team which has improving assistance to children without discovered that millions of pounds of found that TE7, an experimental culture parental care. charity donations and taxpayers’ money of cancer cells used in labs for the past A plan of action has now been have been wasted on worthless cancer twenty years, was the wrong cancer. developed by the Government of studies. Gerry Northam, reporting for “Fortunately, for us our research was Bulgaria with the ultimate objective of the BBC Radio Four programme ‘File based on a number of cell types, so the closing the institution in Mogilino. It On 4’ discovered that the results of impact of a mistaken identity for this will be implemented in partnership with thousands of studies have been invali- line has actually been fairly minimal to UNICEF and an alliance of non govern- dated. His investigation found that some us,” said Dr Tselepis who is studying the mental organisations. As part of the scientists have failed to carry out simple cancer at the Cancer Research UK plan, on 7 and 8 November, UNICEF and inexpensive checks to ensure they laboratories in Birmingham University. conducted a joint assessment mission of are working with the right forms of “But I’m sure there’s many other labora- the institution in Mogilino, with the human tumour cells. tories UK and worldwide-based that essentially base lots of their conclusions Agency for Social Assistance and These cancer cell-lines, grown in flasks on one cell line and in that case, this representative of the alliance of NGOs kept at body temperature, form the basis mistaken identity has a massive impact to identify the immediate needs. of many experiments. To the naked eye on conclusions that people draw from cell-lines for different cancers all look The main finding of the team confirmed such studies,” he added. that the overall standard of care fairly much the same – a cluster of tiny provided to all sixty-five children in that dots on the bottom of the flask. Using Scientists at the German Government’s institution was bad and the staff were the right cells is vital for much research, collection of tumour cell cultures have not adequately qualified. The situation but even under a powerful microscope, also recently checked the identities of of three children was critical and they it can be hard to tell them apart. the samples they’re sent by researchers were hospitalised, while another twenty all over the world. They found discrep- In fact, human cancer cell-lines can be children needed immediate additional ancies in 17% of all tumour types, a contaminated by rat or mouse cancer care and feeding to alleviate deprivation finding which left them astonished. cell-lines as Professor Geoff Pilkington, caused by meagre nutrition and care. who runs the biggest laboratory in the This problem is compounded by the fact Based on the assessment and the plan UK studying brain tumour research, can that studies based on erroneous research developed by the Government’s Social testify. He told the BBC that “whole data will be printed in reputable scien- Assistance Agency, a group of care programmes of research had to be tific journals and become part of the providers and medical experts are being redone using verified human brain accepted literature, thus misleading selected and will start working in the tumour cells” because of this type of future researchers. Earlier this year institution immediately. Meantime, indi- contamination. “It’s hugely expensive nineteen eminent cancer specialists from vidual assessments and plans for alter- and it’s incredibly frustrating and it the UK and USA wrote to the US native care are being developed, while means that the laboratory is put into Health Secretary urging tough action to
41 Eurohealth Vol 13 No 3 MONITOR end this waste of time, effort and money. Research found high levels of support 30% press ads and 21% per cent had The US authorities replied that there for smokefree by both the general public seen Smokefree England advertisements appeared to be “abundant evidence” that and businesses. Three quarters of adults on billboards. 49 % said the ads “stuck many studies and publications had been support the law and 79% believe it will in their mind” and 91% understood the compromised. The letter’s originator, have a positive effect on public health. message of the advertising. Professor Roland Nardone of the A greater proportion of smokers (47%) October 2007 also saw the age of sale for Catholic University of America, said the support the new law than oppose it tobacco products increased from 16 to best way to get scientists to comply (37%). 18 years, while in 2008, hard hitting would be to withhold research grants Of over 275,000 businesses inspected picture warnings will be required on all and publication in scientific journals between 1 July and the end of tobacco products produced for the UK unless their research used authenticated September, 98% were found to be market from 1 October. cell-lines. This verification can be compliant with the new law, with 84% achieved using a technique of DNA The Smokefree England three month displaying the correct signage. 86% of profiling which compares the cell-line report and further information about the businesses said the implementation of legislation can be found at with a list of known contaminants and the new law had gone well and 78% said http://www.smokefreeengland.co.uk. can cost as little as £180 per sample. it was “a good idea”. However the Medical Research Council, The number of calls to the smokefree Public health in England: improvements the major source of public funds for compliance line has also tailed off and challenges such research in the UK providing £70m considerably, falling from over 1,000 Life expectancy is at the highest level of grants annually for cancer studies, calls during the first week of operation ever, deaths from cancer, heart disease told the BBC that there was no evidence down to an average of twenty a day in and stroke are falling, and infant that this problem is happening on a September. Also, there have only been mortality is at its lowest level ever significant scale. Nonetheless, one of the seventy fixed penalty notices issued to according to the Health Profile of UK’s leading cancer medicine experts individuals smoking in smokefree places England 2007, published on 22 October told the programme that it was time for since 1 July, both of which suggest that, by the Department of Health in the scientific community to put its house as in Scotland and Ireland, the ban has England. in order. “No grant or no publication," been largely self-enforced. said Professor Karol Sikora, of Imperial The Profile contains international College, London. “If one of the leading Minister of State for Public Health, comparisons and compares the health of journals, which all of us want to publish Dawn Primarolo, said that the report England to that of the European Union. in, said: ‘You have used cell-line - just “confirms that smokefree law is not only It reports that early death from the two give us the certificate of authenticity’. popular, but that the vast majority of the biggest killers, circulatory disease and Now we can tell all that and it doesn’t general public believe it is good for cancer are reducing faster in England necessarily cost a lot of money.” public health. People of all ages are than the average for the EU, while reaping the benefits of healthier, less deaths from motor vehicle traffic The transcript of the File on 4 smoky work and social environments, accidents in the UK are amongst the programme ‘Cancer Research’ is which in turn are seen as an incentive for lowest in the EU. available at http://news.bbc.co.uk/1/ many to get out and socialise more.” She Whilst the statistics show that there has shared/bsp/hi/pdfs/20_11_07_fo4_ added that she was “especially proud to been ongoing improvement in many research.pdf hear that nine out of ten businesses say aspects of the nation’s health, the Health that implementation went well and that Profile also shows that there are some Smokefree England: The first three the majority of people, smokers issues where progress is slow. Regional months included, are supportive of the new health inequalities still exist, and rates of The introduction of smokefree work- legislation. The evidence is clear, obesity, diabetes and alcohol related places and public places has run secondhand smoke is a killer and hospital admissions are rising. smoothly. People are particularly removing it from enclosed public and enjoying a healthier atmosphere in all work environments marks the single In comparison to the EU-15, the workplaces including pubs and clubs, biggest improvement in public health for prevalence of obesity in England is the with the primary benefits of cleaner air a generation." highest. Deaths from chronic liver and not smelling of smoke after a night disease and cirrhosis have risen In the run-up to 1 July, Smokefree out - according to a three-month report markedly, and England has risen above England provided detailed information issued on 2 November by the the EU-15 average. Despite declining and support to businesses, as well as Department of Health in England. teenage pregnancy rates, the UK also has running a high profile campaign to the highest proportion of births to under When surveyed, the top three benefits ensure the general public were aware of 20s compared to other Western people had noticed since England and ready for the law. The figures appear European countries. became smokefree were that clothes and to speak for themselves: general hair don’t smell of smoke after visiting a awareness of smokefree law reached Public Health Minister, Dawn pub or club; that there was a more 98% in mid-July. 85% of adults said Primarolo, acknowledged that “there is pleasant or better atmosphere in pubs, they had seen publicity about the intro- still a lot to do in tackling health clubs and/or restaurants; and the air was duction of smokefree law, with 75% inequalities.” She said that to address cleaner citing TV ads; 41% TV programmes; this there would be major improvements
Eurohealth Vol 13 No 3 42 MONITOR to GP services across the country, The increase in alcohol consumption For the health service in general, the including greater flexibility in opening would be 29% (2.8 litres per capita) if results show a number of positive times, and over 100 new GP practices in the sale of alcohol was allowed in, for results, including the level of confidence the 25% of Primary Care Trusts with the example, supermarkets. Taking into and trust in the care received in hospital poorest provision.” account the increase in negative external- and community settings being rated ities associated with alcohol, the risk of highly (67–86%), while a majority of She went on to add that “whilst we have increased sales and consumption of respondents were admitted to hospital in made good progress in stopping people alcohol and conservative estimates of a timely manner (76% immediately). smoking, I am determined to move increased per capita consumption of further and faster to respond to all these While General Medical Service (GMS) alcohol associated with a private challenges – with a cross government cardholders (individuals entitled to most licensing system, the authors conclude drive to tackle obesity, improve diet and services free of charge) were more likely that the consequences of establishing a activity levels and promote safe and to use health services and have poorer private licensing system would be detri- sensible drinking … our ambition is to health, there was no notable difference mental to Swedish public health and reverse the rising tide of obesity and in service satisfaction between card- safety. overweight in the population, by holders and non cardholders. The results enabling everyone to achieve and This report is available at also confirm the paradox that people maintain a healthy weight. Our initial http://www.fhi.se/upload/ar2007/ want access to both local and specialist focus will be on children: by 2020, we Rapporter%202007/Monopolstudie_eng_ services. While a large majority of aim to reduce the proportion of over- ver19_0711.pdf respondents stated that they believe that weight and obese children to 2000 acute hospital services should be levels.” Ireland: Largest ever health research provided in every county, seven out of study finds strong satisfaction with ten respondents also indicated a pref- The health profile of England 2007 can health services erence to be treated at a specialist or be accessed at http://www.dh.gov.uk/en/ On 28 September 2007 the Health concentrated acute centre where there is Publicationsandstatistics/Publications/ Service Executive (HSE) published evidence that this will provide the best PublicationsStatistics/DH_079716 consumer research results which show outcome for them. Nonetheless, ease of that there is strong satisfaction with access remains very important to most Sweden: Report on the consequences of health services and a high degree of respondents. privatising retail alcohol sales confidence and trust in health profes- As a member of the European Union, Professor Brendan Drumm, Chief Exec- sionals. Commissioned by the HSE in Sweden since its entry has been ques- utive Office of the HSE, said that the 2006, the study was carried out by the tioned about its alcohol retail monopoly results are “a true reflection of how the School of Public Health and Population and there exist rather constant pressures majority, rather than the vocal minority, Science in University College Dublin from the EU to eliminate aspects of view the health service” and that “it is (UCD) in partnership with Lansdowne national alcohol policy which have time that staff got the credit for what is Market Research. historically been established for Sweden very positive feedback from people who in the interest of protecting public health Insight 07 is the first independent large are using our services.” and safety. While the EU Court has scale study undertaken among people Professor Drumm also pointed out that upheld the legality of an alcohol retail who have used hospitals and community the role of patients or healthcare system in Sweden, there are other pres- based health services. The study iden- consumers is central to the success of the sures to reduce or eliminate the provi- tified for the first time what proportion Health Transformation Programme and sions of the retail monopoly. The recent of the population is using which service. influencing change. He stated that “it is European Court decision to overturn The General Practitioner (GP) is increasingly acknowledged that the most the Swedish law which bans internet confirmed as the most frequently successful approach to building a safer sales of alcohol is just such an example. consulted point of the health service and and quality health care system is when is the best rated service. One third of the What potential consequences would a the health service works together with population had some contact with the privatisation of the Systembolaget patients and communities” he said at hospital system in the past 12 months; alcohol monopoly have on Sweden’s today’s launch “and the information almost two thirds had been in contact public health? This question is the focus from this study will help us achieve with their GP; and one fifth reported of a new publication from the Swedish this.” contact with community services other National Institute of Public Health. The than their GP. The study involved detailed face-to-face report, written by an international team interviews with 3,517 people across the of experts, presents the potential effects Professor Cecily Kelleher of UCD country. Respondents were asked about of a privatisation of the current system commented that “this pattern of service their experience of the public health and of selling alcohol. According to the use, which shows high utilisation of GP social care services during 2006 and conservative estimates presented in the services, coupled with the fact that the 2007. report, an elimination of the alcohol vast majority of respondents stated that monopoly in Sweden would lead to a they got their health information from The full results of the survey can be 14% increase in alcohol consumption the GP, reinforces the central part accessed at http://www.hse.ie/en/ (1.4 litres per capita) if sales were primary care plays in the promotion, Publications/HSEPublicationsNew/ restricted to licensed speciality stores. provision and maintenance of health.” INSIGHTCustomerSatisfactionSurvey
43 Eurohealth Vol 13 No 3 News in Brief
EC health services impact assessment eating together with friends or family five years to complete, and involving tool launched was also a key ingredient. For example, nine teams from around the world, data This web-based tool launched by DG in Sofia, the city council and the Euro- from seven thousand published studies Health and Consumer Protection is de- pean Commission put on an event in a were analysed. Convincing evidence di- signed to help produce a Health Systems city centre cinema where forty chefs and rectly linking body fat to six cancers in- Impact Assessment (HSIA) as part of four hundred children explored healthy cluding colorectal and post-menopausal the European Commission's impact as- eating issues and watched a special breast cancer was identified. screening of the film ‘Ratatouille’. Obe- sessment procedures. The report is available at sity is on the rise across the EU, with Member States are fully responsible for http://www.dietandcancerreport.org/ twenty-two million children categorised health policy and the organisation of as obese or overweight, while twenty health systems, but nevertheless EU thousand obese children are diabetic and policies often have an impact on health millions more are heading towards heart Ukraine: prisoners unaware that TB and, in particular, many policies have disease. More than 1.4 million are esti- can be cured unintended positive or negative conse- mated to have liver disorders. A new WHO study conducted in quences for Health Systems, due to their Ukrainian prisons shows that most pris- large and complex structures in every More information at oners do not know that they can protect Member State. http://ec.europa.eu/dgs/health_ themselves from tuberculosis (TB), or consumer/events/minichefs_en.htm The tool provides information on the that it is curable. Individuals in prison objectives and health system functions are up to one hundred times more likely that a proposal may impact on, either in to get TB than the general population. a positive or negative way. It will also di- Mixed messages in latest EU drugs The study calls for better efforts in rect users to information and evidence report working with inmates. It offers recom- from past initiatives to help determine After over a decade of rising drug use, mendations on how to provide them whether a proposal will have an impact, Europe may now be entering a more sta- with knowledge about TB and how to and if so, what that impact might entail. ble phase, says the Lisbon-based Euro- avoid infection or cope with treatment. pean Monitoring Centre for Drugs and More information at The study stresses that doctors and Drug Addiction (EMCDDA). Not only http://ec.europa.eu/health/ph_overview/ nurses should be offered more tools to are there signs that heroin use and drug co_operation/high_level/index_en.htm bridge the knowledge gap. They should injecting have become generally less also be given special training to equip common, but new data suggest that lev- them with skills not only to inform but els of cannabis use may now be stabilis- also to motivate the inmates. Alcohol Forum underway ing after a sustained period of growth. The summary of the first meeting of the Research results will become a basis for Nevertheless, positive messages are European Commission Alcohol and the WHO Office in Ukraine to draw up marred by high levels of drug-related Health Forum is now available online. detailed proposals on how to improve deaths and rising cocaine use. Moreover Commitments for action by participat- the situation concerning TB awareness the EU risks failing to meet targets to re- ing umbrella organisations are scheduled and hence TB control in the prison sys- duce drug-related deaths: there are be- to start in January 2008, with the next tem. They will be discussed with the tween seven and eight thousand plenary session set for April. State Department of Ukraine for Execu- overdose deaths per year, with no down- tion of Punishment to explore possibili- More information at ward trend detectable in the most recent ties for further cooperation. http://ec.europa.eu/health/ph_ data. These are among the findings of determinants/life_style/alcohol/Forum/ the EMCDDA’s annual report on the More information at alcohol_forum_en.htm State of the Drugs Problem in Europe http://www.euro.who.int/PressRoom/ published on 22 November. pressnotes/20071109_1 The report is available at Europe-wide day promotes healthier http://www.emcdda.europa.eu/events/ eating for children 2007/annualreport.cfm Over four thousand European chefs helped children to take part in the first European healthy eating day in Novem- Report links body fat to increased ber. The day saw chefs giving demon- Additional materials supplied by cancer risk strations in schools and fun events in The World Cancer Research Fund to- EuroHealthNet restaurants as the EU teamed up with gether with the American Institute for the European Association of Chefs to 6 Philippe Le Bon, Brussels. Cancer Research launched its second ex- champion the cause. Lessons were or- Tel: + 32 2 235 03 20 pert report entitled ‘Food, Nutrition, ganised on how to prepare simple, bal- Fax: + 32 2 235 03 39 Physical Activity and the Prevention of anced meals that taste good. The idea of Email: [email protected] Cancer: a Global Perspective.’ Taking
eurohealth Vol 13 No 3 44 Eurohealth is a quarterly publication that provides a forum for researchers, experts and policy makers to express their views on health policy issues and so contribute to a constructive debate on health policy in Europe
ISSN 1356-1030