Eurohealth

RESEARCH • DEBATE • POLICY • NEWS Volume 12 Number 3, 2006

French health system reform: Implementation and future challenges

Interview with Xavier Bertrand, French Minister of Health

Pharmaceutical and human resource policies in France

Hospital reform: a new era of public/private competition?

Germany: Is Bismarck going Beveridge? • Climate change and health • Sexually transmitted infections Obesity control • Mental health reform in Romania • Stem cell politics • Choice and deregulation in Sweden Eurohealth Plus ça change……?

LSE Health, London School of Economics and Political Plus ça change, plus c’est la meme chose – the more Science, Houghton Street, London things change, the more they stay the same! All too WC2A 2AE, United Kingdom C fax: +44 (0)20 7955 6090 often this can be said of health care reform. It is apt email: [email protected] therefore, that much of this issue of Eurohealth is www.lse.ac.uk/LSEHealth devoted to the French health system. Zeynep Or, Editorial Team

Chantal Cases and colleagues at the Institute for EDITOR: Research and Information on Health Economics David McDaid: +44 (0)20 7955 6381 O (IRDES) in Paris have brought together contributions email: [email protected] describing and reflecting on the consequences of major FOUNDING EDITOR: Elias Mossialos: +44 (0)20 7955 7564 reforms enacted in 2004. We are especially delighted to email: [email protected]

feature an interview with Xavier Bertrand, French DEPUTY EDITOR: Minister of Health. Sherry Merkur: +44 (0)20 7955 6194 M email: [email protected] Previously ranked by WHO as the best performer, the EDITORIAL BOARD: Reinhard Busse, Josep Figueras, Walter Holland, French health system is not without problems. It has Julian Le Grand, Martin McKee, Elias Mossialos

traditionally operated with little regard to efficiency or SENIOR EDITORIAL ADVISER: cost containment. It has the highest rate of pharma- Paul Belcher: +44 (0)7970 098 940 ceutical use in the EU, while, until recently at least, there email: [email protected] M DESIGN EDITOR: has been little attempt to incorporate cost effectiveness Sarah Moncrieff: +44 (0)20 7834 3444 into policy making. The health workforce is ageing; email: [email protected]

geographical inequalities in access to services exist. SUBSCRIPTIONS MANAGER Moreover, promotion and prevention have not been Champa Heidbrink: +44 (0)20 7955 6840 email: [email protected] high priorities. E Advisory Board The 2004 reforms make use of economic incentives to Anders Anell; Rita Baeten; Nick Boyd; Johan Calltorp; Antonio Correia de Campos; Mia Defever; Nick Fahy; influence the behaviour of health professionals and the Giovanni Fattore; Armin Fidler; Unto Häkkinen; Maria public. These include a system of gate keeping for Höfmarcher; David Hunter; Egon Jonsson; Meri Koivusalo; Allan Krasnik; John Lavis; Kevin McCarthy; Nata primary care, activity-based payments and managerial Menabde; Bernard Merkel; Stipe Oreskovic; Josef Probst; freedom in hospitals, incentives to use generic drugs, Tessa Richards; Richard Saltman; Igor Sheiman; Aris N Sissouras; Hans Stein; Jeffrey L Sturchio; Ken Thorpe; support for general practice training and investment in Miriam Wiley public health campaigns. Article Submission Guidelines Will the reforms lead to sustainable change? Will the see: www.lse.ac.uk/collections/LSEHealth/documents/ eurohealth.htm French experience be of relevance elsewhere in Europe? In truth, it is too early to say, but the initial signs are Published by LSE Health and the European Observatory T on Health Systems and Policies, with the financial support encouraging. According to M. Bertrand, for the first of Merck & Co and the European Observatory on Health time in ten years the Statutory Health Insurance has Systems and Policies. stayed within expenditure limits. The potential to realise Eurohealth is a quarterly publication that provides a forum for researchers, experts and policymakers to express their greater savings while still investing in high quality views on health policy issues and so contribute to a innovative therapies remains strong. It is to be hoped in constructive debate on health policy in Europe. a few years, when speaking of the reforms we might be The views expressed in Eurohealth are those of the authors alone and not necessarily those of LSE Health, Merck & Co able to say plus ça change, plus c’est la difference! or the European Observatory on Health Systems and Poli- cies. David McDaid Editor The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Sherry Merkur Deputy Editor Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, CRP-Santé Lux- embourg, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

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ISSN 1356-1030 Contents Eurohealth Volume 12 Number 3

Eurohealth Debate Michael W Adler is Professor Emeritus of Genitourinary Medicine, Centre for Sexual 1 Can adaptation reduce the health effects from Health & HIV Research, Royal Free & climate change? University College Medical School, University Robert Mendelsohn College London, UK.

Yvon Berland is Professor of Medicine and President of the French National Observatory Public Health Perspectives of Health Professions. 3 Sexually transmitted infections in Europe Xavier Bertrand is the Minister of Health, Michael W Adler France.

Yann Bourgueil is a Research Director, Institut 7 Obesity-control policies in Europe de Recherche et Documentation en Economie Philipa Mladovsky and Caroline Rudisill de la Santé (IRDES), Paris, France.

Chantal Cases is Director, Institut de Recherche et Documentation en Economie de la Santé Focus on France (IRDES), Paris, France. 10 French health system reform: recent implementation and Isabelle Durand-Zaleski is Head of Department future challenges at the Department of Public Health, APHP Chantal Cases hôpital Henri Mondor, Paris, France.

12 Interview with Xavier Bertrand, French Minister of Health Anne-Maree Farrell is Lecturer, School of Law, University of Manchester, Manchester, UK.

15 Pharmaceutical policy in France: a mosaic of reforms Carine Franc is a Researcher at the Institut Nathalie Grandfils and Catherine Sermet National de la Santé et de Recherche Médicale and the Institut de Recherche et Documentation 18 Health targets in France: role of public health and social en Economie de la Santé (IRDES), Paris, health insurance reform laws France. Isabelle Durand-Zaleski Jack Friedman is a Post Doctoral Fellow, Department of Comparative Human Devel- 21 French hospital reforms: a new era of public-private opment, University of Chicago, Illinois, USA. competition? Zeynep Or and Gérard de Pouvourville Nathalie Grandfils is a Research Fellow, Institut de Recherche et Documentation en Economie 24 Health care human resource policy in France de la Santé (IRDES), Paris, France. Yann Bourgueil and Yvon Berland Melanie Lisac is Project Manager, International Network Health Policy & Reform Coordinator, 27 New governance arrangements for French health insurance Bertelsmann Stiftung, Gütersloh, Germany. Carine Franc and Dominique Polton Anna Melke is a former journalist and currently a PhD candidate, School of Public Administration, University of Göteborg, European Snapshots Sweden. 30 A new policy agenda in Sweden: choice and deregulation Robert Mendelsohn is Edwin Weyerhaeuser Anna Melke Davis Professor, Professor of Economics, and Professor in the School of Management, Yale 31 Health care reform in Germany: is Bismarck going Beveridge? School of Forestry and Environmental Studies, Melanie Lisac and Sophia Schlette New Haven, Connecticut, USA. Health Policy Philipa Mladovsky is a Research Assistant at LSE Health, London School of Economics and 33 Stem Cell Politics Political Science, UK. Anne-Maree Farrell Zeynep Or is Senior Economist, Institut de 36 The challenges facing mental health reform in Romania Recherche et Documentation en Economie de la Jack R Friedman Santé (IRDES), Paris, France.

Dominique Polton is Director of Strategic Research and Development, Caisse Nationale d’Assurance Maladie, Paris, France.

Evidence-informed Decision Making Gérard de Pouvourville is Research Director, 40 “Risk in Perspective” Risk communication: a neglected tool in Centre National de la Recherche Scientifique and also at Institut National de la Santé et de protecting public health Recherche Médicale, Paris, France. 43 “Bandolier” Delivering better health care 2 Caroline Rudisill is a Research Assistant at LSE Health, London School of Economics and Political Science, UK.

Catherine Sermet is a Research Director, Institut Monitor de Recherche et Documentation en Economie de la Santé (IRDES), Paris, France. 46 Publications

47 Web Watch Sophia Schlette is Project Director, International Network Health Policy & Reform 48 News from around Europe Coordinator, Bertelsmann Stiftung, Gütersloh, Germany.

Eurohealth in perspective

Objectives Backed by experts

The aim of Eurohealth is to bridge the The Editorial Team is based at LSE Health gap between the scientific and policy- and works with an Editorial Board. Euro- making communities by providing an health is also supported by an international opportunity for the publication of Advisory Board, which is comprised of a evidence-based articles, debates and distinguished list of academics and policy- discussions on contemporary health makers from leading health policy research system and health policy issues. centres, national Ministries of Health and international organisations, such as the World Health Organi- zation and the European Parliament. Eurohealth is also able to Features draw on the expertise of the European Observatory on Health Systems and Policies, which brings together eminent • Debates academics and research centres from across Europe. • Public Health Perspectives

• Health Policy Developments Feedback

• Evidence-based decision making for We very much value your continued feedback and health care suggestions on future topics and potential contributions. • Monitoring the latest EU and country- These can be sent in the first instance to the Editor, level developments plus information David McDaid at [email protected] on new publications, health-related Eurohealth is available electronically for download at: websites and much more www.euro.who.int/observatory/Publications/20020524_26 EUROHEALTH DEBATE Debate: Can adaptation reduce the health effects from climate change?

Summary: This article argues that much of the available literature on the impact of climate change on health has grossly overestimated the likely effects by persistently ignoring the potential of adaptation to reduce actual negative health outcomes. Specific examples are provided for malaria and heat stress. Spending resources on adapting to climate change, helping individuals avoid diseases and providing medical protection (such as vaccines) can all be effective measures in reducing the risk of climate change related illness. Key words: Climate change, Public health, Adaptation, Malaria, Heat stress,

Robert There are many impression that human health is one of Vector-borne diseases Mendelsohn predicted damages the primary reasons to curb greenhouse There are many infectious diseases that associated with climate gas emissions. may be climate sensitive because they change but one of the depend on an ecological vector This article argues that the climate health most salient and difficult to weigh is the (mosquitoes, flies, snails) to spread.2 If literature has grossly overestimated the potential loss of health.1 Scientists predict climate conditions change, the geographic likely health effects from climate change that there are many mechanisms that domain of that vector may change as by persistently ignoring the potential of might lead to future mortality and well. The disease may be able to spread to adaptation to reduce actual negative morbidity.2 Infectious diseases may new territories where the local popu- health outcomes. Victims are likely to increase as warming increases the lation represent ‘potential’ new cases. take measures to avoid future risks, for territory of dangerous vectors such as example by reducing exercise in the heat Two of the most prominent infectious mosquitoes or tsetse flies. Heat waves of the day or by avoiding mosquito bites diseases that have a clear link with climate could kill unsuspecting citizens. Concen- with netting. Public health organisations are malaria and dengue fever.2 Both trations of ozone could increase. There can take important measures to reduce diseases depend on mosquitoes which could be malnutrition, fish and shellfish the spread of infectious diseases by have very specific climatic ranges. For poisoning, stress from migration, and spraying mosquitoes or inoculating example, malaria is caused by the more frequent or severe floods, droughts people against potential diseases. The pathogen Plasmodium falciparum and and storms. result of all of these adaptations is that Plasmodium vivax. These pathogens are Although the numbers of potential deaths the actual number of people that will die transmitted by the Anopheles mosquito, and illnesses from climate change are or become ill from climate change may be which requires minimum temperatures of uncertain, estimates in the literature are quite small. Greenhouse gases are not 20˚C for breeding. Furthermore, the frequently large. For example, a 2.5˚C likely to cause the large ‘potential’ breeding season must be long enough to warming is predicted to cause 137,000 increases in future morbidity and allow the pathogen to come to maturity. potential deaths per year.3 A doubling of mortality predicted by the literature. As temperatures warm, currently cool carbon dioxide (CO ) may cause 360–520 wet places become potential new 2 Two important mechanisms where the million cases of malaria.4 Health damages infection zones. For a specific climate links between climate and health have reported for the US alone range from $9 scenario, researchers count the number of been quantified are reviewed: malaria and to $69 billion,1 out of total climate people who live in these new zones in heat stress. In both cases the potential change damages of between $61 and $139 order to estimate the number of potential threat and plausible adaptation response billion. The literature gives the new cases. Using this approach, it was are discussed in detail and the article estimated that climate change could cause concludes with a discussion of the policy between 360 to 520 million new potential ramifications of these arguments. Robert Mendelsohn is Edwin malaria cases by 2100 depending on the Weyerhaeuser Davis Professor, Professor of Economics, and Professor in the School of Management, Yale School of Forestry and Environmental Studies, New Haven, Do you disagree? Eurohealth would like to invite your responses to this article. If you Connecticut, USA. are interested in presenting an alternative perspective please send a brief outline of your Email: [email protected] proposed argument to Sherry Merkur at [email protected]

Eurohealth Vol 12 No 3 1 EUROHEALTH DEBATE future climate scenario.4 another in London increased mortality would likely generate greater health by 15% that same year.10 Heat waves benefits per ton than controlling green- This estimation assumes that there is no have most impact on older people and house gases. adaptation. Individuals make no attempt seem to affect cities more than rural to avoid the illness and governments and In contrast, spending resources on areas.8,10 non-profit organisations do nothing to adapting to climate change may be a very slow the vector or disease. In practice, Although developing countries may be effective way to protect human health. however, individuals, non-profit organi- particularly vulnerable to heat waves, the Limiting harmful vectors, helping indi- sations and governments are likely to bulk of the current evidence comes from viduals avoid diseases, and providing respond to new health threats. Indi- studies in developed countries. Some medical protection (such as vaccines) can viduals can avoid being bitten by authors speculate that global warming be effective measures to reduce the risk of reducing outdoor activity at times of the will cause additional mortalities from climate change related illness. Once these day when mosquitoes bite or by wearing heat waves.2,11 They argue that future diseases are under control, the impact protective clothing. Individuals can also warming will increase the magnitude and from climate change will likely be install mosquito nets to keep these insects severity of heat waves. In the absence of minimal. Furthermore, the abatement from indoor locations. Governments can any adaptation, this prediction might be programme has the added benefit of spray areas with high infection rates to reasonable; however, there are a number preventing millions of cases of illness reduce mosquito populations and they, of adaptations that individuals can make. today rather than only at the end of the together with non-profit organisations, First, over several years, they can become century. may invest in vaccines that protect popu- physically acclimatised,11 that is, their Another important but broader lations from a disease. Health care organ- bodies will adjust to higher temperatures abatement strategy is simply devel- isations can treat diseases when they making them less vulnerable. Second, opment. As per capita incomes rise, indi- occur to lessen their impact. All of these vulnerable individuals can adjust their viduals and societies can afford to take responses can reduce the effect of vector activity schedules to avoid the hottest measures to reduce health risks on their borne diseases, most specifically malaria. times of the day. Many cultures in warm own. The near absence of malaria in climates, for example, take siestas during For example, yellow fever is caused by a countries with incomes over $3,100 is a early afternoon. Third, building struc- virus that is transmitted by mosquitoes, stark case for the influence of anti- tures can be changed to reduce heat the Aedes aegypti. Climate change could poverty programmes. Clearly, as incomes build-up and increase air conditioning. increase the number of potential cases of rise, other potential concerns, such as Because people do take these precautions yellow fever as the geographic range of having adequate resources to purchase as the risk increases, the threshold the Aedes aegypti increases.5 However, food, will also disappear. temperature where one begins to see heat there is a vaccine that limits yellow fever. related mortality increases in warmer Scientists concerned about the link Furthermore, infected countries have locations.2 Therefore, the actual number between health and climate should focus initiated mosquito controls in places of heat related deaths from global more attention on how society can where yellow fever once was rampant. As warming is likely to be quite small. manage the environment and health a result, yellow fever is largely under services in order to reduce health effects. control, even in developing countries. Conclusion Rather than exaggerating the threat of Controlling malaria is more than just a Literature predicting the number of climate change, the most important task possibility. Current climate conditions potential poor health cases arising from is to bring infectious diseases and other allow malaria to exist in many countries climate change conspicuously avoids concerns under control so that they are including parts of Europe and the United incorporating adaptation. The resulting no longer a threat today or in the future. States. The Lewis and Clark expedition at ‘potential’ numbers of cases of illness and Health analysts need to take adaptation the beginning of the nineteenth century death grossly overestimate the numbers seriously and begin to develop practical reported malaria along the Ohio River. that are likely to occur. If adaptation was plans to limit the health impacts of However, health controls such as those factored into future predictions, the climate change. listed above have largely wiped malaria actual number of new cases of illness and out of these wealthy countries. In fact, premature mortality is likely to be much there are virtually no malaria cases in any smaller than the literature now predicts. REFERENCES country with a per capita income greater The emphasis of the literature on 1. Pearce D, Cline W, Achanta S et al. The than $3,100.6 As development increases potential cases rather than likely cases has Social cost of climate change: greenhouse incomes over the next century, few coun- damage and the benefits of control. In: distorted climate change policy. Because tries will remain below this critical Bruce J, Lee H, Haites E (eds). Climate of these large numbers, human health minimum income. Change 1995: Economic and Social Dimen- effects are often cited as one of the sions of Climate Change. Cambridge: primary reasons to control greenhouse Heat stress Cambridge University Press, 1996. gases.13 However, if the actual number of Daily mortality has been linked with heat health cases is small and abatement quite 2. McMichael A, Githeko A, Akhtar R et waves in temperate climates.7,8 Heat costly, abating greenhouse gases may be a al. Human health. In: McCarthy J, waves are short periods of unusually high Canziani O, Leary N, et al (eds). Climate very poor strategy for protecting human temperatures. The literature has noted Change 2001: Impacts, Adaptation and health. Abating more traditional pollu- that daily mortality rates climb during Vulnerability. Third Assessment Report of tants such as small particulates, sulphur these events, for example, in 1995 a heat the Intergovernmental Panel on Climate dioxide, ammonia and nitrogen oxides wave in Chicago killed 514 people9 while Change. Cambridge: Cambridge

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University Press, 2001:451-485. Available on-line at http://www.grida.no/climate/ipcc_tar/wg2 Sexually transmitted infections /347.htm 3. Fankhauser S. Valuing Climate Change: in Europe The Economics of the Greenhouse. London: Earthscan, 1995. 4. Martens WJM, Kovats RS, Nijhof S, et al. Climate change and future populations Michael W Adler at risk of malaria. Global Environmental Change 1999;9:S80–S107. 5. Gubler DJ. Yellow Fever. In: Feigan R, Summary: Sexually Transmitted Infections (STIs) present a major public Cherry J (eds). Textbook of Pediatric Infec- health problem with far reaching health, social and economic consequences. tious Diseases Philadephia, PA: WB This review is limited to three important STIs seen in the European Union Saunders, 1998:1981–84. (EU) – chlamydial and gonococcal infections and syphilis. It looks at 6. Tol RSJ, Dowlatabadi H. Vector-borne epidemiological trends, reports consequences and costs, and sets out prin- diseases, climate change, and economic ciples for the effective control of STIs. The extent to which both services growth. Integrated Assessment and notification systems have been developed varies throughout the EU; 2001;2:173–81. however, the EU can identify and endorse common principles that it would 7. Kunst AE, Looman CWN, Mackenbach wish to see applied, as well developing a programme of collaborative work. JP. Outdoor air temperature and mortality in the Netherlands: a time-series analysis. Keywords: Sexually transmitted infections, Public health, Gonorrhoea, American Journal of Epidemiology Chlamydia, Syphilis, Europe 1993;137:331–41. 8. Ando M, Kobayashi IN, Kawahara I, et al. Impacts of heat stress on hypothermic disorders and heat stroke. Global Environ- Introduction Union (EU) – chlamydial and gonococcal mental Change 1998;2:111–20. Sexually Transmitted Infections (STIs) infections and syphilis. Other infections 9. Whitman S, Good G, Donoghue ER, et present a major public health problem and such as genital warts and herpes are not al. Mortality in Chicago attributed to the are common causes of illness and death in covered here, but the trends are similar to July 1995 heat wave. American Journal of the world with far reaching health, social the three diseases to be discussed. Also, Public Health 1997;87:1515–18. and economic consequences.1–2 Failure to not all countries are reviewed since clear trends can be seen from those selected, or 10. Rooney C, McMichael AJ, Kovas RS, diagnose and treat the more traditional Coleman M. Excess mortality in England infections, such as gonorrhoea, chlamydia adequate data is not available. and Wales and in Greater London during and syphilis, can often have a deleterious the 1995 heat wave. Journal of Epidemi- effect on pregnancy and the new born, e.g. Surveillance and services ology and Community Health miscarriage, prematurity, congenital and The availability of services and surveil- 1998;52:482–86. neonatal infections and blindness. Other lance/notification systems vary between complications and sequelae, particularly in European countries and will thus affect 11. Kalkstein LS, Greene JS. An evaluation 3 of climate/mortality relationships in large women, such as pelvic inflammatory our understanding of the epidemiology. US cities and the possible impacts of disease, ectopic pregnancy, infertility and There is no comprehensive information climate change. Environmental Health cervical cancer are large health and social and surveillance system or uniform service Perspectives 1997;105:84–93. problems. The majority of infections with provision within the EU. However, the the human immunodeficiency virus (HIV) United Kingdom has had a free and confi- 12. Zeisberger E, Schoenbaum E, Lomax P. are acquired through the sexual route. dential network of clinics since 1918. Thermal Balance in Health and Disease: These clinics are run by specialists, who Recent Basic Research and Clinical Also, it is important to realise that the Progress, Section III Adaptation. Berlin, presence of an STI, particularly genital provide regular statistical returns of cases Germany: Birkhaeuser Verlag, 1994:540. ulcer disease, but also genital discharges, seen and diagnoses to the Health can enhance both the acquisition and Protection Agency. These data do not 13. Smith JB, Schellnhuber HJ, Monirul transmission of HIV. cover cases diagnosed outside clinics, for QM et al. Vulnerability to climate change example, within primary care. Despite this, and reasons for concern: a synthesis. In: the UK surveillance system is considered McCarthy J, Canziani O, Leary N, et al The facts and size of the problem (eds). Climate Change 2001: Impacts, This short review will be limited to three to be one of the best in Europe. In Adaptation, and Vulnerability. Third important STIs seen in the European contrast, many other European countries Assessment Report of the Intergovern- do not have specialists in STIs or dedicated mental Panel on Climate Change. clinics. For example, patients may be seen Cambridge: Cambridge University Press, Michael W Adler is Professor Emeritus of privately, by dermato-venerologists or in 2001: 913–67. Available on-line at Genitourinary Medicine, Centre for primary care. Notification is often http://www.grida.no/ Sexual Health & HIV Research, Royal voluntary and incomplete. climate/ipcc_tar/wg2/657.htm Free & University College Medical School, University College London, UK. These differences in service provision and Email: [email protected] capture of the data make it difficult and

Eurohealth Vol 12 No 3 3 PUBLIC HEALTH PERSPECTIVES

Table 1: Number of cases of gonorrhoea – selected European countries unwise to compare numbers and rates of STIs between countries within the EU. At % increase Country/Year 1995 2000 2001 2002 2003 2004 best the data gives some indication of last decade trends within countries.4 Belgium 130 145 241 289 304 321 (146%) Gonorrhoea In the early to mid 1970s most European Denmark 287 335 304 230 186 414 (44%) countries saw a peak in cases of gonor- rhoea. It is thought that the advent of HIV Ireland 91 290 349 214 186 – (104%) infection in 1980 led to safer sex and accel- erated the reduction in gonorrhoea. Sweden 246 590 529 505 596 569 (131%) However, this has not been sustained in all countries. United Kingdom 10,598 20,520 – 24,958 24,157 24,157 (128%) Since the mid 1990s, most countries have seen an increase in gonorrhoea rates and Azerbaijan 2,039 952 – – – 2,580 – numbers of cases (Table 1). For example, Belgium, Denmark, Ireland, Sweden and Belarus 16,963 9,887 – – 5,757 – – the UK have shown substantial increases over the last decade of 146%, 44%, 104%, 131% and 128% respectively. The data Estonia 2882 867 – – 532 – – from Eastern Europe are often incomplete and difficult to interpret in relation to trends. Rates of gonorrhoea vary with age, Table 2: Number of cases of chlamydia – selected European countries sexual orientation and social deprivation. In the UK the highest rate of gonorrhoea Country/Year 2000 2001 2002 2003 2004 in men are seen in those aged 20–24 years and in women 16–19 years of age. Belgium 689 790 1,064 1,468 1,653 Chlamydial infection

Finland 11,731 12,142 13,681 – – In most countries, genital chlamydial infection is the commonest diagnosed STI with very marked increases (Table 2). This United Kingdom 63,037 – 82,206 89,431 – increase reflects changing sexual behaviour and increased partner change. However, of Azerbaijan 1,344 – 262 – 95 importance is that fact that some countries are implementing national screening Belarus 7,991 12,187 13,248 17,548 – programmes and using non-invasive, more acceptable urinary based assays, which will give rise to an increased prevalence but not Estonia 3,805 4,187 4,107 2,094 – necessarily incidence, even though most experts feel that both are occurring. As with gonococcal infections, the young are Figure 1: Rates of genital chlamydial infections by sex and age group disproportionately affected (Figure 1). In other countries, particularly Denmark and Norway good laboratory notification systems are in place, which also show considerable increases over the last decade. Syphilis Syphilis was a major problem during the first half of the 20th century, but declined dramatically with the wide-scale use and availability of penicillin in the late 1940s and 1950s. In many EU countries it virtually disappeared in the late 1980s and mid 1990s, but now most countries are showing an increase, particularly in men who have sex with men (Table 3, Figure 2).

Consequences and cost Data sources: KC60 and STISS/ISD(D)5 returns from Genito-Urinary Medicine (GUM) Complications are costly to both the clinics, United Kingdom. country and the individual. For example,

4 Eurohealth Vol 12 No 3 PUBLIC HEALTH PERSPECTIVES between 10–40% of patients with Table 3: Number of cases of chlamydia – selected European countries chlamydial trachomatis infections develop pelvic inflammatory disease (PID) and Country/Year 2000 2001 2002 2003 2004 some go on to experience ectopic preg- nancy and infertility.5–6 Swedish data suggests that women who had a history of Belgium 25 271 204 300 302 PID were six times more likely to have an ectopic pregnancy and fourteen times Denmark 54 51 35 79 114 more likely to have tubal factor infertility 7 than women without evidence of PID. Finland 204 159 128 138 – The number of cases of PID are probably increasing in the EU, but the actual data Ireland 46 279 303 235 – are not easily available. This occurs because the clinical diagnosis is often inac- curate and usually only hospitalised cases Sweden 99 78 128 178 194 are notified.8 Infertility can often be associated with United Kingdom 1,784 – – – 2,254 chlamydial and gonococcal infections. Fertility rates in the 25 countries of the EU Azerbaijan 512 – – – 282 have been steadily declining since the 1960s – from 2.59 (1960) to 1.88 (1980) to Belarus 10,527 – – 4,810 – 1.46 (2002) (Table 4). This may be partly due to the increase in the two infections mentioned but no good data exists within Figure 2: Diagnosis of syphilis (primary and secondary) by exposure category countries showing this direct correlation. It should be recognised that other causes of infertility also exist. The financial costs of PID are consid- erable. For example, the costs of sub- fertility services in the UK could be £75 million per year but the economic impact has never been actually been studied.9 In the United States, direct and indirect costs associated with PID and its sequelae were estimated at over $4.2 billion in 1990 and were anticipated to exceed $10 billion by 2000.10

Why are STIs increasing? Further policy and strategic decisions should be based on an understanding of why STIs are increasing in the way described. Like many socio-medical condi- Data sources: KC60 and STISS/ISD(D)5 returns from GUM clinics, United Kingdom. tions, for example, suicide, alcoholism, cancer and heart disease the explanation Table 4: Fertility rates in Europe for the increases are multi-factorial some of which are: 1960 1970 1980 1990 2000 2002 Attitudes towards sex and sexual behaviour – declining age of first intercourse; increasing number of lifetime partners; EU-25 2.59 2.34 1.88 1.64 1.48 1.46 increasing number of individuals having concurrent partnerships; increasing EU-15 2.59 2.38 1.82 1.57 1.50 1.50 proportion of men who have ever had a homosexual partner; and increasing unsafe sex. STIs and HIV; certain groups (professional tution; and stigma within a society can Social/economic – populations are now travellers, armed forces and immigrants) isolate individuals so that they do not seek more mobile nationally and interna- are at risk – they are separated from their out appropriate health promotion, infor- tionally; tourism has increased with families and social restraints; poverty, mation and services. visitors to areas of the world with particu- urbanisation, war and social migration Structural – a failure to provide adequate larly active prostitution and high levels of often result in increased levels of prosti- services and partner notification will result

Eurohealth Vol 12 No 3 5 PUBLIC HEALTH PERSPECTIVES in an increase in STIs; paradoxically the and trend assessments to provide data for introduction of good services will appear programme planning and monitoring. REFERENCES to lead to an apparent increase in STIs as Various surveillance methods can be used, 1. Adler MW, Meheus A. Sexually trans- more people are diagnosed. such as clinical notification, laboratory mitted diseases and sexual health – notification, sentinel sites surveillance epidemiology. In: Warrell DA, Cox TM, Strategic and policy implications for the (either of syndromes or of aetiological Firth JD, Benz Jnr, EJ (eds). Oxford control of STIs diagnosis), prevalence studies in specific Textbook of Medicine. Oxford: Oxford A set of principles can be established for population groups and aetiological surveys University Press, 2003. 4th edition: 479–83. effective control of STIs: in patients. 2. Adler MW, Cowan F. Sexually trans- Reduce infectiousness of STIs – i.e. using mitted infections. In: Detels R, McEwen J, What is the role for the European Union? condoms Beaglehole J, Tanaka H (eds). Oxford Each country will develop its own Textbook of Public Health – The Practice Reduce duration of infection – Encourage approach to control of STIs. The extent to of Public Health. Oxford: Oxford diagnosis and treatment of symptomatic which both services and notification University Press, 2002. 4th infection, such as encouraging health systems have been developed varies edition:1441–52. seeking behaviour and asymptomatic throughout the EU; however, the EU can infection screening, partner notification identify and endorse common principles 3. Lowndes CM, Fenton KA. Surveillance and targeted treatment. that it would wish to see applied as well as systems for STIs in the European Union : having a programme of collaborative Facing a changing epidemiology. Sexually Reduce risky behaviour – reduce the rate work. Thus, it is essential that the Transmitted Infections 2004;80:264–71. of partner change; delay onset of sexual following are in place: intercourse; improve selection of partners. 4. Fenton KA, Lowndes CM. Recent – Effective sex and health education / trends in the epidemiology of sexually These principles are usually classified as promotion starting in schools with transmitted infections in the European primary and secondary prevention. uniform syllabus Union. Sexually Transmitted Infections Primary prevention aims to keep indi- 2004;80:255–63. viduals uninfected. These include: behav- – Condom availability ioural interventions that are aimed at 5. Simms I, Stephenson JM. Pelvic inflam- – Services for the diagnosis and treatment enhancing knowledge, skills, and attitudes matory disease epidemiology; What do we of STIs and partner notification run by to help people protect themselves against know and what do we need to know? those with specialist knowledge infection, for example, health promotion Sexually Transmitted Infections to decrease partner change and increase – Screening programmes: consideration 2000;76:80–87. condom use; structural interventions that to be given to national or opportunistic 6. Stamm W, Guinan M, Johnson C. Effect are aimed at broader societal and economic screening programmes, for example, of treatment regiments for Neisserie issues that drive the spread of STIs; and chlamydia gonorrhoeae on simultaneous infections biomedical interventions including – Training of those providing services with Chlamydia trachomatis. New condoms, vaccines, vaginal microbicides, England Journal of Medicine or male circumcision to prevent the acqui- – Surveillance/notification in place to 1984;310:545–59. sition of infection. Secondary prevention monitor/control programmes and aims to reduce the risk of individuals trends 7. Westrom L. Sexually transmitted infected with an STI transmitting onwards. diseases and infertility. Sexually Trans- – Effective research programmes: labo- Secondary prevention works to enhance mitted Diseases 1994;21:S32–37. ratory, behavioural, clinical and health seeking behaviour; improve access epidemiological 8. Adler MW. Trends for epidemiology and to diagnosis and treatment; ensure appro- pelvic inflammatory disease in England and priate case management early detection Therefore, the EU has a role in many Wales and for gonorrhoea in a defined and treatment of symptomatic and asymp- aspects of addressing the increasing chal- population. American Journal of Obstetrics tomatic infection; and encourage partner lenge of STIs, such as making best practice and Gynecology 1980;138:901–4. notification (contact tracing). in all of above available to all countries; encouraging training for health care 9. School of Public Health, University of Supporting primary and secondary workers through the use of experts in the Leeds. Effective Healthcare; The prevention field of STIs in the countries; developing Management of Sub-fertility. Leeds: The implementation of effective control basic, applied and behavioural research University of Leeds, 1992. within countries and encouraging the programmes requires underpinning with 10. Washington A, Katz P. Cost of and exchange of workers throughout the EU support components. These include: (i) payment source for pelvic inflammatory to share expertise and knowledge; as well training for health care workers and disease. Journal of the American Medical as encouraging and facilitating a uniform educators; (ii) laboratory services in place Association 1991;226:2565–69. to support clinical services. At least one dataset and basic surveillance system for reference laboratory should be developed STIs throughout the EU. in every country to allow for quality control and analysis of referred specimens; and (iii) information systems or surveil- lance should be implemented together, This article was prepared based on a policy brief prepared for the European Commission, such as epidemiological data for magnitude DG Employment and Social Affairs, under the project Health Status and Living Conditions (VC/2004/465).

6 Eurohealth Vol 12 No 3 PUBLIC HEALTH PERSPECTIVES Obesity-control policies in Europe

Philipa Mladovsky and Caroline Rudisill

Summary: Worsening diets and rising levels of physical inactivity have contributed to Europe’s obesity prevalence reaching epidemic proportions. This has resulted in a range of policy actions at the international, EU and national levels. Yet coordination across EU countries remains underdeveloped. Improved evidence on effectiveness and cost effectiveness of obesity prevention programmes, harmonisation of data and a stronger focus on obesity in children all merit greater attention.

Keywords: Obesity policy, Europe, Evidence

Obesity prevalence in the World Health Without further action, an estimated 150 Changes in diets are but one factor, Organization European Region has now million adults (20% of the population) and another is the reduction in physical activity reached epidemic proportions having 15 million children and adolescents (10% seen in most of Europe. Increased tripled over the last two decades.1 Between of the population) in the WHO European automation in the workplace and at home 10–27% of men and 10-38% of women in Region will be obese by 2010.1 has reduced the need for physical labour. the European Union are obese, compared Moreover, individuals may walk or cycle to the United States where obesity has to work and school much less than in the reached 28% of men and 34% of women. past, while there may be financial incen- In fact, Cyprus, the Czech Republic, “need for immediate policy tives to sell ‘brownfield’ school sports Finland, Germany, Greece and Malta have fields for urban development projects. a higher proportion of overweight indi- interventions and strategies While the importance of diet and physical viduals in their populations than the to curb the rise in obesity” activity cannot be stressed enough, it United States.2 Diabetes, cardiovascular should also be acknowledged that genetic diseases and certain forms of cancer are predisposition and ethnicity as well as some of the conditions associated with socioeconomic factors such as income and overweight and obese individuals. education level will have a substantial Public health experts lay the blame for this impact on the risk of obesity for any one Europe’s growing prevalence rates of over- phenomenon partly on a ‘snacking’ culture individual. weight children is of particular concern. and the more general consumption of England and Poland display the sharpest foods and drinks with high calorific Economic impact rates of increase over the last twenty content. They point to the replacement of In addition to profound adverse long-term years.2 Childhood obesity creates the traditional ‘family meal’ with a fast health consequences, there is also a particular health concerns not only food culture where individuals consume substantial economic burden. Specifically, because 50–75% of overweight or obese foods of less nutritional value that are also this includes health and social care system children will remain obese in adulthood,3 high in fat, salt and calorific content. costs due to increased use of primary and but also because they show early signs of Children can be nutritionally disadvan- secondary health care services as well as ‘diseases of old age’, such as type 2 taged at an early age. The regulation of long-term care. These are however far diabetes.2 school meals may be weak; caterers usually outweighed by the costs of long-term have few incentives to provide healthy These alarming trends highlight the need absence and premature retirement from options. Meanwhile, many schools raise for immediate policy interventions and the labour market due to increased additional revenue through site based strategies to curb the rise in obesity and morbidity and mortality. The LipGene vending machines selling sweets and prevent associated chronic diseases. project (http://www.lipgene.tcd.ie) sugary drinks to pupils. reviewed recent obesity trends in the EU- Philipa Mladovsky and Caroline Rudisill are Research Assistants at LSE Health, London School of Economics and Political This article is based on a section of the 2006 report ‘Health Status and Living Conditions Science, UK. in an Enlarged Europe’ prepared for the European Commission, DG Employment and Email: [email protected] Social Affairs, under the European Observatory on the Social Situation.

Eurohealth Vol 12 No 3 7 PUBLIC HEALTH PERSPECTIVES

15, finding that in 2002 at least half had obesity inducing lifestyles across socio- The Nordic countries (Denmark, Finland, obesity levels greater than 20% among economic groups. Iceland, Norway and Sweden) have also men and women, with total annual costs of put into action a joint policy on obesity.8 Responses to the consultation included €32.8 billion.4 Interventions to combat Several countries, including the Nordic those of governments, public health insti- obesity cost a fraction of this. For example, states, have set quantitative targets for tutions, industry, academia and the general an EU-wide subsidy to reduce the market obesity control programmes, while others public and were published in September price of meat and diary products that have use aspirational targets. Many recognise 2006. Many responses called for an a better fatty acid profile would cost that monitoring systems, as well as buy-in increasingly multi-sectoral approach, with approximately one third of the total costs at the regional and local level, are needed greater coordination amongst EU coun- of obesity.4 This analysis is of course to meet such targets. tries in setting guidelines and making use somewhat simplistic and it is crucial to of evidence-based findings. They also Most national policies are multi-sectoral, determine whether such interventions highlighted the need to focus on child and reflecting the diverse causes of obesity. actually work before any major youth obesity as well as clearer, evidence- They involve the health and education investment. based nutrition information for the public. sectors in addition to the food industry. The EC approach and the responses from For example, the 2005 Belgian National European and international obesity stakeholders reinforced many WHO Food and Health Plan, launched by the policy recommendations, but the continued Federal Minister of Social Affairs and The scale of the obesity epidemic has investment in the EU Common Agricul- Public Health, was developed in part- resulted in a range of actions at the inter- tural Policy, which generously subsidises nership with many stakeholders including national, European and national levels. the production and consumption of animal the food industry, consumer groups, WHO has adopted a broad-ranging fat, tobacco and wine in contrast to healthy patient organisations, health professionals approach to obesity through its Global fruit and vegetables, clearly does not and scientists. The Plan includes a media Strategy on Diet, Physical Activity and concur with WHO recommendations. campaign, national food guide, school Health.5 This fosters the formulation and meal regulations, professional education promotion of national policies, strategies for the food and hospitality industries, and actions to improve diet and encourage implementation of a national policy physical activity. WHO also issues recom- “Many national policies promoting breast feeding, increased use of mendations on many related issues ionised salt, the appointment of food including consumer information, identify the private sector committees in hospitals and further scien- marketing to children, agricultural policies, tific research on nutrition and dietary food production, taxation, subsidies and as the key partner in behaviour. direct pricing, transport, physical education and nutrition in schools, and influencing dietary Many national policies identify the private incentives to encourage preventive health behaviour” sector as the key partner in influencing services. To implement these recommen- dietary behaviour. For example, as part of dations, WHO further recommends the the Spanish 2005 National Strategy for establishment of national coordinating Nutrition, Physical Activity and mechanisms as well as multi-sectoral and Prevention of Obesity, the private sector multi-disciplinary expert advisory boards Europe-wide actions include the WHO signed six partnership agreements with with close local involvement. It also advo- European Ministerial Conference on government. This brought together cates continuous monitoring of major risk Counteracting Obesity, that took place in governmental partners from the Ministries factors and further research, especially Istanbul, in November 2006. At the of Health and Consumer Affairs, Agri- through community-based demonstration conference representatives of EU Member culture, Fisheries and Food, and Industry, projects and policy evaluation. States, together with the WHO Regional as well as the governments of the seventeen Office for Europe, adopted a European Autonomous Communities, with repre- European level actions 7 Charter on Counteracting Obesity. It sentatives of the food, hotel and catering The importance of coordinated action at aims to give policy guidance and provide a industries. an EU-level was recognised in the publi- strategic framework for strengthening cation by the European Commission (EC) action on obesity throughout Europe. The What do we know about the of a consultative Green Paper on obesity draft Charter will be discussed and effectiveness of obesity policies? in 2005.6 The paper noted the potential for submitted for adoption by Member States Obesity treatment studies have yielded industry self-regulation of the marketing at the conference. some evidence to inform policy aimed at of foods high in fat and sugar as well as the National level actions curbing the epidemic. Evidence on the use importance of clear communication of the of surgical, pharmacological and lifestyle- links between diet and risk of disease. The At the national level, there has been based interventions (including counselling consultation invited the opinions of all renewed attention for obesity. Belgium, and behavioural therapy) to treat adult stakeholders on such issues as how best to Bulgaria, the Czech Republic, Denmark, excess weight and obesity suggest only incorporate healthy diets and physical Germany, Ireland, Latvia, Spain, Turkey moderate weight loss.9 Mechanisms of activity into the workplace; ways to better and the United Kingdom have all estab- greater importance in the uptake of inter- integrate public health campaigns against lished specific policies, programmes or ventions, such as building doctor-patient obesity with health care service actions; published recommendations aimed at trust, prove more difficult to measure.10 and methods to reduce differences in reducing obesity in the last three years. The effectiveness of fiscal instruments such

8 Eurohealth Vol 12 No 3 PUBLIC HEALTH PERSPECTIVES as pricing policies, taxes and subsidies EU-wide policy holds a particularly costs of obesity in the EU. The Proceedings require careful evaluation. The limited important place because of the trans- of the Nutrition Society 2005;64(3):359–62. available evidence provides only tenuous national nature of some key factors, 5. World Health Organization. Global support for a cause-and-effect relationship including the food industry. Careful devel- Strategy on Diet, Physical Activity and between such interventions and changes in opment of EU-wide policies in areas of Health. Geneva: WHO, 2004. Available at the consumption of unhealthy foods. Some competence are well merited. http://www.who.int/gb/ebwha/pdf_files/ of the limitations relate to an inability to WHA57/A57_R17-en.pdf demonstrate causality, while others 6. Commission of the European Commu- concern the difficulty of generalising nities. Green Paper: Promoting Healthy findings from one or more studies to “as many as three quarters Diets and Physical Activity: A European different national or regional settings in of all overweight or obese Dimension for the Prevention of Over- Europe.11 weight, Obesity and Chronic Diseases. Luxembourg: Commission of the Research on the treatment and prevention children will become over- European Communities, 2005. Available at of obesity in children is particularly weight or obese adults” http://ec.europa.eu/health/ph_ limited and what is conducted is often determinants/life_style/nutrition/ 8 poor in quality. Some of the difficulties documents/nutrition_gp_en.pdf identified in monitoring the impact of childhood obesity programmes in Europe 7. World Health Organization Regional Office for Europe. European Charter on can apply equally to adult focused inter- 4. Greater focus on obesity in children Counteracting Obesity. Istanbul: World ventions including small sample sizes, We noted that as many as three quarters of Health Organization Regional Office for limited longitudinal data, a continued all overweight or obese children will Europe, 16 November 2006. Available at reliance on US-tested approaches and vari- become overweight or obese adults, thus http://www.euro.who.int/Document/ ation in data collection methods used the problem of childhood obesity requires E89567.pdf across countries.12 particularly urgent attention. Actions 8. The Nordic Council of Ministers for targeted specifically at children need to be Fisheries and Aquaculture, Agriculture, Policy recommendations to decrease implemented and evaluated. One step Foodstuffs and Forestry (MR-FJLS) and obesity prevalence would be to set guidelines on appropriate the Nordic Council of Ministers for Social To sum up, the evidence to inform clinical nutrition and physical activity targets. Security and Health Care (MR-S). Health, and public health interventions to control Countries could also curtail advertising Food and Physical Activity: Nordic Plan of 9 obesity is still emerging. Notwithstanding targeting children and support more active Action on Better Health and Quality of the recent attention to the issue at the EU- methods of transportation through the Life Through Diet and Physical Activity. level, the means for coordinating obesity development of dedicated cycle networks Copenhagen, 2006. policy amongst EU Member States also which are safe from the hazards of motor 9. Jain A. What Works for Obesity: A remains underdeveloped. Useful lessons vehicles. Public health campaigns could Summary of the Research Behind Obesity might also be drawn from other areas of focus on providing health-related infor- Interventions. London: BMJ Publishing public health where successful measures to mation direct to children, while the Group, 2004. Available at influence behaviour have been introduced, education sector might encourage the http://www.unitedhealthfoundation.org/ 13 most notably tobacco control. There are introduction of health promotion obesity.pdf many areas for action; four areas that education into the school curriculum. 10. Clancy CM. Commentary – The would benefit from urgent attention are Critical Challenge of Obesity. Rockville, highlighted. MD: Agency for Healthcare research and 1. Evidence on effectiveness and cost effec- REFERENCES Quality, 2004. Available at tiveness of obesity prevention 1. World Health Organization Regional http://www.unitedhealthfoundation.org/ Office for Europe. 10 Things You Need to obesity_clancy.doc Policies have focused on food marketing Know About Obesity. Istanbul: WHO, 11. Goodman C, Anise A. What is known regulations, an endeavour that the food, 2006. Available at http://www.euro.who. about the effectiveness of economic instru- drink, vending and advertising industries int/Document/NUT/ObesityConf_ ments to reduce consumption of foods have resisted. Additional research is 10things_Eng.pdf high in saturated fats and other energy- needed on how voluntary self-regulation dense foods for preventing and treating by these stakeholders might compare with 2. International Obesity Task Force (IOTF). EU Platform on Diet, Physical obesity? Health Evidence Network Report, mandatory measures in influencing eating Activity and Health: International Obesity 2006. Available at http://www.euro.who. behaviours. Moreover, the role of new Task Force EU Platform Briefing Paper. int/HEN/Syntheses/obesity/20060713_8 methods of communication, such as the Brussels: IOTF, 2005. Available at 12. Wilson P, O’Meara S, Summerbell C, internet and the mobile phone, require http://www.iotf.org/media/euobesity3.pdf Kelly, S. The prevention and treatment of greater understanding. 3. Flodmark CE, Lissau I, Moreno LA, et childhood obesity. Quality and Safety in 2. Harmonisation of data al. New insights into the field of children Health Care 2003;12:5–74. and adolescents’ obesity: the European 13. Yach D, McKee M, Lopez AD, Greater harmonisation in data methods perspective. International Journal of Novotny T. Improving diet and physical may improve trans-national evaluation of Obesity and Related Metabolic Disorders activity: 12 lessons from controlling policy and programmes. 2004;28(10):1189–96. tobacco smoking. British Medical Journal 3. EU-wide policy development 4. Fry J, Finley W. The prevalence and 2005;330(7496):898–900.

Eurohealth Vol 12 No 3 9 FOCUS ON FRANCE French health system reform: recent implementation and future challenges

Chantal Cases

Summary: This article provides a brief overview and an introduction to several contributions in this issue on recent reforms within the French health system. While the initial results appear promising, more questions than answers remain as to the long term impact of reform measures. One less obvious, but critical element for the success of the reforms, is the need for robust information systems.

Keywords: France, Health policy, Health reform

The French health system has some strong continuous need, to not only maintain, but Health Insurance Reform Acts, ques- characteristics: a satisfactory level of access also improve the quality of care and ensure tioning priority setting for health care, to care and service utilisation, an abundant access to innovative medicines, remain while Carine Franc and Dominique Polton availability of choice without any signif- major challenges for the health authorities. comment on the evolution of French icant waiting lists and a high level of life health insurance governance. Gérard de expectancy. Indeed, the World Health Major reform Pouvourville and Zeynep Or present Report 2000 ranked France as having the To tackle these challenges, several major developments in hospital reform and set best health care system in the world.1 Yet, reforms have been introduced from out the key issues that need to be resolved not many people in France took particular summer 2004. In August of that year, two if success is to be achieved. Regulation of pride in this ranking despite a general laws were adopted: the Public Health the pharmaceutical sector, a major driver of recognition of the distinctive role played Policy Act and the Health Insurance health care costs, is analysed by Nathalie by the mixed public and private system. Reform Act, followed in 2005 by new Grandfils and Catherine Sermet, while agreements between the national health Yvon Berland and Yann Bourgueil sum up The health system faces numerous chal- insurance funds and medical trade unions recent health care human resource policies. lenges, many of which are common to on rules governing private practice. A year Given the current demographic pressures neighbouring countries. First, health before, ‘hôpital 2007’ aiming to reform the on health care professionals, they question expenditures continue to increase, leading hospital sector had been launched and the the extent of opportunities related to the to sizeable budget deficits for the social Social Security Act also was revised to future supply of the health workforce. security fund. Second, there will likely be implement new rules on funding hospital a significant decrease in the number of patient care. In January 2006, a new Governance and structure doctors per head of the population in the strategic plan was also introduced to foster According to the Minister of Health, the near future. Coupled with the persistent health workforce development, reinforcing main objectives of the recent reforms have unequal distribution in existing medical measures announced in previous years. been to improve health system organi- professionals across the country, this could sation and management. They aim to create tensions in respect of the supply of This issue of Eurohealth contains a change the behaviour of key actors and care, as equal access to care remains a core number of articles reflecting on some key place a special emphasis on the monitoring system objective. The ageing of the popu- dimensions* of those recent reforms which of health care expenditure by health care lation also contributes to uncertainties have significantly altered the governance professionals. The reforms focus both on over future health care workforce needs. and regulation of the health system. In an the renewal of the organisation and Third, given the excessively high rates of interview, Xavier Bertrand, our Minister of management of the health system on one mortality in those under 65, there is an Health, discusses some of the major hand, and financial measures and incen- urgent need to develop preventive actions strengths and weakness of the French tives on the other. Moreover, the reforms within a coherent public health health system, the rationale for the latest will have strong implications for health framework. Last, but not least, the reforms, their initial results and future information systems. prospects. Isabelle Durand-Zaleski looks at both the Public Health Policy and the First of all, the two major laws of the Chantal Cases is Director, Institut de Recherche et Documentation en Economie de la Santé (IRDES), Paris, * See also Com-Ruelle L, Dourgnon P. Can physician gate-keeping and patient choice be France. Email: [email protected] reconciled in France? Analysis of recent reform. Eurohealth 2006;12(1).

10 Eurohealth Vol 12 No 3 FOCUS ON FRANCE reform change significantly the governance turnover. Last but not least, there are so far as funding methods for free practice and organisation of the health care system. special fee-for-service patterns and were not threatened. Opinions are now The Public Health Policy and Health financial support to encourage doctors to changing. There is increasing scepticism Insurance Reform Act insist on the role of relocate and practice medicine in more among professionals about the adminis- the state and parliament in priority setting deprived areas of the country. trative burden faced, the relative in the health sector. They give more power complexity of coordinated care pathways, to local and/or dedicated structures for Need for robust information systems and a measurable decrease in activity and implementation. The Health Insurance Another cross-cutting, albeit less obvious, income for some specialists. The recent Reform Act also renewed the governance feature of these reforms is the general need vote by professionals for regional liberal of national health insurance by reinforcing for robust information systems at every medical unions’ illustrates that the popu- still further the position of the government level. The creation of a comprehensive larity of those unions who participated in in national insurance fund management, electronic patient record, coupled with the the implementation of the reform have something that has been increasing since preferred doctor system in primary care, is waned. In public hospitals planned the mid 1990s. Beyond these measures, a presented as a core component of the reforms impacting on the status of salaried new branch (the fifth) of the social security Health Insurance Reform Act, while quan- doctors now face strong opposition, while system was created in 2005 to provide titative targets and indicators are the both the public and the private sectors support to people living with disabilities. backbone of the Public Health Policy Act. have expressed concern (for different A comprehensive set of data on private and reasons) as to the implementation of the Elsewhere the ‘new hospital governance’ public hospital costs are essential for convergence of activity-based tariffs. permits more flexibility and relative designing fair activity-based tariffs, as well internal organisational freedom to public as for a series of quality of care and Questions to address hospitals, despite relatively strict controls performance indicators to evaluate the Given that past reforms only have had a on hospital management. The organisation effect of the new system on hospital temporary impact, the first question that and planning of health care facilities has results. Intensive use of health insurance comes to mind is on their expected long also been simplified. Hospital regulatory reimbursement data are vital for the moni- term impact on health care expenditure. It power was shifted, to some extent, from toring of anticipated changes in health care is clearly too early yet to provide an the central to regional level. The consumption; moreover, another planned answer. This will largely depend on the controlling role of regional hospital measure is the implementation of joint data likelihood of structural change in the agencies in charge of defining targets files on compulsory and complementary prescribing and consumption behaviours of through contracts with individual hospitals health insurance. health care professionals and consumers. So has been reinforced. At a higher level, a far, patients seem to complied with the strategic plan for health workforce devel- Though the implementation of all these access restrictions introduced under the opment promotes group practice and also reforms has not as yet been achieved, the preferred doctor reform, with 80% of the experiments with the transfer of tasks High Council on the Future of Health insured signing up to contracts. The most away from doctors to paramedical staff. Insurance (Haut Conseil pour l’Avenir de difficult challenge is for doctors to change l’Assurance Maladie), set up in 2003 by the their practising habits in favour of less Financial incentives Prime Minister, provides some initial idea expensive and better quality care; the fee- Financial instruments are increasingly used of their impact in its 2006 evaluation for-service payment is still preserved and as incentives to promote behavioural report.2 It states that the health insurance no noteworthy financial incentives have change by health system actors. Beyond budget deficit reduced in 2005, to (a still been introduced. Whether activity-based the traditional, but substantial level of substantial) €9.1 billion compared with hospital financing can improve hospital assistance to boost investment in hospitals, €11.2 billion in 2004. A deficit of €7.3 efficiency without damaging quality or the implementation of activity-based billion was forecast for 2006. The equal access to care, including innovative payments in both the private and public improvement is in part due to an increase therapies, will be major concerns of future sectors will significantly change the land- in income and a decrease in reimbursed evaluation, as will be the consequences of scape and supply of hospital services. The outlays. In fact, much of this reduction is the reforms for health inequalities. implementation of a French-type non- due to a reduction in overall health care mandatory gatekeeping system is also built spending, rather than a drop statutory So at present, while the initial results are on a system of financial incentives mainly health insurance reimbursement. Never- promising, more questions than answers directed towards patients.* This is theless, the High Council noted that in remain on the long term impact of the intended to encourage them to move along 2005 that there was a modest increase in the reforms. recommended coordinated care pathways. share of health expenditures directly paid Pharmaceutical regulations also include out of pocket by private households (from financial incentives for pharmacists to 8.47% of expenditure on medical services REFERENCES substitute generic products for original and goods in 2004 to 8.74% in 2005), 1. World Health Report 2000. Geneva: medications when these are prescribed by reversing the trend of previous years. World Health Organization, 2000. doctors, as well as charging levies on the 2. Rapport du Haut Conseil pour l’Avenir pharmaceutical industry related to adver- Growing opposition de l’Assurance Maladie. [Report of the tising, sales promotion expenditures and Some aspects of the reforms have received High Council on the Future of Health genuine support, or at least no strong Insurance]. Paris: Ministry of Health, July * A small annual capitation based income opposition from stakeholders. In 2006. Available at was also introduced for the ‘preferred particular a large contingent of health care http://www.sante.gouv.fr/htm/ doctors’ providing primary care. professionals were behind the reforms, in dossiers/hcaam/rapport_2006.pdf

Eurohealth Vol 12 No 3 11 FOCUS ON FRANCE Interview with Xavier Bertrand, French Minister of Health

This interview was conducted and edited jointly by Chantal Cases, Karine Chevreul, Nathalie Meunier, Julien Mousques and Zeynep Or at IRDES – Institut de Recherche et Documentation en Economie de la Santé.

In your opinion what are the strengths funding with activity based payment; and major objectives? How do they differ and weakness of the French health care finally, structural reforms placing more from previous reforms? system today? emphasis on clinical services in hospitals. The reforms stem from a strong and The strength of our health and welfare These will take time to implement. consensual report1 by all the main health care actors united in the High Council.*** system is the French people’s adherence to Another challenge, in my opinion, is more This report on the future of statutory the fundamental principle of contribution strategic: the prevention of ill health. In health insurance advocated reform and based on the ability to pay, and the receipt terms of curative care, the World Health modernisation to ensure improved organ- of care on the basis of need. This type of Organization considers the French health isation and management. In order to system ensures solidarity and freedom; for system to be one of the best in the world. organise our health system better, we need patients, freedom in choice of physician In terms of prevention however, I believe to have better integration between primary and for health care professionals, the that we can, and we must, make real and secondary care, and also ensure that freedom to set up practice and prescribe. progress. We can meet this goal not only this care is coordinated around individual Today, our health system is at a pivotal by providing increased coverage of patient records and the preferred doctor or point for which we must determine a preventive activities within our health ‘médicins traitant’. Many European coun- number of priorities. Three seem crucial to insurance,** but also by promoting health tries have already been on this track for me: the future health system workforce education and better awareness on health years, unlike France prior to 2004. (medical demography), the modernisation issues, as well as taking more responsibility of hospitals, and the prevention of ill for those risk factors that can affect health Introducing new governance arrangements health. such as excess drinking and smoking. In for statutory health insurance, alongside The future supply and geographical distri- my opinion, prevention is the key chal- better enforcement of these changes will bution of health care professionals is an lenge, and the key driver, improvements in also help improve management of the essential issue for us all. I hope that we quality, led by the training of health care health system. We have decided to take start from now on to show our professionals and accreditation of health great efforts to clamp down on abuse and commitment to a new path, one where care facilities. fraud within the system; this is not a trivial equal access for all becomes a requirement issue. I believe that in a welfare state char- and a reality. Modernising hospitals and Since 2004, several reforms have been acterised by solidarity, we must at all costs other health facilities is equally an implemented, in particular the Health ensure that this sentiment applies to all. important question that we have recently Insurance Reform Act. What are their Better management aims, before all else, to begun to tackle as part of the 2007 Hospital Plan.* The plan has several tiers: firstly, a new approach to hospital provision in regionally organised schemes, * See Article by Zeynep Or and Gérard de Pouvourville in this issue. based on a key concept – complementarity; ** For example, bone density measurement techniques have been included since 1 July secondly, an important reform of hospital 2006. *** Includes representatives from the State, Statutory Health Insurance, Complementary Insurance, Parliament, health care professionals, social partners, trade unions and indi- English translation by Nadia Jemiai and viduals. The Council, created in 2003, is responsible for evaluating the health care system David McDaid at LSE Health. and formulating recommendations.

12 Eurohealth Vol 12 No 3 FOCUS ON FRANCE reduce and eventually eliminate super- possible to reconcile the increase in fees reducing waiting times or containing fluous spending in the health system. This seen in the reforms with the aspirations hospital expenditure). In your view, is amounts to approximately €5 to €6 of specialists to preserve their revenues. there a productivity problem for French billion per annum, including redundant Already, we are observing a decrease in health care facilities? How does this consultations. Thus these measures should the revenues of dermatologists as well as manifest itself? not affect the quality of care, on the ear, nose and throat specialists? Above all else, I believe that we can and contrary they should improve it. First, we should look at the facts: in the that we must improve organisation among I am also interested in changing behaviour, twelve months since the reform, three and within both public and private facil- because it is this change which will guar- quarters of French people over sixteen, ities. I think the principal challenge for antee a healthier future for all. We are some thirty-seven million people, have hospitals today, other than modernisation, particularly concerned with monitoring voluntarily chosen their ‘médecin traitant’ is the way in which work is organised and the reforms from their planning to their (preferred doctor or gatekeeper). The the working conditions for health system implementation. As you are aware, the ‘médecin traitant’ in fact has the same logic personnel. Currently, the activity based excessive delay in publishing decrees has as the long standing concept of the family payment gives us complete transparency been a continuing French malaise. I am doctor, that is seen in the provinces. Thus between funding and activity levels. In my committed to responding swiftly to this the reforms are reinforcing already existing opinion, this can improve still further problem: 85% of decrees published by the good medical practice/habits for some hospital efficiency. The convergence of end of 2004 were linked to an Act patients. Others are now entering a system tariffs between the public and private published on 13 August that year. I believe that has better coordination of care. The systems is clearly drawn up by legislation, that today politics is all about delivery, ‘médicin traitant’ has a dual role: to ensure with an intermediate target set for 2008 particularly when it comes to health policy. the coordination of care to improve quality and a final goal to be realised in 2012. We and also to eliminate superfluous activity. are currently working on this. We need to How would you currently assess the In France, the numbers are constant: one define what responsibilities should be preliminary impact of the Health out of every six medical examinations is devolved to the different public and private Insurance Reform Act? undertaken twice, leading to greater facilities. It is important not to forget to Today, the reform is progressing and is expenditure without any additional account for their particularities and making a difference. We have been hearing benefit. I would prefer that this 15% share accordingly include these in remuneration, about reforms in France for more than of expenditure, some €1.5 billion, be used so as to ensure that we are not misled over twenty-five years. However, this is the first in a much better way to improve health convergence criteria. time in ten years that the Statutory Health through the funding of new activities. It is Insurance has stayed within its expenditure true, certain specialties today have seen We have noticed that the introduction of limit. This is a historical achievement. This their activity levels reduced. Reinforcing activity based payment has led to an moderating tendency in health expenditure communication and information on this increase in activity… can be seen during all of the past eighteen issue is essential for both health system I am not aware of any other country which months, particularly in urban areas. professionals and patients. has not been through this initially. This is Without the reforms introduced in 2005, why we have taken the decision to the deficit would have amounted to €16 Today, one of the issues that remains decrease hospital fees this year, knowing billion. Instead, it now amounts to €8 somewhat unclear is the place of that, compared to last year, the increase in billion. I have made a commitment to hospitals in the health care pathway. activity will still result in an additional €2 reduce the deficit still further to €6 billion Hospitals are part of the reform process. billion for health care providers. by the end of 2006. This will however leave The health care pathway, monitoring room for some flexibility, for example to health care patterns, for example in regard Precisely, does it not worry you that this continue to reimburse €1 billion worth of to the development of generic medicines decrease in fees will be difficult for the new drugs per year. This equally enables and the use of personal medical records, key stakeholders to understand? us to face the challenge of the health care affects both primary care services and The situation has always been clear, workforce through concrete measures,* to hospitals. Let us not forget that just one adjusting fees is not a new tool. Last year, move the system in a direction more and a half years ago, a very ambitious there was considerable overspending focused on prevention, starting this year reform was also implemented. Hospital which we have integrated into our new with more initiatives within the health policy today needs some stability, with expenditure targets, so as to ensure there system. Reducing the deficit through follow-up and adjustment if necessary. are no further excess expenditures. We are reform will allow us to move along the starting from a position with a predicted path towards improved quality and Let us come back to hospitals and the increase in activity of 2.6%. With only a modernisation. new activity based payment for public 1% decrease in fees, revenues for health and private establishments. This type of care organisations will thus continue to Coming back to the issue of coordinated reform has also been implemented in increase this year. However, it is important care, will introducing gatekeepers risk most other European countries to to note that if the primary care sector can hurting our country’s traditional principle increase efficiency. However, the objec- be successful in its efforts to meet objec- of free access to specialists? Also, is it tives vary among countries (for example, tives, then the hospital sector should be capable of doing the same, notwith- standing the risk of course, that a major public health crisis might necessitate an * See Article by Zeynep Or and Gérard de Pouvourville in this issue. increase in activity.

Eurohealth Vol 12 No 3 13 FOCUS ON FRANCE

If some health care institutions are found geographic equity of access to hospitals? €1,500 per month. I am proud that the to be managed inefficiently, how much Equity of access to care in France is a French system provides for this. We have, room for manoeuvre will they have to fundamental and non-negotiable principle. nonetheless, as a result of removing some restructure? If a health service provider faces diffi- drugs from the list of reimbursable items, We have made available greater financial culties, it is appropriate to examine how generated savings of some €300 to €385 assistance to support the contracting they envisage their own future. If million to the Statutory Health Insurance. process between the regional hospital necessary, significant help with the This does not however compensate for the agencies and local health care facilities. contracting process can be provided. We additional €1 billion in expenditure that is This will leave real room for manoeuvre are not solely relying on a fee-based due to new drugs that will be covered by for those health care facilities in difficulty system. Some health care services focus on Statutory Health Insurance. geriatrics, follow-up care and rehabili- who wish to undertake restructuring in Since 1999, we have all known that some tation and therefore will not necessarily order to return to balanced budgets. It is drugs have not necessarily provided the gain any greater benefits from activity the first time that such important resources added clinical benefits expected. Today, we based payment. However, we are not have been distributed at the local level. must make it clear that some conditions going to end these services! would benefit more from the use of alter- Do you think that regional hospital native therapies. Sometimes drugs are not Previously, we spoke about the trans- agencies will have enough flexibility to the most appropriate treatment. For determine the choice of specialist parency of fees, but is it not particularly example, nasal irrigations are at least as services provided by hospitals? This difficult to evaluate costs for services of effective as expectorants or other similar might possibly increase hospital effi- general interest? products to treat child colds. In another ciency, but may also imply a drift away This is the reason why this year I have example, support stockings provide a real from the underlying principles of the decide to greatly increase (12.1%) the alternative to more complex therapy for health system? funding for both services of general varicose veins. We must change our indi- A word of caution. Hospital activity will interest and contract support. I believe that vidual behaviours, while industry must always be dependent, first and foremost, this was not accounted for last year. Now direct innovation towards public health on health care needs rather than on effi- we must agree on the real financial needs priorities. To respond to the health chal- ciency concerns. I suspect that the only of these services. This should reassure and lenges we all face, research and devel- way to achieve lasting success is to monitor instill confidence in the future and in our opment should be one of the first priorities medical practice within a better organised commitment to modernise the hospital for industry. health care system. Indeed, in a system sector. underpinned by managed care, providing In comparison to our neighbouring coun- greater access to scanners for instance, will In all European countries the definition of tries, France still remains in a favourable not lead to an increase in the number of the publicly funded package of health position in terms of nutrition and obesity. scans conducted. But on the other hand, it care services is a major issue. We must Are there any lessons we can share on could reduce some costs. The fact is that if reconcile containment of health care this with other European countries? we comply with health and safety regula- expenditure, support for innovation, I would caution against giving lessons to tions, but do not have access to appro- protecting jobs in the local pharmaceu- anyone else. Each country has its own priate technological support, additional tical industry, against responding to the solutions which are dependent on history medical transportation costs will be principal public health issues, particu- and local practices. We have taken a incurred moving patients to facilities larly chronic diseases. What is your number of initiatives under the national where procedures can be performed. vision for achieving this? nutrition plan. For example, we no longer When health care needs are justified, we The real issue at stake is to be able to allow the sale of sugary products and must provide all necessary means. In this succeed in moderating, medically speaking, carbonated drinks in schools. We are way, we reduce waiting times and provide health expenditure so that its progress, working with an agro-food industry which more timely diagnoses, treatment and reas- which is both unavoidable and desirable, is understands that there must be change. We surance to patients. compatible with our growing national are also working to improve communi- economy. This should be achieved without cation in terms of food advertising and in For example, this would imply that you encroaching upon the share of national strengthening actions at a local level, as I would be able to adjust fees if drifting resources needed for older people, truly believe that these will be more was noticed in the choice of activities education, research, etc. The real challenge effective. We will also work to improve provided in some health care facilities? is to control expenditures by monitoring food quality and presentation. By working The rules of the game are clear, fees can be and improving medical practice; this is with health professionals and general prac- adjusted up and down. This also assumes what I wish for and am working towards. titioners we will better deal with obesity, that there will be monitoring, which the We must find the answers to taking greater especially among disadvantaged groups. Statutory Health Insurance [Agency] responsibility for our health, to determine These actions must be taken on behalf of would carry out. for example which drugs should be priori- people of all ages, not just children. There tised in terms of cover by Statutory Health is much exchange of information on these To try to summarise, general services Insurance, without forgetting that issues at the European level. and contract support provided to currently in France we reimburse some Regional Hospital Agencies would be very costly drugs. For example, we reim- Do you feel that Europe can have some one of the means used to ensure burse breast cancer drugs which cost influence over decisions on interventions

14 Eurohealth Vol 12 No 3 FOCUS ON FRANCE to prevent ill health? It is important to be aware that health care Pharmaceutical policy in does not fall within the competence of the European Union. Unlike animal health, human health truly is the responsibility of France: a mosaic of reforms each Member State. Europe cannot impose policy in this area.

We were thinking of the discussions that have recently taken place on the future Nathalie Grandfils and Catherine Sermet prohibition of smoking in public places. Let us also talk about the harmonisation of policies on the price of tobacco. There is a Summary: Pharmaceutical policy was one of the key components of the 2004 lot to do on this subject. Health Insurance Reform in France. Regulatory measures being implemented To conclude, what in your view are the focus on measures to reduce levels of expenditure, including greater use of principal challenges for European health generics and the introduction of reference pricing, as well as measures to promote systems to confront in the coming years? access to innovative therapies and the provision of better information to both First, we must take into account the real medical professionals and patients on the most appropriate use of medications. By challenge of dependency and ageing. This 2007, more than €2 billion in savings are expected as a result of these reforms. will have many consequences, not only for health policy. Decisions on social welfare Keywords: France, Pharmaceuticals, Health policy, Health reform policy will be a major factor which will have impacts elsewhere: the future supply of medical professionals, coverage of new forms of treatments and the introduction France has the highest level of per capita better access to innovative therapies. of an information technology system to expenditure on pharmaceuticals in Europe. benefit both the patient and the health care − Providing better information to both Expenditure has been rising at an professional. A second challenge is to doctors and patients, so as to ensure increasing rate: it has more than doubled empower patients to have a greater say on both a better understanding of what since 1990, while pharmaceutical health matters. This is a legitimate aspi- drugs are available on the market, and consumption as a share of total health care ration. improve patients’ understanding of consumption has also increased from 18% medicines. We must also plan for new health chal- in 1990 to 21% by 2004;1 this is evidence lenges. At the beginning of this new of more rapid growth in the pharmaceu- Measures to reduce expenditure century there are no certainties about tical sector. Pharmaceutical policy was one future health risks. We have already seen of the key components of the 2004 Health Use of generics this with avian influenza, as well as with a Insurance Reform; this was reinforced by Encouraging the greater use of generics number of emerging or re-emerging the government’s decision to establish a constitutes one of the key levers of phar- illnesses which particularly affect us ‘drug plan’ running from 2005 to 2007. maceutical policy. Since the right to because of our overseas links. I believe that Regulatory measures being implemented substitute generic for branded drugs was today, with global warming and climatic are targeted at both supply and demand enacted in 1999, pharmacists have become imbalances, (for instance because of defor- side factors and take three forms: key players in the spread of their use in estation), coupled with the increase in France. This right is also accompanied by global travel, viruses no longer know any − Strict state regulatory measures financial incentives for wholesalers to borders. We must raise awareness among intended to reduce the costs generated maintain a margin equal to that of the Europeans on these subjects and adopt a by the health insurance system without original medicine.* Only those drugs common approach to much research, for modifying entitlement to services. appearing on an approved list of generics example on cancer. We can then be much − Promoting better clinical control of can be used as substitutes. A small number more effective, in particular in the fight costs on one hand through measures for of active drugs that are heavily used (for against HIV/AIDS and infectious illnesses, more efficiency and patient safety, example, paracetamol) do not appear in which are, in my view, the real public while on the other being in favour of this list for policy or legal reasons. health priorities. Specific agreements signed in January 2006 Nathalie Grandfils is a Research Fellow between the Statutory Health Insurance REFERENCE and Catherine Sermet is Research and pharmacists refer to the twenty most 1. Fragonard B (President). Rapport du Director, Institut de Recherche et Docu- haut conseil pour l’avenir de l’assurance mentation en Economie de la Santé maladie [Report of the High Council on (IRDES), Paris, France. * In making the margin calculation, the the Future of Health Insurance]. Paris: Email: [email protected] margin of the original medicine is generally Ministère de la Santé et des Solidarités, higher than that of the generic equivalent, English translation by David McDaid at January 2004. except in the case where the original price is LSE Health linked to that of the generic.

Eurohealth Vol 12 No 3 15 FOCUS ON FRANCE expensive medications (statins, proton increased effectiveness of new products In the absence of a legal framework, an pump inhibitors, and angiotensin II and predicted sales volume. When a drug increasing number of medicines purchased receptor antagonists). The objective is to does not have any additional effectiveness by hospitals were resold by hospital phar- achieve a prescribing rate for generics of its price is fixed in such a fashion as to macies to outpatients at very disparate 70% by the end of 2006 (compared with generate savings for the Statutory Health price levels. These products were 35% in 2002), with an intermediate target Insurance. It is the case, for instance, that nonetheless reimbursed by the Statutory of 60% by mid 2006; this appears to be on generic medicines have their price fixed at Health Insurance on the basis of actual track, the intermediate target had already a rate between 30% and 40% lower than expenditure incurred by patients. In 2004, been achieved by the end of 2005. the price of the original equivalent. a limited list of drugs which can be sold by hospitals was established; these specialist Doctors, culturally accustomed to Parallel to this framing of pricing policy in drugs are subjected to a process known as prescribing branded drugs, committed favour of generics, a law on the financing ‘dépôt de prix’ – which requires the drug themselves to INN (International Non- of social security in 2003* introduced manufacturers to propose a reasonable proprietary Name) prescribing (i.e. reference prices (tarifs forfaitaires de price to CEPS. This procedure permits prescribing using the international responsabilité, TFR). This scheme, which higher reimbursable prices for innovative chemical name of the medicine) during the applies to seventy chemical entities, reim- patented drugs. This price is then used as medical convention (used to make agree- burses both generics and their original the reference for reimbursement. Medi- ments between the doctors and the equivalents based on the price of the cines not currently on this list that are Statutory Health Insurance) of 2001. generic is becoming de facto a mechanism essential for the treatment of outpatients Despite the subsequent change in prices, for price regulation: 70% of these original must, from now on, much to the disad- only 8.5% of all pharmaceutical prescrip- medicines have realigned their prices to vantage of their manufacturers, be regis- tions were made using INN by the end of those of the generic alternatives. Pharma- tered on this list of reimbursable drugs 2005. In March 2006 however, doctors cists have however registered a protest where prices are fixed by the CEPS. committed themselves to prioritising the against a decrease in their profit margins prescription of drugs for which generic by making fewer switches to generic alter- Optimising expenditure alternatives were available to pharmacists. natives. The generics manufacturers have A second series of measures are based on a equally opposed what is a relatively neutral concept introduced in 1994 and broadly To provide information and accustom measure from the patients perspective, reaffirmed in the 2004 reforms: ‘clinical patients to the use of generic medicines, since the difference in price between the control over health expenditure’. It is a the Statutory Health Insurance launched a two is covered by complementary health question of maximising efficiency, clinical major public campaign in 2003 across insurance schemes. appropriateness and quality in prescribing; different media outlets, followed in 2005 these behavioural changes would then lead and 2006 by two campaigns targeted Marketing of larger packets of medicine to better control of wastage and a decrease specifically at those patients who still used The health insurance reform of 2004 in expenditure. little or no generic medicines. Today nine envisaged a move to more efficient package out of ten French people say they are in sizes in respect of prescription medicines Improving access to innovative drugs in favour of generics. for some chronic diseases. Manufacturers ambulatory as well as hospital care The global impact of this policy favouring must make a request for market authori- For ambulatory care, a series of measures the increased use of generic medicines, has sation for packet sizes that allow three have been brought together in one slowly begun to bear fruit; in 2005 the months treatment for four classes of drugs: framework agreement, signed in 2003 increased use of generics allowed the anti-hypertensives, lipid lowering drugs, between the LEEM (Les Entreprises du Statutory Health Insurance to save over oral anti-diabetics and treatments for Medicament), an umbrella body for the €500 million. On the horizon by 2007, osteoporosis. The CEPS have committed pharmaceutical industry, and the CEPS, more than €1 billion in savings will have themselves to ensuring that the drug followed by a hospital agreement in 2004. been realised as a result of these measures, manufacturers’ price per dose of These agreements anticipate an acceler- which culminate in the ‘natural’ extension medication will remain the same regardless ation in the pace of licensing and reim- of the list of medicines with generic equiv- of packet size. The savings generated will bursement of innovative drugs thanks to alents and an envisaged decrease of 13% in instead result from the automatic reduction the procedure of dépôt de prix: the the price of generic medicines. in the margins enjoyed by pharmacists. industry makes a proposition to CEPS to have one coherent price similar to that seen Introduction of reference prices Fixed prices for some hospital drugs in Germany, Italy, Spain and the United In France the price of reimbursable ambu- The reform and its ensuing measures Kingdom, anticipating the first four years latory medicines are fixed by the initiated a profound change in regulatory of sales volume. Subsequently the CEPS Economic Committee for Medical measures for hospital drugs. In effect, would then ratify this price. Products (Comité Economique des while the price of ambulatory drugs were Furthermore, a list of innovative but Produits de Santé, CEPS) based on three the subject of regulation, the price of expensive drugs are now reimbursable essential criteria: the price of treatments hospital-based drugs remained entirely within hospital budgets. This allows all already available on the market, the uncontrolled until 2004. hospital departments to benefit from

* This law was first established in 1996 with the target of determining the general conditions to financially balance social security, based on anticipated revenue and fixed expenditure objectives.

16 Eurohealth Vol 12 No 3 FOCUS ON FRANCE increased access to innovative medicines. − Approximately two hundred specialist begun to provide objective and free infor- The approach seems to have led to an drugs have disappeared from the mation to doctors that is in the best increase in the prescription of such medi- positive list since 2003. These de-reim- interest of patients. Improving information cines. bursements were apparently very for patients is being achieved primarily unpopular and the chance of prescrip- through media campaigns. Using the The framework agreement of 2003 tions being transferred towards those campaign model previously used to furthermore required an annual agreement medications remaining on the positive promote generic prescribing, the Statutory to be signed between the industry and the list have been largely symbolic with Health Insurance has developed two other State. Under the terms of these agreements, little to show until now. national information campaigns. One is in the industry is committed to making respect of antibiotics: “Les antibiotiques payments if growth in reimbursable ambu- − Sixty-two other specialities (including c’est pas automatique” (antibiotics are not latory drug sales exceeds a ceiling fixed treatments for varicose veins) have seen an automatic option), and the other annually under the law on the financing of their rate of reimbursement decrease focusing on the “INN – the real name of social security.* Highly innovative drugs over a transitory period from 35% to the drug”. and all generics are exempt from this rule. 15%. These products will be de-listed Those companies that have not signed up by the beginning of 2008. This fall in Conclusion to these agreements are today very few in the rate of reimbursement has however Despite a succession of reforms over the number and they fall within the terms of a only served to transfer the costs last ten years, pharmaceutical policy has ‘safeguard clause’ which makes them liable between statutory and complementary encountered many difficulties which have to pay a tax on their sales turnover which health insurance. slowed the pace of implementation consid- is at least equivalent to that which would erably. The public authorities are caught have been paid had they signed up to the Increasing benefits via more deductions between the need to contain health expen- agreement. from the pharmaceutical industry diture and the need to support a pharma- Since the first law on the financing of ceutical industry which makes an In June 2006 the LEEM and CEPS went health insurance in 1996, the pharmaceu- important economic contribution to the further by signing a hospital master tical industry has been subject to various country. framework agreement; this extended the additional charges. One of these levies a agreements and safeguard clauses to all tax on advertising expenditures and has Doctors are not very receptive to measures hospital drugs sold to all non-hospitalised been the subject of numerous revisions. intended to change their practice: thus patients in the same way as those drugs The law on the financing of social security prescribing patterns that do not conform receiving specific financing. in 2006 envisages a further increase in this with guidance are still very numerous and tax. Another charge is based in sales INN prescription is still not part of the Establishing agreements between doctors turnover and its increase in relation to the medical culture. Many doctors reject the and the Statutory Health Insurance previous year. In addition to this contri- very notion of financial responsibility. The In 2005, the Statutory Health Insurance bution, the 2004 law on the financing of system for financing health care, by taking signed a number of specific agreements social security included a one off charge of full responsibility for prescribed drugs with doctors associations covering the 0.6% for the pharmaceutical industry. This does not encourage patients to take more years 2006 and 2007. These had the aim of was linked to the sales turnover of each responsibility, which can be seen in improving efficiency in prescribing, whilst company. The 2006 financing law has particular through the low level of self- containing expenditure related to five made this an annual charge and also medication. classes of pharmacotherapy: antibiotics, included a one off increase to 1.96%. statins, anxiolytics and hypnotics, proton Nonetheless, and despite an impression of pump inhibitors and anti-hypertensives expansion, successive reforms have piece Improving the quality of information and and anti-coagulants. Moreover, doctors are by piece progressed towards a more prescribing committed to respecting a ‘prescribing coherent policy for the regulation of phar- The High Authority for Health (La Haute book’ which allows them to separately maceuticals. In total, until now (in 2005 Autorité de Santé, HAS ), established as prescribe drugs that have a long lasting and 2006) only about €1 billion in savings part of the 2004 reforms, has been given a effect (at full price) from other medications have been linked to these policies because major role in the promotion of good (which are priced at 65%, 35% or 15% of of the delays in implementation of certain practice and better utilisation of health care full price depending on circumstances). measures. But savings for the year 2007 are services. It ensures, along with the French expected to be more than €1 billion, Agency for the Safety of Health Products Revision of the positive list mainly due to the promotion of generics. (Agence Française de Sécurité Sanitaire des All ambulatory drugs reimbursable by the Produits de Santé, AFSSAPS) the publi- Statutory Health Insurance have been the cation of numerous guidelines on clinical subject of a re-evaluation of their clinical REFERENCES practice. At the same time, the reforms use in order to determine whether they wished to organise the role of health 1. Organisation for Economic Co-operation should be kept on the list of reimbursable and Development Eco-Santé France visitors when putting in place a charter for drugs (positive list). The basket of care has OECD 2005. Paris: OECD, 2005. home visits. been changed in two ways by this re- evaluation: As part of this charter, companies have

* This rate, known as rate K, was equivalent to 4% in 2003, 3% in 2004, and 1% in 2005–2007.

Eurohealth Vol 12 No 3 17 FOCUS ON FRANCE Health targets in France: role of public health and social health insurance reform laws

Isabelle Durand-Zaleski

Summary: Two major laws were passed within a few days of each other by the French Parliament in August 2004. The first set public health priorities and targets; the second reformed the financing, organisation and regulation of the health care delivery system. The purpose of this article is to examine the consistency between the two and to identify possible factors in this prioritisation process which resulted in the publication of 104 distinct health targets.

Keywords: Health targets, France, Health policy, Public health, Priority setting

Public health targets integrated into reports produced by the followed the usual pattern of firstly taking In 2004 for the first time, the French High Committee of Public Health for the account of estimates of the magnitude of Parliament discussed and endorsed a Minister of Health. As limited action was health problems using mortality and Public Health Law1 which listed 104 taken after each report, targets and prior- morbidity data (such as Disability health targets for the years 2005–9. This ities tended to pile up, which may also be Adjusted Life Year (DALY) estimates law thus allows for planning and budg- an explanation for the very comprehensive published by the World Health Organi- eting for public health actions over a five- list of 104 targets now presented in the zation). This initial identification of major year period, rather than confining planning public health law! health problems was then followed by an to the traditional one-year period. The analysis of the current scientific infor- When selecting those 104 health targets, political need for such a law can probably mation on prevention and treatment the law considered both diseases and deter- be traced back to the different crises that strategies available, bearing in mind minants of health. Targets were defined reduced public confidence in the health existing resources within the French health either for the total population or for authorities: AIDS-contaminated blood, so and social care systems. specific population sub-groups and they called ‘mad-cow’ disease and, more were included in the list (along with their Targets were presented with one or more recently, the August 2003 heat wave that accompanying programmes) if they could measurable indicators that would reflect an killed an estimated 15,000 older people. meet nine criteria (see Box 1). evolution in the health states of the popu- Back in the late 1990s, the Ministry of lation or selected population sub groups. The methods used to select health targets Health launched a series of ‘public health Priorities were given pragmatically to conferences’, one in each region, involving different stakeholders: patients’ represen- Box 1 Criteria for health targets tatives, payers, professionals and (to a certain extent) the general population. Those conferences produced, in each Achievable within five years region, a list of health priorities or targets. Measurable given the current level of scientific knowledge and availability of resources They were periodically summarised and Would contribute to a reduction in health inequalities

Gender-specific

Isabelle Durand-Zaleski is Head of Gives priority to improvements in the health of infants, children and adolescents Department at the Department of Public Health, APHP hôpital Henri Mondor, Gives priority to actions for the prevention of disease or any worsening of a given health Paris, France. condition Email: isabelle.durand- Cost-effective [email protected] Favours cooperation between health care, social welfare professionals and other relevant Acknowledgement: the author gratefully stakeholders acknowledges the contribution of Includes elements of appraisal/assessment of effect on population health Professor Didier R Tabuteau

18 Eurohealth Vol 12 No 3 FOCUS ON FRANCE

Both laws consistently emphasise and Box 2 Categories for health targets enforce requirements for information systems, for regional decision-making, for 1. Determinants of health (alcohol, tobacco, nutrition and exercise, health in the work- quality assurance and for more preventive place, environmental health) measures. The Public Health Law states the possibility of using claims data to help 2. Reducing iatrogenic (doctor induced) risks inform public health policy, while the 3. Reducing antibiotic resistance Social Health Insurance Reform Law permits electronic medical records and has 4. Improving pain management created a public institute to consolidate 5. Reducing the burden of disability and manage health databases. Moreover, the Public Health Law instituted regional 6. Reducing the burden of communicable diseases planning for the implementation and 7. Improving maternal and child health monitoring of the 104 health targets. The Social Health Insurance Law meantime 8. Reducing the burden of malignancies enabled changes in financial administrative 9. Improving management of diabetes structures to create financial incentives for professionals in underserved areas and also 10. Reducing the burden of psychiatric disorders created agencies to coordinate the supply 11. Reducing sensory deficiencies of health care at a regional level. This does not, however, concern ambulatory care or 12. Reducing the burden of cardiovascular disorders services yet, although both laws allow for 13. Reducing the burden of respiratory diseases pilot projects by regional health authorities (in contrast to the current regional hospital 14. Improving quality of life of people with chronic inflammatory bowel disease authorities). 15. Reducing the burden of non-malignant gynaecologic disorders Quality assurance is another important 16. Reducing the burden of end-stage renal disease element in both laws; the Public Health Law, for instance, created a National 17. Reducing the burden of rheumatic diseases (osteoporosis, rheumatoid arthritis, low Cancer Institute, while the Social Health back pain) Insurance Reform Law mandated health 18. Reducing infant mortality and improving access to prenatal screening technology assessment, the development 19. Ensuring equal access to prevention and care for patients with rare diseases of guidelines and review criteria, hospital accreditation and professional practice 20. Improving dental health appraisal, all under the responsibility of a 21. Reducing the burden of suicide and accidents single national health authority.

22. Specific population groups: Learning disabilities and dyslexia, improved access for Prevention had traditionally been left out women to contraception and terminations, older people. of reimbursement, possibly under the unspoken assumption that this should be the responsibility of the individual. Both actions for which data and evidence of now responsible for hospital budgets, new laws however explicitly cover positive effect were available. In other while welfare and social services are also, prevention; the Public Health Law alters cases, the law specified that more data or to some extent, financed through regional the social health insurance code to make knowledge needed to be generated. budgets. Following the April 2004 regional the financing of public health programmes Programmes were prepared to deal with elections, which led to socialist party possible at the regional level. specific health problems identified by the majorities in 20 of the 22 regions, discus- High Committee of Public Health:2 sions on the financial empowerment of Disconnection between priority setting cancer, violence and addictive behaviour, regions took a new, more political, turn. and financing environmental hazards, chronic diseases There are however inconsistencies, most and ageing, and orphan/rare diseases. All Consistency between laws notably the disconnection between 104 targets were placed within 22 different Only a few days after the approval of the priority setting and financing. The above- chapters (see Box 2). For each target, the Public Health Law, French parliamen- mentioned targets do not constitute a law indicates whether additional infor- tarians approved another law reforming binding obligation for financing organisa- mation/data are still required. the regulation and financing of health care tions. Also noteworthy is the fact that such (the Social Health Insurance Reform Law). This attempt at health targeting is marked primers for a public health policy as an This law also responded to a major by the willingness of the government to electronic medical record system and a financial crisis, as the total deficit of the delegate power to the regional health common regulatory authority appeared in Social Health Insurance was then almost authorities, as they are considered to be the the social health insurance reform law. This €10 billion. The consistency between both most capable of identifying health needs can be seen as an illustration of the laws has now been examined.3 Each law and providing care to their populations. ongoing rivalry between the administra- affects both the code of public health and This empowerment in fact started with tions in charge of public health and health the code of social health insurance. hospital care as the regional authorities are financing.

Eurohealth Vol 12 No 3 19 FOCUS ON FRANCE

Reflections on priority setting consume 60% of total healthcare fectly competitive market created by social The simultaneous publication of both laws resources) but would support preventive health insurance. Both the rent-seeking created an occasion to reflect upon the services for themselves and for their model and the role of professional interest relationship between priority setting and families. The same applies to the chosen groups provide an explanation for the very financing. Priority listing and setting objectives of: (i) reducing iatrogenic strong emphasis on the reduction of should take account of the available budget (doctor induced) risks – any person may demand (rather than supply) to control and, in turn, the budget should be made receive a treatment for a minor ailment and health care expenditures. available to finance the government’s therefore become at risk; (ii) reducing low health priorities. Governments that have back pain – affecting an estimated one Conclusion followed an explicit priority setting million plus people in France; or (iii) The simultaneous publication of the public approach have rejected a cost-effectiveness reducing the burden of non-malignant health and social health insurance reform or cost-benefit dominated approach but gynaecologic disorders, which may laws enabled the population (including instead attempted to define the boundaries concern a large population of women. researchers) to reflect upon the principles of individual versus collective responsibil- and theories that govern priority setting in ities.4 In the case of the French Public health care. The French government, Health Law, the leading principles (final unlike others,4 did not explicitly define goals) stated in the preamble to the law “One lesson perhaps is which principles of justice were used to were not to maximise health gains but define priorities; priorities however were rather to reduce inequalities (including that priority setting and indeed set while the financial reforms to gender disparities), protect the young and financing laws should the health care system were being voted for favour primary prevention. The processes separately. to reach these goals were the promotion of not be separate” This legislative activity has taught us firstly evidence-based and cost-effective inter- that the connections between priorities and ventions, as well as quality assurance and financing are so strong that each law coordination of care. Interest groups and bureaucratic decision resulted in major changes to the codes of making may also be a factor in the discon- the other; another lesson to be drawn Some elements of utilitarianism could be nection between priority setting and perhaps is that the priority setting and found in the emphasis on the young and on financing. According to the interest group financing laws should not be separate. cost-effective interventions, but economic model, ‘individuals that have the lowest Secondly, that there was common ground evaluation alone cannot account for all costs of organisation’ are most effective in between both bills, such as the need for priorities selected. Following the approach securing health care resources for their 5 better information systems, reinforcement of Goddard et al., political economy own purpose. This can be seen in the case of preventive systems, development of models were examined to see if they could of cancer care where both professionals quality assurance and empowerment at the shed any light on the health priorities and patients have well structured organi- regional level for the implementation of chosen and on the apparent inconsistencies sations, as well as for rheumatoid arthritis, health policies. Thirdly, that priority between the public health and the social HIV and Hepatitis C infections and the setting in democratic societies is not done health insurance reform laws. Goddard prevention of hospital-acquired infections solely to maximise societal health gain but and colleagues suggest that priority setting (one of the most active patients’ associ- also results from bureaucratic and political in health does not correspond to predic- ation in France). The rivalry between the negotiation. tions of economic rationality, but not bureaucracies in charge respectively of because of errors or haphazard decisions, public health policy and health care but rather because policy makers also have financing has resulted in a double steering REFERENCES to serve their own interests in addition to system at the regional level, as well as the 1. Senát de France. Loi de Santé Publique those of the population. curious fact that one institution in charge [Public Health Law] Paris: Senát, 19 (among other tasks) of evidence-based Several models of political economy can be January 2004, drawn into this discussion of health practice and quality assurance in cancer http://www.senat.fr/leg/tas03-042.html priority setting. In addition to the maximi- care was created by one law, while the sation of health gains, the majority voting institution with the same duties for the rest 2. French High Committee on Public model, the role of interest groups, the of medicine was created by the other. Health. Health in France 2002. Paris: John Libbey, 2003. economic theory of bureaucracy and the The rent-seeking model may explain why rent-seeking models have all been it was necessary to state that better co- 3. Tabuteau DR. Politique d’assurance maladie et politique de santé publique proposed. ordination between ambulatory and [Social health insurance and public health hospital care, as well as between preventive The majority voting model explains why reform laws] Droit Social 2006;2 and curative medicine, is necessary. The ‘policy makers seek to direct resources (February). toward key population groups’, for time spent by professionals either in example, towards votes in important hospital or in private practice to educate 4. Klein R. Priorities and rationing: prag- constituencies or notoriously volatile voter and coordinate care for patients with matism or principles? British Medical Journal 1995;311:761–62. groups. The focus on health for the young chronic diseases is not valued by social and on primary prevention may be the health insurance. The rent-seeking model 5. Goddard M, Hauk K, Preker A, Smith P result of such thinking from the explains why such important elements of C. Priority setting in health- a political government. Most citizens are not ill, (for the quality of the health care system have economy perspective. Health Economics example in France 10% of the population been long neglected because of the imper- Policy and Law 2006;1:79–90.

20 Eurohealth Vol 12 No 3 FOCUS ON FRANCE French hospital reforms: a new era of public-private competition?

Zeynep Or and Gérard de Pouvourville

Summary: In 2003, the French government launched an ambitious reform plan, known as ‘Hôpital 2007’, with the objective of improving overall efficiency and management within the hospital sector. A major element of the reform was the intro- duction of an activity-based payment system both for public and private hospitals which were previously paid under two different schemes. While this reform is a step in the right direction, further measures are required that will regulate carefully the conditions for competition between public and private providers without discour- aging quality improvement and risking large increases in expenditure.

Key words: France, Hospital reform, Activity-based payment, Competition.

The hospital sector in France is a real mix and management within the hospital been discontinued. Regulatory powers of public and private provision where sector. have been shifted from the central level to private-for-profit hospitals account for the regions by reinforcing the role of about one third of all hospital beds and Hôpital 2007 regional hospital agencies (ARH – Agences almost half of those for surgery. French The measures introduced by this reform régional d’hospitalisation) in controlling patients have complete freedom of choice plan, aimed on the one hand at improving hospital activities. The regional organi- to be treated in either sector and, unlike overall efficiency and organisation of all sation plans (SROS – Schéma régional most other European countries, long health care facilities and on the other at d’organisation sanitaire) which placed an waiting times are not a problem on the modernising the organisational and emphasis on the demographic and political agenda. However, given that it management structures within public epidemiological characteristics of each absorbs almost half of total health care hospitals by giving them more autonomy. region’s population became the only tool expenditure, the hospital sector has been The plan had three major planks: used to guide hospital planning. under increasing pressure in recent years 1. Modernisation of healthcare facilities 2. Renewal of the hospital financing to improve efficiency. Moreover, the and simplification of hospital sector system. sector’s funding arrangements and organi- planning. sational structure are complex with little The second and most important measure transparency as to the efficiency and This first phase of the reforms put the was the introduction of an activity-based productivity of individual health care facil- emphasis on the modernisation of payment system both for public and ities. Therefore, the current government hospitals by boosting investment to private hospitals. Previously, public and launched in 2003 an ambitious reform improve their general infrastructure. This private hospitals were paid under two plan, known as ‘Hôpital 2007’, with the was also necessary to support national different schemes. On the one hand, the objective of improving overall efficiency health priorities including improving public and most private not-for-profit cancer treatment, perinatal care and mental hospitals had global budgets with funds health. Total investment in hospitals has allocated by the ARHs. These allocations Zeynep Or is Senior Economist, Institut doubled between 2003 and 2006, while in were mainly based on historical costs, de Recherche et Documentation en parallel, the organisational structure and making little adjustment for hospital effi- Economie de la Santé (IRDES), Paris, planning of health care facilities have been ciency or specific public health targets. France. Gérard de Pouvourville is simplified. Private for-profit hospitals, on the other Research Director, Centre National de la hand, had an itemised billing system with The sanitary chart (an index of local health Recherche Scientifique and also at Institut different components: daily tariffs needs) which used to control, among other National de la Santé et de Recherche covering the cost of accommodation, things, the number of beds and medical Médicale, Paris, France. nursing and routine care, and a separate Email: [email protected] equipment authorised for each hospital has

Eurohealth Vol 12 No 3 21 FOCUS ON FRANCE payment based on the diagnostic and ther- investment strategy and the use of new which means providing 24 hour emer- apeutic procedures carried out, with interventions are also set through this gency care, an obligation to non-discrimi- separate bills for costly drugs and medical bureaucracy. One striking example of this natory practices, that is to accept any devices. In addition, doctors working in is the fact that hospital managers still do patient who seeks treatment, and taking private hospitals are paid on a fee-for- not have the power to layoff staff, whether part in activities related to national/ service basis unlike those working in medical or non medical. regional public health priorities. public hospitals, who are salaried. There will be fixed yearly grants, plus a Issues to be resolved The new activity-based payment system fee-for-service element, to cover the It would not be an exaggeration to say that has been implemented progressively in the standard costs of maintaining emergency rarely has a health reform in France public sector (for public and private not- care and related activities. Budget received as much support as this reform. for-profit hospitals) from January 2004. A ‘envelopes’ are determined taking into Both public and private hospitals and all of payment is made for each patient treated account the yearly activity of providers. the medical organisations involved agreed in acute care (rehabilitative, long-term and There are two separate ‘envelopes’: one for with the major principles and the proposed psychiatric care are not as yet included) education, research and innovation related new method of financing. The differences based on the Groupes Homogène de Séjour activities (MERRI – Missions d’en- in treatment between the public and (GHS – the equivalent of diagnosis related seignement de recherche, de reference et private sectors have long been a subject of groups) prices for the public sector. The d’innovation ) and one for financing activ- debate in France. The private sector has activity-based element of the payment will ities carried out for the ‘public good’ claimed that global budgets reward ineffi- increase gradually each year: 10% in 2004, (MIGAC – Missions d’intérêt général et ciency and have prevented a real bench- 25% in 2005, 35% in 2006 and so on. d’aide à la contractualisation) to meet marking process which would demonstrate national or regional health priorities (for Private hospitals on the other hand have that private hospitals are more efficient. example, prevention) or specific public been paid entirely using the new case-mix Public hospitals conversely saw the global missions (for example, providing care for based system since 1 March 2005. budgets as an instrument of rationing at-risk groups). These ‘envelopes’ are However, a transition period was allowed which strangled the most dynamic of funded from regional budgets and where ‘national prices’ have been adjusted, hospitals and did not give them any room distributed by the regional hospital first taking into account the prices for the to respond to changes in demand. agencies on a contractual basis following private sector, and second using a tran- nationally defined rules. It is still not clear sition coefficient for each provider based what specific activities are covered or how on its own historical costs/prices. The the cost of different elements (such as objective is to harmonise the prices for all “rarely has a health reform research) will be assessed. providers (public and private) by 2012. in France received as much Finally, a closed list of expensive drugs and 3. A new governance structure for public medical devices (Médicaments et dispositifs hospitals. support as this reform” médicaux implantables) is paid retrospec- Following the first two steps of the reform tively, according to the actual level of process, the last phase has been to give prescriptions made. This decision was public hospitals the flexibility they need to taken for two reasons. First, there is a deal with this new financial environment. The government stated that the “equal strong political consensus to offer equal The idea is to simplify the administration treatment of the public and private access to innovative technologies, and of public hospitals and give more sectors” was a major objective of the including such costs within a fixed price autonomy to medical staff over managerial reform. Ironically the word “competition” per case could push hospitals to switch to decisions. Hospitals will also have the was hardly ever mentioned in this context, cheaper and less innovative drugs. Second, opportunity to create large clinical depart- even though implicitly one of the ratio- the private sector was already billing for ments (hubs of medical excellence) in order nales for the reform was to increase expensive drugs retrospectively, whereas to organise their medical activities in a competition within the hospital sector and they were included in the global budget for more efficient way. These centres, under hence foster efficiency. Increasingly, public hospitals. However, this mode of the responsibility of a doctor, will enjoy however, attention is being paid to the payment for ‘innovation’ encourages the organisational and administrative implications of a unique payment system use of innovative drugs while potentially autonomy, subject to an internal contract with one price (price competition) and the reducing the budget envelope for inno- with hospital management. initial consensus on the need for more vation in other areas. Given the global cap transparency and efficiency has since been on hospital expenditures a large increase in While public hospitals now have obtained peppered by some scepticism and ques- drug expenditure would need to be some freedom over their internal organi- tions concerning issues of implementation. compensated by a reduction in GHS tariffs sation (number of centres, departments, which cover the cost of innovative diag- etc.), their autonomy is still strictly limited Quantifying the cost of ‘public missions’ nostics, surgical or organisational proce- in other ways. The boards and executives For public hospitals (and private hospitals dures. of hospitals are still under the control of participating in so called ‘public missions’) the Ministry of Health and the ARHs. there are three types of additional The construction of the MIGAC budgets Resource allocation is still the result of a payments to compensate ‘specific is also an issue of concern as the decision mixture of predefined rules and bureau- missions’. These include research and on the size of these envelopes seems to be cratic negotiations. Most of the education, assuring the continuity of care, political rather than evidence based (see management rules concerning recruitment, interview in this issue with Xavier

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Bertrand). Both the public and the private comparisons. rate of increase in activity is already higher sectors have expressed concern as to the than the targets set. We note that part of More fundamentally, to be able to compare future size of this budget. The private this increase was actually due to a large costs or introduce cost-based competition sector fears that this budget may be used increase in expenditures on expensive between the public and private sectors, it as a mechanism to make up for ineffi- drugs and medical devices. would be necessary to have costs calcu- ciencies in public hospital performance, lated in the same manner in both sectors. This type of regulatory mechanism is while the public sector has concerns that Surprisingly, for a country where the problematic. Adjusting prices depending the value of their ‘public mission’ will be private sector provides more than half of on the volume of activity assumes constant underestimated. Hopefully, the need to all surgery and one third of maternity care, productivity gains without taking into assess the cost of different public activities little is known about the actual costs or account the type of activity produced. will help improve transparency within inputs used by private hospitals. Very little When this is not the case, depending on the public hospital budgets. progress has been made in producing impact of new technologies on costs, there One price for all? comparable cost information between the is a risk of setting prices (progressively) two sectors. not linked to costs at all. This would Currently the GHS prices for private and encourage health care facilities to opt for public hospitals are calculated differently. Adjustment for quality less expensive care/therapies. In particular, the prices in the public sector One acknowledged shortcoming of include ‘all costs’ (fixed and variable) activity-based payment is that there is no Conclusion linked to medical care, while in the private link between the prices set and the quality The implementation of Hôpital 2007, espe- sector fees for medical staff and devices of services provided. The facilities where cially the introduction of a new financing such as MRI scanners are paid separately costs are higher than average might be less regime for hospitals in France, will result over and above GHS tariffs. Although the efficient, but they might alternatively be in significant change in hospital behaviour new funding system recognises the distinc- providing a higher quality of care. Indeed, and resource allocation. While the core tiveness of public hospitals and their there are inherently perverse incentives to measures introduced by the reforms are missions, there are still a number of ques- increase the volume of activity at the based on sound principles, there are a tions as to the rationale for applying the expense of quality, unless there are specific number of issues that need to be resolved if same tariffs to both public and private regulatory safeguards. their expected impact is to be achieved. facilities. The fact that public hospitals also have to carry out a number of additional Currently, very little information is Activity based payment schemes are activities of a very different nature might available to compare the quality of care intended to increase productivity and effi- have an indirect impact on their cost func- between and within public and private ciency. In the French context however, tions. facilities. One recent study shows that (where there is no gatekeeping for hospital (while this is not a direct indicator of care care) improving the efficiency of individual For instance public hospitals, by law, quality) the qualifications of medical hospitals does not forcibly require an cannot select their patients and are more personnel are significantly higher in the overall increase in activity in the hospital likely therefore to treat those patients that public sector.1 It should also be noted that sector. However, the introduction of a are more expensive to treat than what is public and private facilities are not prospective activity-based payment system covered by an ‘average cost’ payment. currently subject to the same rules of introduces strong incentives for this to Even for the same DRG, the technical health care security and safety. Such rules occur, albeit with all the problems of procedures performed and the severity of are better established in the public sector, unjustified hospitalisation that this may the disease treated are not the same in each although, because of their growing number imply. In order to offset any such negative sector with, on average, the public sector and complexity, this should not be inter- incentives, regulation of access to hospital dealing with more severe or technically preted as meaning that they are better care, both public and private, should be complicated cases. Moreover, the obli- enforced. enhanced. gation of providing emergency care incurs not only reimbursable direct costs, but also Containing cost v. increasing productivity In addition, because of the hybrid funding indirect costs and consequences. For system in the public sector, with a mix of In order to contain the overall costs of instance the management of non-planned prospective (for care) and retrospective hospital care, the new system introduces care disrupts the scheduling of elective (special missions, expensive drugs and national and regional level expenditure surgery, with lower bed occupancy rates devices) payments, there is a high risk of targets for social security concerning acute etc. cross-subsidisation. This could lead to an care expenditure (with separate targets for increase in expenditure (or a decrease in The activities of the private sector are the public and private sector). It was tariffs) that are not related to productivity highly concentrated on surgery, maternity announced that if the actual growth in gains, thus threatening the financial care and highly technical specialties, unlike volume of activity produced exceeded the viability of even the most productive of public facilities that provide a compre- target, prices would subsequently go public hospitals. hensive package of care. The average down. Not surprisingly, in 2005, both number of case-mixes making up hospital public and private sectors exceeded their At the same time it is not clear what will activity in private hospitals is therefore targets (by more than 3.5%) costing an happen to good and bad performers. In a only half of those in public hospitals. Thus, additional €650 million to the health truly competitive market, those hospitals the economies of scope that the private insurance fund. While the government let where costs are higher than tariffs must sector benefits from through its ability to this go unchecked in 2005, it decided to reduce their unit costs, or they will go specialise are not considered in cost reduce GHS prices by 1% in 2006, as the bankrupt and close. However, this would

Eurohealth Vol 12 No 3 23 FOCUS ON FRANCE be politically unacceptable in France. Moreover, since public hospital managers Health care human resource do not have much room for manoeuvre – they cannot layoff staff or close down certain services – their main strategy can policy in France only be an increase in volumes to reduce unit fixed costs. Given that productive hospitals will also increase their activity to gain more revenues, the overall effect is a total increase in expenditures, which will Yann Bourgueil and Yvon Berland jeopardise the national spending target. It is also not clear if the good performers will be allowed to retain surpluses, nor how they might be used. Summary: The number of full-time doctors in France is decreasing. Inequalities Finally, if the issues that have been dealt in the distribution of the health work force are of concern with some regions in with above are not settled, and if the the north having medical density rates 60% lower than those found in the south. convergence process moves on towards Mechanisms used to regulate the supply of medical professions appear to have the same average tariff for both sectors, been ineffective and general practice remains an unattractive career option. A then the private sector will have huge new strategic plan was announced by the government 2006. This includes oppor- opportunities to increase profitability and tunities for training in general practice in medical school, the development of gain market share from the public sector financial incentives to encourage doctors to locate in areas of most need, and because of their greater flexibility. One delegation of some clinical activities to other health professionals. consequence may be that they will offer better career and remuneration opportu- nities to doctors and nurses compared Keywords: France, Health workforce, Health reform, General Practice with the public sector, thus aggravating the problems in recruiting medical staff in under-served areas, with implications for access to care. Thus, while recent French The number of full-time doctors in France France, the geographical distribution of hospital reforms are a step in the right is decreasing. This is due to a combination doctors across the country is uneven. direction, further measures are required of factors, including the decline in the There is more than a two-fold difference that will regulate carefully the conditions numbers of medical students between 1971 between the north and south. for competition without discouraging and 2001; the introduction of the 35-hour Furthermore, the large number of doctors quality improvement and risking large working week in France; and the EU reaching retirement age in the near future increases in expenditure. In France as else- working time directive limiting the will exacerbate the situation (see Figure). where, assuring fair competition between maximum working week (Directive Yet, despite this general trend, it is still public and private hospitals is not an easy 93/104/EEC). Moreover, the increasing unclear as to what the actual shortages of task. number of women (60% of all new staff might be as there is no single source medical students in 2002), and a change in of comprehensive data available on the younger professionals’ attitudes towards actual distribution of the different types of REFERENCE work will lead to significant reduction in health professionals. 1. Audric S, Baubeau D, Carrasco V et al. the actual worked time of health profes- Les établissements de santé, un panorama sionals. Background Following several public reports and pour l’année 2003. [Health facilities: an In France, the number of doctors is overview for 2003]. Paris: Ministere de la surveys in the 1990s pointing to the need currently relatively high at 3.4 per 1,000 Sante et des Solidarites, Direction de la for better information on health workforce inhabitants. This compares well with recherche, des études, de l’évaluation et des demographics, the Ministry of Health countries such as Germany (3.4 per 1,000), statistiques, 2005. Available at created a National Observatory of Health Denmark (3.2 per 1,000), Finland (2.6 per http://www.sante.gouv.fr/drees/donnees/e Professions (Observatoire National de la 1,000) and the United Kingdom (2.2 per s2003.pdf Démographie des Professions de Santé, 1,000); however, it is rather lower than that ONDPS) in 2003. Its major responsibil- FURTHER READING of Italy (4.1 per 1,000).1 Moreover, in ities are to collect, analyse and commu- Pouvourville G. Les conditions d’une concurrence loyale entre le secteur public nicate precise and objective information et privé [Conditions for fair competition relating to all categories of health care between the public and private sectors]. Yann Bourgueil is a Research Director, professionals. The ONDPS also engages in Revue Hospitalière de France Institut de Recherche et Documentation research on working conditions, planning 2006;508:12–15. en Economie de la Santé (IRDES), Paris, needs for health professionals and profes- France. sional development. It also works in coop- Or Z. Hospital Payment Reform. Health Policy Monitor 2005; France, Survey 5. Yvon Berland is Professor of Medicine eration with Observatories of Health Available at and President of the National Obser- Professionals found in each region. They http://www.hpm.org/en/Surveys/IRDES/ vatory of Health Professions (ONDPS). bring together local representatives of 05/Hospital_payment_reform.html Email:[email protected] doctors, the state authorities, sickness

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Figure: Predicted total number of doctors and number per 1,000 population assuming locations where doctors might practice. A 7,000 new students per annum.2 special committee chaired by the president of ONDPS suggested a number of measures to reduce regional inequalities, but expressed their respect for the ‘free settlement’ of doctors.4 This implies that there are no real disincentives for those doctors who want to locate in areas where there is already a high density of health professionals. Because the ONDPS is recognised in the health sector as a reliable source of data, analyses and recommendations, its recom- mendations have been received with great interest by both professionals and the media. They have also raised knowledge and awareness of this issue. Subsequently in response to the growing expectations for policy development, the current government announced a new strategic plan in January 2006 aimed at improving 5 funds, hospital agencies and medical country they choose. health workforce development. This schools. They also coordinate surveys and includes the development of incentives to Moreover, general practice is not attractive other initiatives to help ensure the health encourage doctors to practice in medically for medical students, and consequently workforce matches demand. deprived areas, improvements in working they have developed strategies to avoid this conditions and actions to increase the Two reports published by the ONDPS in career option. Indeed in 2005, 600 training supply of doctors. Another feature is the 2005 and 2006 concluded that, compared posts in general practice remained unfilled. promotion of the greater delegation of to other countries, the number of doctors Students who were not ranked high clinical activities from doctors to other is currently not a cause for concern in all enough to access a specialist training medical staff such as nurses. areas.2,3 However, the declining numbers position preferred to repeat their exams in will be most acute between 2008 and 2015. 2006, rather than enter general practice Developing incentives to practice in Concentrating on primary care catchment training. The poor opinion that students medically deprived areas areas (30,000 to 50,000 population) that may have of general practice may be due Deprived areas are defined by two criteria: were defined as being deprived of health to only working in hospitals, with little low medical density (an area where the care professionals (see later section in opportunity to learn about primary care number of doctors is 30% below the article) these reports concluded that very work. General practice commonly national average) and high professional few areas currently fell within these considered exhausting due to patient activity (an area where the per capita criteria; nonetheless, those that do demands. medical activity in terms of patient visits is encompass 2.6 million inhabitants (4% of The ONDPS has made a number of 30% above the national average). The the population) and affect 1,600 GPs (3% recommendations to address this situation: precise list of deprived areas is set by of the workforce). Inequalities in the regional authorities after consultation with distribution of the health work force are of – Promoting a single register for all regional stakeholders. greater concern with some regions in the professionals north having medical density rates 60% Stating that doctors working in medically – Regionalising the Examen Classant lower than those found in the south. deprived areas face unattractive working National conditions, including long hours and a lack Mechanisms used to regulate the supply of – Making changes to the curriculum in of time for continuing medical education medical professions, appear to have been medical and paramedical education, discourages young doctors from locating ineffective in ensuring access to an including a more robust generalist in such areas. Thus, the plan provides adequate number of various specialists. education for doctors before any several incentives to encourage group Currently, there are two main tools of specialisation, training outside teaching practices and to improve working condi- medical demographic regulation: numerus hospitals, better promotion of general tions in these areas: clausus, which limits the number of practice, and the reinforcement of para- students allowed to enter medical school, – The health insurance fund will pay a medical skills. and the Examen Classant National, which 20% higher rate of remuneration to ranks medical students after six years of – Restructuring the health workforce doctors working in a group practice in study. These rankings determine what supply by grouping practice both in medically deprived areas. medical speciality a student may pursue. primary and secondary care and – Local authorities in rural areas will be Regional inequalities are also partly redefining health professions. able to provide financial aid to doctors explained by the freedom both specialists However, the ONDPS did not propose who wish to set up a practice (for a and GPs have to work in any part of the any policies restricting the geographical minimum period of three years) in

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deprived areas, or provide them with entering medical school, as well as the a gate keeping model as in the English professional facilities or personal number of junior doctors, will also be NHS, confirms a more important role for housing. They can also give a study increased in the medically deprived areas. GPs.8 This policy could be enhanced if allowance of up to €24,000, offer a there are decreasing numbers of specialists The plan also introduces measures to housing grant up to €400 per month or in ambulatory care. A greater recognition encourage doctors to continue to practice provide accommodation to medical of GPs in the provision and teaching of for more years and to dissuade early students in their sixth year of study if primary care could become more retirement. The 2003 law reforming these students commit to locating for a acceptable to specialists if they work in retirement rules allows individuals to have minimum period of five years in a collaboration rather than in competition. an activity based income on top of their medically deprived area. From this perspective, the challenge will be pensions. The cap on the additional to define a new contract for doctors – Doctors participating in out-of-hour income has also been raised from €30,000 working in the ambulatory sector in order services in such areas will benefit from to €40,000 for doctors retiring beyond age to guarantee equal access to care for all of a tax revenue rebate on their income 65. Moreover, doctors older than 60 are the French population. from this activity for up to a maximum exempt from out-of-hour shifts. of 60 days or €9000 per year. Delegation of medical tasks from A single regional office will be in charge of REFERENCES physicians to other medical staff disseminating all available information on Skill mix and especially the delegation of 1. Organisation for Economic Cooperation these incentives in order to increase tasks from physicians to other health care and Development. Eco-Sante Database doctors’ knowledge and understanding. 2003. Paris: OECD, 2003. professionals are considered an important issues by the Ministry of Health. The plan 2. Observatoire national de la démographie Improving working conditions aims to improve cooperation between des professions de santé. Rapport annuel It is generally accepted that operating in doctors and these professionals. Evalua- 2004 [Annual report 2004]. Paris : group or multidisciplinary practices would tions first begun in 2005 looking at sharing ONDPS, 2004. Available at improve both the quality of health care and or transferring tasks from doctors have http://www.sante.gouv.fr/ondps the quality of life for doctors. A special now been extended from five to fourteen 3. Observatoire national de la démographie fund (Fond d’Aide à la Qualité des Soins pilot schemes.6 These projects have been des professions de santé. Rapport annuel de Ville, FAQSV), which was set up within limited to very precise situations in a few 2005 [Annual report 2005] Paris : ONDPS, the national health insurance budget to practices, impacting on a very limited 2004. Available at finance innovations in ambulatory care number of patients and professionals e.g. http://www.sante.gouv.fr/ondps organisations among other things, will be looking at the role of nurses in dialysis or used to make capital investments to set up 4. Berland Y. Rapport de la commission radiotherapy as well as the conduct of eye Démographie médicale [Report of the multi-speciality group practices. sight tests by opthamologists/orthoptists. Medical Demography Commission] Paris: Additionally, a new status of ‘associated ONDPS, 2005. Available at The ONDPS has supervised these pilot partner’ has been created for young www.sante.gouv.fr/htm/actu/berland_dem evaluations.7 Initial results confirm their doctors. This will allow them to join a omed/sommaire.htm feasibility in terms of safety and quality. practice without having to make a capital 5. Bourgueil Y, Chevreul K. Demographic General recommendations for a widening investment. The plan also has abolished the plan for health professionals. Health Policy and further generalisation and devel- difference in the maternity leave period Monitor 2006; France, Survey 7. Available opment of advanced practice nurses will be permitted to female doctors compared to at http://www.hpm.org/en/Surveys/ produced by the end of 2007 under super- that enjoyed by other employed women. IRDES/07/Demographic_plan_for_health_ vision of the HAS (Haute Autorité de This will facilitate a better balance between professionals.html Santé), a body similar to the National family and professional life, and is essential Institute of Clinical Excellence (NICE) in 6. Arrêté du 30 mars 2006 modifiant et given the increasing number of female complétant l’arrêté du 13 décembre 2004 England and Wales in its functions. doctors. relatif à la coopération entre professions de santé [Decree of 30 March 2006 modifying Conclusion Increasing the number of doctors and the and supplementing the decree of 13 The demographic pressure on the health proportion of GPs in workforce December 2004 relating to cooperation care workforce may have a dramatic The plan also increased the numerus between health professionals]. Journal impact on future health care supply and clausus, which restricts the number of Officiel 2006;83 (7 April). organisation in France. In one sense, this entrants to medical schools from 4,700 7. Berland Y, Bourgueil Y. Rapport sur cinq situation is a threat to the equilibrium students in 2002, to 6,300 in 2005, and to expérimentations de coopération et de délé- between health care professionals. In 7,000 per year for the period 2006 to 2010. gation de tâches entre profession de santé another, it offers an opportunity to Furthermore, from 2006, a two-month [Report on five pilot schemes on cooper- support restructuring policies, both in the training period in general practice has been ation and delegation of tasks between hospital and ambulatory sectors. This offered to medical students in at least third health professionals] Paris: ONDPS, June implies, for instance, a re-definition of the year of study, in order to improve their 2006. Available at roles of specialists and general practi- knowledge about general practice. Previ- http://www.sante.gouv.fr/ondps tioners in the ambulatory sector. ously, as we have noted, French medical 8. Com-Ruelle L, Dourgnon P, Paris V. students did not have any training period The recent reform of the médecin traitant Can physician gate-keeping and patient in general practice before choosing their which introduced a preferred doctor choice be reconciled in France? Analysis of speciality. The proportion of students scheme, while not clearly oriented towards recent reform. Eurohealth 2006;12(1).

26 Eurohealth Vol 12 No 3 FOCUS ON FRANCE New governance arrangements for French health insurance

Carine Franc and Dominique Polton

Summary: This article traces the development of statutory health insurance in France, highlighting challenges in governance and power arrangements between the state and the health insurance funds. The impact of the 2004 Health Insurance Reform Act is also discussed. This introduced new governance arrangements that on the one hand can be seen as a reinforcement of the power of the state in the management and regulation of the health system. At the same time significant decision making powers have been shifted from the state to UNCAM, the new National Union of Health Insurance Funds.

Keywords: France, Health policy, Health insurance, Governance

Background Today 95% of the population is covered The governance of the health care The French national health insurance by three schemes providing a uniform system: problems and past reforms scheme was established in 1946,* just after package of benefits: the general health The social security system created in 1945 the Second World War, as an employment insurance scheme (Régime Général), the was associated with the idea of social based statutory system. The three main agricultural scheme (Mutuelle Sociale democracy; the Régime Général (covering objectives inspired both by the Agricole, MSA) and the national insurance 85% of the population) was thus organised ‘sozialpolitik’ of Bismarck (1881) and the fund for self-employed non-agricultural as a network of health insurance funds famous report of Beveridge (1942) were: workers (Régime Social des Independents, headed by elected boards of directors unity (a unique national fund), universality RSI). In addition, there remain several comprising representatives of employees (equal access) and uniformity (equal insurance systems for some professional (the majority) and employers.*** It treatment). At the end of 1946, the French groups who already had insurance included 129 local funds, 16 regional funds social security system covered health coverage in 1945, including civil servants, and a national fund (Caisse Nationale d’as- insurance including accidents at work, mariners, miners, railway-workers, and surance Maladie, CNAMTS). Employees maternity allowances, disability insurance, employees of the national bank. and employers were to manage the a pension scheme, and family allowances sickness benefits, financed through payroll Health insurance in France has, therefore, for workers and their families. contributions. always been more concentrated and Statutory health insurance was only uniform than that seen in other ‘Bismar- Since 1945, the governance of the health extended to farmers in 1961 and to self- ckian’ systems (such as the German care system has been the subject of employed non-agricultural workers in system). Universality was achieved in 2000 numerous debates and several reforms, the 1966. By then the objective of unity had through the Universal Health Coverage most recent of which were part of the been abandoned and independent schemes Act (Couverture Maladie Universelle, health insurance reforms of 2004. Two were created for these two professional CMU), which enshrined the right to issues are at stake: (1) the division of power groups. statutory health insurance coverage on the between the state and the health insurance basis of residence, thus providing coverage funds over governance of the funds and the to the non-insured fraction of the popu- relationships between the two, and (2) the Carine Franc is a Researcher at the lation.** internal management of the health Institut National de la Santé et de Recherche Médicale and the Institut de Recherche et Documentation en * The edict of 19/10/1945 concerned among others risks, the risk of illness and the law Economie de la Santé (IRDES), Paris, passed on 22/05/1946 worked on the principle of the continued spread of social security France. to the whole population. Dominique Polton is Director of Strategic ** Estimated at about 1% of the population. Before the CMU Act a system of personal Research and Development, Caisse insurance existed and premiums were financed by local governments for those with low Nationale d’Assurance Maladie incomes. (CNAMTS), Paris, France. *** The same principles of professional representation apply to the governance of the Email: [email protected] two other main funds, but they will not be analysed in detail here.

Eurohealth Vol 12 No 3 27 FOCUS ON FRANCE insurance scheme itself. These two issues prominently on the political agenda. An directors. But in 1967, in the first major have always been considered to be prob- important step was taken in 1996 with the reform of social security these elections lematic, especially in respect of the Juppé reform: notably it addressed the were replaced by a system of trade union recurring problems of cost containment issue of legitimacy and democratic control appointments. This also meant that there and deficit management found within the of state decisions by reinforcing the role of was parity in representation between French health care system. parliament.1 Thereafter, the parliament has employers and employees, whereas before set a projected target (ceiling) for health employees had been in the majority. In The respective roles of the Government insurance spending for each subsequent 1982, with the political left coming to and the sickness funds year, known as the national ceiling for power, the intention to return to the From the very beginning, the system was health insurance expenditure. However, up original principles of 1945 was announced, hampered by the fact that although the to 2005, this objective has only been with a return to elections and employees social security scheme was to be managed attained once, in the first year 1997. The majority boards. In practice, however, by representatives of both employers and reform also created regional hospital such elections only took place once, in employees, in the health care sector the agencies linking the state and the sickness 1983. extent of these management responsibil- funds at the regional level, but in practice The 1996 Juppé reform reversed the policy ities was limited, especially in terms of giving pre-eminence to state influence. and returned to the 1967 position again financial responsibility. This is another key appointing board members and reintro- difference to other social insurance ducing parity between employers and systems, such as the German system. In employees. In addition, parliamentary fact, the French health care system has “state authorities and the involvement from 1996 also raised ques- from the beginning been a hybrid system tions about the legitimacy of employers (in between the Beveridge and Bismarkian health insurance funds and trade unions as a source of democratic models). This historical feature partly were increasingly in control. The links between professional explains the difficulties that it has encoun- status and health insurance were also tered ever since. conflict” relaxed: wage contributions were replaced In the initial division of powers between by a tax on income in 1996 with coverage the state and the sickness funds, funda- based on residency in 2000. mental decisions about the level of contri- At the beginning of the new millennium butions, the extent of the benefit package The Juppé reform was thus seen by many governance of the health care system and the fee schedules* belonged to the as giving the state more control of the remained a burning issue. After several state. The state also handled policy health care system. This trend was further attempts at clarification, the division of concerning public hospitals (planning and reinforced by the Social Security Funding responsibilities still remained unclear. The budgets) and drugs (price setting), while Act of 2000, which gave the state responsi- state authorities and the health insurance the health insurance funds negotiated bility for the whole hospital sector, funds were increasingly in conflict, with collective agreements with professionals in including private for-profit hospitals that the trend towards state control regularly private practice, including the level of previously were regulated by the insurance denounced by the health insurance funds. prices (nevertheless these agreements had funds. In return, a more clear delegation to be approved by the government). was given to CNAMTS regarding the This tension reached a critical point in ambulatory care sector budget (profes- September 2001, when the main employers In addition, there was also a division of sional fees and prescriptions). However, union withdrew from the boards of all the power across different geographical again in practice, this delegation of respon- health insurance funds, on the grounds entities, both within the state and the sibilities was only implemented during the that the funds did not have the ability to sickness funds. For instance, up to the first year. effectively regulate health care expendi- 1990s hospital planning was designed by tures; the legitimacy of these boards thus the regional directorates of the state while The internal management of the health became even more questionable. At the the budgeting process was at the insurance funds same time, the deficit of the general scheme département level. For a period of time, The issue of organisation structure and was soaring (€6 billion in 2002, more than tariffs for private-for-profit hospitals were decision making power within the health €11 billion in 2003 and 2004), increasing set independently by each regional fund insurance funds is also linked to the rela- still further demands for a strong cost (with its own boards of directors). tionship between the funds and the containment policy. Several reforms have attempted to address government. Historically, social insurance Thus, in August 2004 the Health Insurance the conflicts and contradictions arising managed by employers and employees and Reform Act introduced changes in the from the complexity of this institutional based on payroll contributions, was seen institutional arrangements, addressing landscape. Over time, this balance has as a more coherent and legitimate mech- both the issue of shared decision making tended to shift towards increased state anism than direct state intervention. power between the state and the health intervention, particularly since the issue of This ‘social democracy’ was to rest upon insurance funds, and the status and balancing the public accounts, and thereby direct elections to the funds’ board of management of the latter. controlling public expenditure, has figured New governance arrangements The reforms have been largely inspired by * Setting reference values for health care services provided by the various categories of a consensual report from the High Council professionals in private practice.

28 Eurohealth Vol 12 No 3 FOCUS ON FRANCE for the Future of Health Insurance, which impact on health expenditures. From now voluntary insurers body, UNOCAM, has stressed the necessity to redesign respon- on, the government can only refuse the to be consulted on decisions related to co- sibilities in the management of the health approval on legal or public health grounds. payments. care system by identifying a ‘chief’ in This means that the sickness funds are fully The health insurance funds are also now charge to pilot and to insure the coherence responsible for the economic conse- responsible for meeting the financial objec- of the system.2 quences of the agreements that they nego- tives for ambulatory care expenditure. tiate and sign. In respect of hospital care The three main insurance funds (Régime They are assumed to have the capacity and and drugs, UNCAM is more involved in Général, MSA and RSI) are now federated tools to control their health care costs and the decision making process than previ- in a National Union of Health Insurance stay within the limits of the national ously was the case, although the state Funds (Union Nationale des Caisses target/ceiling set by parliament. An inde- retains a leading role. d’Assurance Maladie, UNCAM). This pendent committee monitors the evolution new federation has become the sole of health expenditures during the year in representative of the insured in negotia- order to inform the state and UNCAM if tions with the state and health care “The ability to define there is a risk that this target will not be providers. met. If this is the case, UNCAM is obliged to take measures (notably concerning user The director-general of the UNCAM is levels of co-payment now charges) to balance the budget. also the director of the CNAMTS. He is rests with the health nominated by government and his exec- Conclusion utive power has been strongly reinforced insurance funds” On one hand, the new governance at the expense of the board, whose role is arrangements implemented following the now limited to strategic matters. For 2004 reform can be seen as a reinforcement example, collective agreements with of the power of the state in the doctors and other organisations of profes- The health insurance funds are now management and regulation of the French sionals in private practice are now responsible for defining the package of health system at the expense of employees negotiated and signed by the director- care to be covered (for procedures and employers unions. In comparison with general alone. He also nominates the performed by health care professionals). the past, the national health insurance fund directors of local and regional funds; thus This was previously a state responsibility. (general scheme) has moved towards being operational management is clearly in his The sickness funds are assisted in their an independent agency under state control. hands. decisions by the High Authority of Health On the other hand, some decision making This is thus a new step in the process of the (Haute Autorité de Santé, HAS), which is powers have been shifted from the state to withdrawal of employees and employers in charge of the scientific evaluation of this newly organised insurance fund: the unions from the management of the health diagnostic and therapeutic procedures and notion being that increased autonomy and insurance system. But is it a reinforcement the development of clinical guidelines. responsibility will lead to improved of the state’s power? The answer is Consultation should also take place with performance in system management. Only ambivalent as the reforms reinforce indi- the Union of Voluntary Health Insurers time will tell as to whether this promise rectly the power of the state to the (Union Nationale des Organismes will be kept and these new institutional detriment of employees and employers Complémentaires d’Assurance Maladie, arrangements will operate in a more co- unions by entrusting much power to the UNOCAM), a new institution created by ordinated and efficient manner. director-general of UNCAM. Yet, at the the reform.* same time, important responsibilities have The ability to define levels of co-payment been shifted from the state to this new REFERENCE also now falls under the jurisdiction of the managed health insurance fund. These health insurance funds. Prior to these 1. Ordonnance n°96-344 du 24 avril 1996, concern the financial governance of the reforms, most user charges were co- Ordonnance portant mesures relatives à l’or- health care system, the definition of the insurance fees, fixed by the state. Now, ganisation de la sécurité sociale [Decree on health care package and the regulation of some co-payments may be levied in measures related to the organisation of social prices and tariffs, as well as the negotiation addition to co-insurance rates for each security]. of collective agreements with service consultation with a health professional. All 2. Fragonard B (President). Rapport du haut providers. This shift of power is discussed these user charges are now fixed by the conseil pour l’avenir de l’assurance maladie. further below. sickness funds and no longer by the state [Report of the High Council on the Future New responsibilities (although it can oppose decisions taken on of Health Insurance] Paris: Ministère de la public health grounds). Again the Santé et des Solidarités, January 2004. For instance, in order to regulate ambu- latory health care expenditure, the director-general of UNCAM now has more power than the health insurance * The underlying idea was that in the French health care system, given the role of voluntary funds had previously, to negotiate with the insurance, which covers co-insurance and co-payments for more than 90% of the popu- doctors’ unions and other professionals in lation, effective stewardship of the health care system requires coordination between private practice. Previously, the statutory and complementary insurance. The mutual benefit movement, which is an government could decide to approve or important force in French political life, has strongly advocated the involvement of supple- refuse the result of the negotiations, taking mentary insurers in the collective regulation of the health care system. UNOCAM was into account various factors including the inspired by this proposal.

Eurohealth Vol 12 No 3 29 EUROPEAN SNAPSHOTS

specialists and subsequent appropriate A new policy agenda in treatment within a specified time period. If care cannot be provided within an indi- vidual’s local catchment area, then he Sweden: choice and would be free to seek treatment elsewhere. At present, this guarantee is for guidance only, but proposed new legislation would deregulation enshrine it in law. Furthermore, additional private sector institutions will be included in the list of approved health care providers that can be funded by the public purse. Anna Melke In addition, state grants will encourage providers to move care out of the hospital setting and provide privately managed The September 2006 general election gave during the election campaign. (In Sweden, services. The Minister of Health has also Sweden its first centre right government much of the responsibility for health and proposed the potential privatisation of since 1994. In fact, the Social Democratic social care lies with the county councils some aspects of hospital services in the Party (SDP – Sveriges socialdemokratiska and municipalities rather than central country, i.e. permitting private manage- arbetareparti) has been in power since government.) Nonetheless, the new ment and the accrual of profits.1 He has 1932 with the exception of just nine years. government’s first budget presented to the also announced potential reforms to the The new government is comprised of four Riksdag in October 2006 will have signif- dental care system, such as decreasing user different parties. The new prime minister, icant consequences for health policy. charges, which may help increase access.2 Fredrik Reinfeldt, has managed to obtain a majority of seven seats in the parliament Unemployment and sickness benefits Focus on older people and mental health (Riksdag) by successfully building a The election campaign focused heavily on One of the main areas of proposed addi- coalition between his ‘new’ Moderate the economy and, in particular, on the need tional spending is on health and social care Party (Moderata samlingspartiet) and to reduce the high levels of unemployment for older people. The government plans to competing parties on the right: the Folk and challenges arising from long-term invest in many areas, including promoting Liberals (Folkpartiet liberalerna), Centre absence from the workforce. The centre- an increase in the number of residential Party (Centerpartiet), and Christian right coalition also campaigned on a care beds and doctors, better use of drug Democrats (Kristdemokraterna). While platform which would incentivise indi- treatment, and improved care for people this may seem a very narrow majority, it viduals on long term sick leave to return to living with dementia (and their family represents a remarkable change in a work. One way of doing this was to reduce carers). Older people will also be country where the SDP has long been able the maximum monthly sick pay by about encouraged to make active choices to run minority administrations, relying €1,000 for high income earners. Moreover, regarding their care and service providers. on support from Left and Green parties. a new system for calculating sickness Local elections were also held on the day benefits will be introduced and measures Since 2003, mental health has also been of the general election and the right wing taken to combat supposed irregularities, high on the agenda, most notably because parties were also successful in many of the such as overuse, abuse and inaccurate of the high profile murder of the SDP regional (county councils) and local authorisation of sick leave by general prac- Foreign Minister, Anna Lindh, by Mijailo (municipalities) governments. titioners. There will also be changes to Mijailovic, a man acknowledged in his trial unemployment insurance resulting in to have significant mental health problems. Health policy in Sweden on the national higher contribution rates and lower benefit Subsequently, a national coordinator was level will be determined by officials from levels. Additionally, more thorough appointed to look at the system and see two different parties. Göran Hägglund changes have been announced including how it might be improved. One key (Christian Democrat leader) has been making the self-employed contribute to conclusion was the need for substantial appointed Minister for Health and Social the unemployment insurance and incorpo- additional funding; this is reflected in the Affairs, Maria Larsson (Christian rating this into the general social security new budget. The emphasis will be on Democrat vice president) is the Minister system. enhanced professional training as well as for Elderly Care and Public Health, and an increase in inpatient beds. Preventive Christina Husmark Pehrsson (Moderate) Increasing emphasis on choice actions are also being considered, specifi- is the Minister for Social Security. One key theme in the new budget is the cally related to child mental health Although opinion polls indicate that emphasis on the freedom of choice of care including increased access to psychologists Swedes, like others in Europe, are provider, partly through fostering private and social welfare officers in primary care. concerned with the future of their health sector alternatives. The so-called national Specific funding will also be dedicated to care system, it was only a marginal issue ‘care guarantee’ is to be further developed, care management. placing particular attention on freedom of choice for health care consumers. The State monopolies Anna Melke is a former journalist and guarantee was first introduced in 2005 as a Turning to public health issues, taxes on currently a PhD candidate, School of means of reducing waiting lists and ensures tobacco will increase, while taxes on Public Administration, University of that anyone in need of care is guaranteed alcohol will not decrease. The latter had Göteborg, Sweden. contact with their GP or other relevant previously been suggested in one report as Email: [email protected]

30 Eurohealth Vol 12 No 3 EUROPEAN SNAPSHOTS being beneficial in reducing alcohol More information on the new govern- Swedish Government Official Report. imports,3 and had been endorsed by the ment’s policy at http://www.sweden.gov.se Challenge Without Borders – Alcohol Moderate Party. However, the new Public Policy in a New Era (In Swedish: Gränslös Health Minister confirmed that it would utmaning – alkoholpolitik i ny tid). REFERENCES not be possible to reach a common Stockholm, 2005. Available at http://www. position on tax reductions within the four- 1. Hägglund G. Interview in Dagens regeringen.se/sb/d/5140/a/40647 party coalition.4 Instead, the focus will be Nyheter, 14 November 2006. 4. Larsson M. Interview in Dagens on measures to reduce illegal sales of 2. Hägglund G. Interview in Svenska Nyheter, 18 October 2006. imported alcohol. There has also been no Dagbladet, 22 October 2006. 5. Odell M. Interview in Dagens Nyheter, mention of any reform to the state 3.Ministry of Health and Social Affairs, 15 November 2006. monopoly on the sale of alcohol; some- thing that has often been challenged by the centre-right. The two national institutions responsible for the prevention of alcohol and drug use are to be abolished by 2008. Health care reform in It remains unclear who will now take on these roles. Germany: is Bismarck going In contrast to alcohol, the current retail monopoly of the state-owned pharmacy chain Apoteket AB in the distribution of Beveridge? both prescription and non-prescription medications will end and the market then opened up to other suppliers. A bill setting out how the new arrangements will Melanie Lisac and Sophia Schlette operate has yet to be published, so the precise nature of deregulation in the phar- maceutical sector remains unclear. Chancellor Angela Merkel declared health private health insurers can currently reject care reform a top priority in March 2006. individuals who have no coverage or have Another broader policy issue with At the time, high expectations were placed lost their insurance due to unemployment, potential health impacts is that of on the new grand coalition between the divorce, or low-income jobs. From April gambling. The national betting agency, CDU/CSU (Christlich Demokratische 2007, insurers must offer at least a basic Svenska Spel, is due to be dismantled and Union Deutschlands/Christlich-Soziale benefit package to these individuals. according to comments from the Minister Union in Bayern) and the SPD (Sozial- Care coordination incentives for Local Government and Financial demokratische Partei Deutschlands). The Markets, Mats Odell, foreign companies country anticipated far-reaching reforms To encourage the integration of health care may be allowed to enter the market.5 that would promote competition to providers, as well as better cooperation address the pressing problems of rising between health, social and long-term care, Conclusion expenditure, poor efficiency and evidence- the government will extend financial Considering the turbulent history of some free variations in the quality of care. incentives for integrated care contracts that coalition governments, it will be inter- focus on population-oriented care initia- esting to observe how well the parties New legislation tives. Facilitating selective contracting making up the new government will be Due to come into force in April 2007, the legislators hope will make sickness funds able to work together. After only a few ‘Statutory Health Insurance Competition and health care providers raise efficiency weeks in office, two Moderate ministers Strengthening Act’ (SHI-WSG) aims to and foster competition based on the have been forced to resign as media inves- strike a balance between the need for quality of care. tigations revealed some inappropriate reform and the explicit commitment to Contribution rate and tax funding personal actions, including the employ- safeguard universal access to essential ment of illegal workers, alleged tax health care regardless of the ability to pay. From 2009, the contribution rate will be evasion, and failure to pay the television Key elements of the reform are: determined centrally by ministerial decree, license. Furthermore, other ministers are replacing the rates currently set separately A guaranteed right to health insurance being investigated by the Riksdag for by each of the 250 sickness funds. In potential conflicts of interest in respect of In recent years, Germany has seen the addition, contributions will be supple- their personal investments. number of uninsured individuals climb to mented by tax revenues covering the 200,000. With no obligation to buy or sell health insurance needs of children. It also remains to be seen how the new health insurance coverage, both public and coalition will succeed in its internal nego- Portability of private coverage tiations. Moreover, with Sweden being a The reform bill contains a portability country where almost all parties constantly Melanie Lisac is Project Manager and provision allowing individuals with private ‘crowd the centre ground’ of the political Sophia Schlette Project Director, health insurance to change insurer without spectrum, it will be interesting to observe International Network Health Policy & undergoing a new risk assessment. This how the new government will in practice Reform Coordinator, Bertelsmann provision is also aimed at increasing differ ideologically from its predecessors. Stiftung, Gütersloh, Germany. competition among private health insurers. Email: [email protected]

Eurohealth Vol 12 No 3 31 EUROPEAN SNAPSHOTS

Debate comprises technical solutions They could “compete” over the quality sickness funds (or sell complementary The grand coalition holds a comfortable and efficiency of contracted services or polices), private health insurers managed to majority in the Bundestag and could thus choose to merge with their rivals to remain outside of the health fund and stay easily legislate for substantial reform. The generate major efficiency gains. If, in the business of providing private recent health policy making process has, however, the sickness funds could not comprehensive health insurance. However, however, turned out to be anything but purchase all necessary health services with requirements for purchasing private smooth. Social and Christian Democrats their fund allocation, they would be coverage have been tightened. To opt out differ strongly in their ideas for health care permitted to charge their policy holders an of the statutory health insurance scheme, reform which makes consensus building extra contribution. The debate did not earning a lot is not enough any more; between the coalition partners difficult. however end there. instead, individuals need a three-year Moreover, the technical dispute about the record of income above the opting-out The idea of an extra contribution, whether challenges and solutions for health reform ceiling. Furthermore, private health flat-rate or income-related, has led to and the political dispute about the right insurers have to offer a social health feelings running very high within the SPD. balance between solidarity and individual insurance-like comprehensive benefits The left of the party worried about the responsibility have been overshadowed by package to their clients and thus enter into unfair distributive effects that these extra a battle for resources and political competition with the public sickness funds. charges would have on low-income influence. Leaders of the wealthier earners. Therefore, the SPD wanted to Bundesländer have repeatedly opposed Competition? Yes but… limit any contribution to just one percent federal government proposals for health Finding a consensual solution to health annual income. The CDU/CSU opposed financing reforms, such as the new risk care financing has thus been tricky. All in such a ceiling, arguing that it would restrict adjustment mechanism, because they fear all, the proposal as laid down in the official competition between sickness funds. that the additional financial burden will fall cabinet’s draft for the “SHI-WSG” (25 Because of this and other unresolved ques- on their states. Since the CDU/CSU have a October) does not live up to the expecta- tions, the grand coalition decided to majority in the Bundesrat (upper house tions of health policy experts or the public. postpone the health fund until 2009, which representing the federal states), this peculiar The irony is that those who most loudly happens to be the year of the next general power constellation, with opposition called for competition as the ultimate election. coming from the Chancellor’s own party, means of achieving a sustainable, threatens ratification of any new health care As if coalition quarrels weren’t enough, the affordable health care system are the very bill in the current circumstances. various lobby groups also want to have same players who are now opposing any their say. Their influence on policy makers change. Competition is fine as long as it The regional politicians’ protests have so further complicates the development of affects everybody except oneself. The resembled a preliminary electoral race reforms that are based on health care needs compromise put forward now does have among would-be candidates for the chan- and technical evidence-based assessment. some incentives to improve the quality and cellorship at the next general election that Not unexpectedly, the original reform efficiency of health care and aims to put the Chancellor’s image and her party’s proposals of June 2006 met with strong patient needs and care requirements ahead popularity have plummeted, as frequent opposition from of all those who still lived of the vested interests of long-standing opinion polls clearly show. comfortably under the status quo. institutions. Nonetheless, especially in the The bottom line for the coalition centres area of financing, power games and the around one fundamental ideological Winners or losers? need to find an arrangement that suits both question: is competition the remedy for These players do perceive the risks, i.e. governing parties, have postponed any far- the ailing system, or is ‘state medicine’ the how the reform touches upon their reaching structural reforms. answer? How can they possibly be particular interests, but not the opportu- aligned? When it comes to the issue of how nities (or choose to ignore them): to raise revenue to secure health care REFERENCES Sickness funds that might under the health financing the coalition partners have little fund be forced to merge will have more 1. Lisac M. Health care reform in common ground. freedom to selectively contract with Germany: Not the big bang. Health Policy The health fund providers. Monitor 2006; November. Available at www.hpm.org/surveyde/a8/4 The imminent abolition of statutory The ongoing debate around the proposed 2. Zimmermann M. Health financing health fund vividly illustrates the differing physician associations as collective negoti- reform idea: health fund. Health Policy political views: ating bodies, will mean that providers will Monitor 2006; April. Available at be free to directly negotiate (improved) The health fund, a new health insurance www.hpm.org/survey/de/a7/1 contracts with sickness funds. tool,1 would combine these different 3. Weinbrenner S, Busse R. Proposals for financing approaches. The fund would There are also those private health insurers SHI reform. Health Policy Monitor 2003; centrally pool income-related employer who have won at least a temporary victory. October. Available at and employee contributions as well as Much of the original reforms have been www.hpm.org/survey/de/a2/4 federal tax revenues. Through the health watered down or abandoned altogether FURTHER INFORMATION fund, sickness funds would receive a risk- thanks to their successful lobbying of Bundesministerium für Gesundheit. adjusted flat-rate amount for each insured regional politicians. While the June 2006 Gesundheitsreform [Health care reform]. proposal would have brought private full- person. The sickness funds would be trans- Available at www.die- formed from payers to players and thus cover health insurers into the health fund gesundheitsreform.de (German only). have to manage their resources wisely. and compelled them to compete with the

32 Eurohealth Vol 12 No 3 HEALTH POLICY Stem Cell Politics

Anne-Maree Farrell

Summary: In recent years, the use of human embryonic stem cells (HESC) for research or other purposes, has generated significant political conflict at EU level, which has been mirrored in a number of Member States, as well as in other western countries, such as the United States. This article, identifies the key param- eters of such conflict in an EU context, the strategies employed by EU decision- makers to reach political compromise on a range of issues involving HESC use, and considers some of the wider implications of managing stem cell politics at EU level.

Key Words: Stem cells, Politics, Biotechnology, European Union, Ethics

Ethical concerns ‘signifier’ to cover a range of ethical conflict over ethical aspects concerning the Ethical fault lines in stem cell politics at concerns at EU level over HESC use, funding of HESC research erupted in EU level have focused predominantly (but including upholding the sanctity of human inter-institutional debates over the 6th not exclusively) on research involving life from conception, preserving the Framework (FP6) Programme for HESC use. Unlike adult or ‘multipotent’ integrity of the person, and preventing the Research in the years 2002 to 2003. Despite stem cells which can be used to make a instrumentalisation and/or commodifi- the Commission attempting to lay the limited range of specialised cell types, cation of human beings. Such discourse groundwork for agreement on the issue embryonic or ‘pluripotent’ stem cells are draws inspiration from a number of inter- through obtaining an expert opinion on not limited in this way and therefore are national human rights instruments, and in ethical aspects of human stem cell use, much more attractive for research particular from the EU’s Charter of bringing key stakeholders together, and purposes. The key ethical dilemma which Fundamental Rights. Although the issuing a position paper on the matter, has emerged to frame political debates in Charter is not currently recognised as political consensus proved elusive leading relation to HESC research has centred on legally binding under Community law, it to a moratorium on HESC funding under protection of human life from the moment has nevertheless been relied upon at an FP6. of conception on the one hand, and the institutional level in relation to a wide Although the European Parliament subse- promotion of research leading to new range of administrative and policy activ- quently passed a resolution permitting medical treatments which could alleviate ities, as well as to inform political debates such funding under tightly controlled human suffering and/or promote human involving ethical and/or rights issues. circumstances, the Council was unable to potential on the other hand. At the heart reach political agreement on the matter. In of this dilemma are differing and deeply the absence of such agreement, the held views over what constitutes a human Commission was made responsible for the being. “At the heart of the management of the FP6 programme, Within the EU context, a powerful ethical dilemma are differing and issuing guidelines which permitted discourse around notions of ‘human research into supernumerary human dignity’ has emerged in policy and regu- deeply held views over embryos (i.e. surplus embryos resulting latory debates over the use of the human from in vitro fertilisation treatment that body and its parts generally, and stem cells what constitutes a human were subsequently donated for research in particular. In this regard, the need to being” purposes) created prior to 27 June 2002. preserve human dignity has been used as a Any unresolved questions on potential funding involving HESC research were to be resolved on a case-by-case basis.1 Anne-Maree Farrell is Lecturer, School of Law, University of Manchester, A further opportunity to debate ethical Manchester, UK. Institutional conflict concerns over HESC use presented itself Email: [email protected] Opportunities to express ethical concerns during inter-institutional negotiations over over HESC use have arisen on a number the adoption of the Tissue/Cells This article was written while the author of occasions at EU level in recent years, Directive.2 In the context of such negotia- was on a Leverhulme Trust Research most notably in relation to research tions, conflict arose between the European Fellowship. The Trust’s support is funding programmes, and in legislative Parliament, the Commission and Council gratefully acknowledged. debates over human tissue. Political over whether Community legal compe-

Eurohealth Vol 12 No 3 33 HEALTH POLICY tence to set standards for quality and safety recognise the economic potential to be strates the high stakes involved for those in relation to the use of human tissue/cells derived from successful commercial appli- working in the area, challenges the idea of under Article 152(4)(a) EC could cations resulting from such research. Such the neutral and objective pursuit of scien- encompass ethical concerns over HESC recognition is underpinned by a tific ‘truth’, and lends weight to ethical use. In the absence of a general political commitment to the Lisbon strategy concerns voiced by those opposed to consensus, a compromise was eventually adopted by the European Council in 2000, HESC research and use.8 The current reached whereby it was agreed in non which aims to make the EU the ‘the most approach at EU level is to acknowledge the legally binding terms in the Recital to the competitive and dynamic knowledge- potential offered by HESC research, but Directive that there would be no inter- driven economy by 2010.’5 Supporting to adopt a cautious approach to its ference with the decisions made by innovation and the development of new funding. Such an approach involves ethical Member States regarding HESC use. In medical treatments and commercial appli- and scientific oversight of researchers circumstances where individual Member cations derived from stem cell research granted funding in line with guidelines States did permit HESC use, however, (whether involving HESC or not) repre- specified by the Commission. While such they were to ensure public health sents an opportunity for the EU to guidelines are clearly designed to address protection and respect for fundamental position itself as a global leader in the field. ethical concerns, it is equally clear that the rights in relation to such use.3 Although Although the United States has tradi- intention is to avoid the occurrence of any such an approach resulted in a political tionally dominated research and inno- similar incidents in the EU context of the compromise, which enabled the Directive vation in biotechnology, President George type that arose in the case of the South to be adopted, it nevertheless resulted in W. Bush’s ongoing opposition on moral Korean scientist. EU-wide quality and safety standards in grounds to providing federal funding for What is absent from the current approach relation to HESC use that were less than HESC research,6 presents EU decision- taken by the Commission in this regard, comprehensive. makers with an opportunity to create a however, is any recognition that the research environment, which is more Notwithstanding the political compro- provision of scientific advice or oversight conducive to innovation and research in mises reached in relation to HESC in policy-making and regulatory processes this field, furthering its leadership ambi- research and use under FP6 and the can be problematic, particularly when they tions in the area.7 Tissues/Cells Directive, ethical fault lines involve politically contentious issues; over the issue remain, and have recently something of which EU decision-makers resurfaced in inter-institutional debates were made painfully aware in the context over the proposed 7th Framework (FP7) “EU decision makers also of the BSE crisis of the late 1990s.9 On the Programme. Despite strong differences of basis of the Commission’s current guide- opinion within the European Parliament, recognise the economic lines on HESC research, however, the limited funding for HESC research was assumption appears to be that the scientific agreed in relation to the proposed FP7 potential from successful advice/oversight is value-free and programme in June 2006, and the matter objective. Given the contentious nature of came before the Council in July 2006. commercial applications of HESC research and use, and in the light of Within the Council, a potential blocking past difficulties experienced with the minority of Member States composed of research” provision of scientific advice, it would no Austria, Germany, Italy, Lithuania, Malta, doubt assist in the building of public trust Poland, Slovakia and Slovenia, had formed by EU decision-makers if transparency or around objections to the funding of HESC accountability mechanisms in relation to research. In the end, Germany, Italy and Scientific research and expertise expert advice and oversight on the issue Slovenia agreed to a compromise on Scientists claim that stem cell research were clearer. limited funding for HESC research, with offers the opportunity for the devel- the other five Member States maintaining opment of promising new medical treat- Public views their objections. The compromise reached ments in relation to diseases, including Differences of opinion at an institutional acknowledges that the terms under which Alzheimer’s, Parkinson’s and diabetes. The level over HESC research and use at EU funding for HESC research was granted use of undifferentiated cell lines, such as level are also mirrored among European under FP6 will continue. Certain fields of those derived from HESC, offers much citizens, as was evident from the findings research will be specifically excluded, such more scope for scientists engaged in such of a recent Eurobarometer survey, which as human cloning for reproductive research to investigate the potential appli- canvassed views on biotechnology, 10 purposes and the modification of the cation of stem cells to treat a range of including stem cell research. Of those genetic heritage of human beings. diseases, than does the use of adult stem polled, 59% said they approved of HESC Although any research activities involving cells. The potential offered by such research, and 65% of the use of non- steps which lead to the destruction of research, however, largely remains to be embryonic sources of stem cells, provided human embryos will not be available for realised at the present time and a long-term that it was tightly regulated. Particular funding, it will still be available for subse- view needs to be taken of the prospects of questions directed towards eliciting their 4 quent steps involving HESC. success resulting from such research. views on ethical aspects of such research, however, revealed significant differences of Economic potential Revelations of scientific fraud and opinion. When questioned over whether While ethical concerns about HESC misconduct by South Korean Woo Suk an embryo can already be considered to be research loom large in inter-institutional Hwang, formerly recognised as a leading a human being immediately after fertili- debates, EU decision-makers also international stem cell researcher, demon- sation, 54% of those polled agreed with

34 Eurohealth Vol 12 No 3 HEALTH POLICY this statement, while 32% disagreed. successful than others, and there are gaps in policy and regulatory initiatives, some REFERENCES When presented with the ethical dilemma of which are more serious than others. 1. EU set to fund stem cell research despite of the potential offered by such research lack of Council agreement. EurActiv 19 for new medical treatments against the Regulation of HESC use is not as compre- August 2004. Available at need to protect human embryos, those hensive as it could be given the absence of http://euractiv.com/en/biotech polled were divided with approximately EU-wide quality and safety standards in 40% of the view that it was wrong to use this area in the Tissues/Cells Directive. 2. Commission of the European Commu- nities. Directive 2004/23/EC of the embryos in medical research notwith- Transparency and accountability mecha- European Parliament and of the Council of standing such potential, compared with nisms in relation to the use of scientific 31 March 2004 on setting standards of 40% who approved of such use. When this advice and oversight which underpin quality and safety for the donation, ethical dilemma was posed another way policy-making and regulatory activities in procurement, testing, processing, preser- and those polled were asked about the relation to HESC could be made clearer. vation, storage and distribution of human duty to pursue research that might lead to While recognising that the scientific and tissues and cells. Official Journal of the new medical treatments, even if this economic potential offered by stem cell European Union 2004;L102/48, 7 April. involved HESC research, then 53% agreed research (whether through the use of 3. Farrell AM. Governing the body: exam- with this approach, while 29% did not. HESC or not) needs to be given serious ining EU regulatory developments in Although religious views on what consti- consideration and supported where appro- relation to substances of human origin. tutes a human being clearly influenced the priate, a more critical evaluation of the Journal of Social Welfare and Family Law views of those polled on the merits of risks and benefits of such research also 2005;27(3–4):427–37. HESC research, a clear majority in this needs to be given greater public and 4. Stem cell compromise allows approval of category nevertheless supported such political space at EU level. FP7 by Council. CORDIS News 25 July research, provided that it was tightly regu- 2006. Available at lated. What came through clearly from http://cordis.europa.eu/fetch?CALLER=E those polled was that they wanted more “EU-wide quality and N_NEWS&ACTION=D&SESSION=&R information about the benefits and risks of CN=26062 HESC research, as well as to whether regulation and ethical oversight were suffi- safety standards for 5. Commission of the European Commu- nities. Life Sciences and Biotechnology – A cient in this regard. embryonic stem cell Strategy for Europe. Brussels: Commission of the European Communities, 2002. Managing stem cell politics research are absent from Available at http://ec.europa.eu/biotech- A political consensus on HESC research nology/pdf/com2002-27_en.pdf and use at EU level has not been achieved the Tissues/Cells to date, and it is questionable whether this 6. Babington C. Stem cell bill gets Bush’s first veto. Washington Post 20 July 2006. is possible, or even desirable. The intensity Directive” Available at of current political conflict over the issue http://www.washingtonpost.com/wpdyn/c reflects deeply rooted cultural values, reli- ontent/article/2006/07/19/AR20060719005 gious beliefs, and ethical concerns over the 24.html value and potential of human life. Such In recent years, EU decision-makers have diversity needs to be respected in the trodden a fine line (and often torturous 7. EU funding of stem cell research to search for political compromise. In the path) between a range of ethical, institu- trigger ‘brain gain’. EurActiv 20 August 2006. Available at context of such a search, however, account tional, economic, scientific and public http://www.euractiv.com/en/biotech also needs to be taken of the fact that concerns on stem cell research, particularly policy-making and regulatory activities at in relation to HESC use. What has become 8. Stem cell debacle: the downfall of South EU level take place in a complex multi- apparent is that while political consensus Korea’s star researcher holds a vital lesson. level governance environment, which often may not yet be possible, political [Editorial]. New Scientist 3 December necessitates the employment of a range of compromise is nevertheless achievable 2005. strategies aimed at achieving agreement through employing a range of different 9. Levidow L, Carr S, Wield D. European between relevant stakeholders, institutions strategies which show respect for differing Union regulation of agri-biotechnology: and Member States on contentious issues. views over HESC use, while at the same precautionary links between science, time seeking to find a way forward which expertise and policy. Science and Public In this context, the intensity of recognises the scientific and economic Policy 2005;32(4):261–76. disagreement over HESC research and use potential of such research in a multi-level 10. Gaskell, G, Allansdottir A, Allum, N et has necessitated the use of a diverse range governance environment. In the search for al. Europeans and biotechnology in 2005: of strategies by EU decision-makers, political consensus, however, EU decision- Patterns and Trends. Eurobarometer 64.3. including: obtaining expert opinions on makers need to remain focused on the need Brussels: Commission of the European ethical concerns; bringing key stakeholders to cultivate public trust in their capacity to Communities, Directorate-General together; publishing position papers on the manage HESC use in way that is ethically Research, May 2006. Available at issue; crafting carefully-worded political acceptable, strictly regulated, and recog- http://www.ec.europa.eu/research/press/20 agreements; devising strict ethical and nises the importance of ongoing public 06/pdf/pr1906_eb_64_3_final_report- funding guidelines; and standard-setting may2006_en.pdf. dialogue and critical evaluation of stem cell through regulation, where agreement was research and its applications. possible. Some strategies have been more

Eurohealth Vol 12 No 3 35 HEALTH POLICY The challenges facing mental health reform in Romania

Jack R Friedman

Summary: This article discusses early research findings of an ongoing multi-year fieldwork project exploring the culture of mental health services and mental illness in Romania. In 2005, during two research visits, interviews were conducted with scores of patients and staff at three psychiatric hospitals in Romania – ‘Alex Obregia’ in Bucharest, ‘Socola’ in Ias¸i, and the psychiatric ward in the Policlinic of the Emergency Hospital in Petros¸ani (Jiu Valley).

Keywords: Romania, Mental health policy, Health system reforms, Psychiatric hospitals

Mental health reform and EU accession concerns about the safety of psychiatric most other medical specialities, height- On 16–17 December 2004, a summit of the patients and included wide-ranging ening the feeling that mental illness not European Council of Heads of State met condemnation of everything from issues of only carries a social stigma for patients, but to discuss the prospects for the admission the lack of enforcement of the laws also is stigmatised in the broader health of Turkey, Bulgaria, and Romania into the protecting patients under circumstances of care system.3 While the stigma against European Union. At the conclusion of the involuntary psychiatric commitment, to mental illness has been fought, with summit, the Council submitted a 47-point the lack of specialised mental health care limited effectiveness, by a handful of list of Romania’s progress toward training for nurses. Other issues raised NGOs,* it has proven especially difficult accession. While there were many included economic concerns about the lack for the medical community itself to lobby ‘congratulations’ in the Council’s report of sufficient quantities of basic psycho- for greater support from the state due to on Romania’s reforms, there were also pharmacological medications, and the almost complete lack of good epidemi- many core concerns that alarmed the problems with the physical layout due to ological data. Council. Two of the 47 points on overcrowding in Romanian psychiatric These burdens – the socio-cultural stigma Romania’s progress towards accession hospitals. of mental illness, the economic compe- concerned failures in regards to the While much of the Amnesty International tition for limited resources, the political treatment of people with mental illness or report was undoubtedly accurate, it also struggle to draw attention to the plight of intellectual (learning) disabilities (Points 19 made it perfectly clear that the weight of the mental health care system – make the and 20) while another insisted that blame for these problems rested on the study of the mental health system and Romania pursue “a comprehensive reform state rather than on individuals or groups mental illness in Romania particularly of mental health care” (Point 26). of mental health care workers. For the fertile ground for understanding how This stress on problems in Romania’s most part, mental health care workers have Romania will respond to the demands of mental health care system in such a public struggled to maintain some semblance of a the international community and require- statement around such a highly anticipated therapeutic space for their interaction with ments for accession to the European and charged issue as EU accession was people with mental illness, despite the lack Union. anything but a coincidence. During the of basic resources and a collapsing clinical The study of, and concern for mental summer of 2004, Amnesty International infrastructure. health issues in Romania, has remained reported on the terrible conditions in The mental health care system receives a almost entirely unstudied by Western Romanian psychiatric hospitals.1 These disproportionately small share of the total scholars, as well as remaining a notable and reports were prompted by investigations health care budget, just 3%, given that seemingly shameful topic of discussion into the deaths by exposure of over a mental health problems (excluding among Romanian scholars themselves. dozen patients in Romania during the dementia) account for 12% of the overall Part of the reason for this, certainly, is the winter of 2003. burden of disease.2 This covers a mere infrastructural and institutional state of The reports, however, went well beyond 35–45% of that which is budgeted for Romanian psychiatry and mental health

Jack Friedman is a Post Doctoral Fellow, * Most remarkable of these advocacy NGOs is ‘The Romanian League for Mental Health’ Department of Comparative Human (Liga Româna˘ Pentru Sa˘na˘tate Mintala˘) run out of a single, crowded apartment flat in Development, University of Chicago, Bucharest, and the Aripi Association which is a client-run advocacy group that works out Chicago, Illinois, USA. of a community-based rehabilitation center attached to Bucharest’s ‘Al. Obregia’ psychi- Email: [email protected] atric hospital.

36 Eurohealth Vol 12 No 3 HEALTH POLICY care. During the state socialist period, frequent over-medication of people who paid for psychiatric medication for outpa- psychiatry and psychology were might otherwise have benefited from a tients; however, today, this support has profoundly complicit with the former- combination of more conservative medica- dwindled to the point where most people dictator Nicolae Ceaus¸escu’s state and tions, talk therapies, and social interven- with mental disorders (especially since acted as another arm for the medical tions. they are almost always unemployed due to policing and disciplining of the Romanian their illness) cannot afford their medica- Since 1989, Romania’s psychiatric system populace. However, since 1989, there has tions. has suffered from the economic stagnation been almost no evaluation of the nature of and institutional challenges that have In addition, the desire to limit the cost to the Romanian mental health system. plagued most of the country’s state- the state of the burden of long periods of This research gap has also been reflected in provided services. While the people who hospitalisation, has meant that doctors are state policies and in the planning of inter- are involved in the treatment of patients increasingly pressured to convince patients national aid to Romania for health care with mental illness – psychiatrists, to leave hospital, even when they do not reform. Part of the reason for the neglect psychologists, social workers, nurses, and necessarily think that it is in their best of this issue can be attributed to a combi- others – are deeply committed and profes- interest.* This is particularly difficult for nation of factors including : (1) the reluc- sional individuals, they face profoundly many psychiatrists since (1) there is no tance of international aid to consider challenging obstacles to the efficient and community mental health care system for mental health reforms as ‘cost effective’ efficacious treatment of their patients. In these individuals once they leave the in- interventions in many developing nations, particular, the psychiatric system has been patient setting, (2) most cannot afford the (2) a ‘triage mentality’ on the part of the overwhelmed by three interacting factors. medications that the psychiatrists have government that placed immediate prescribed, making relapse and social primary care concerns above, and to the problems (with the patient’s family, the near exclusion of, mental health care community, the law, etc.) almost assured, reforms; (3) the social stigma of the “there is no community and (3) inefficiencies in the disability laws mentally ill patient/client population in mean that these individuals will return Romanian society; and (4) the fear that a care system for those who regularly whether or not they need to be full policy evaluation of mental health care leave the inpatient setting” hospitalised so that they can continue to in Romania would reveal the fundamen- receive their only source of income from tally pathological structure of the system their disability payments. While all of to the world. these budgetary problems have a dramatic impact on the care of patients, the under- First, due to the financial problems facing Background to the current state of staffing and increased work load on all of state-run sectors, psychiatric institu- Romanian psychiatry psychiatrists mean that they rarely have tions have been increasingly under-funded Romania’s psychiatric system has suffered the time to see patients for more than a few and over-extended by demand for the from diverse and serious problems over minutes each week and they have no time services that they are expected to provide. the last several decades. During the state (or access) to pursue the newest medical These funding woes have been seen in the socialist period, psychiatric hospitals, treatment options or research. downsizing of the number of beds at many along with their regular medical duties, hospitals, despite the fact that most The second major challenge to the became spaces for the political repression doctors and administrators with whom I Romanian mental health system since 1989 of dissidents and others who were deemed spoke insisted that they are seeing more comes from the fact that psychiatric too problematic to simply be jailed by the patients today than in the past. This down- hospitals have recorded increasing Ceauşescu regime. In addition, under sizing is part of a broader effort towards numbers of patients with mental illness – Ceauşescu, the field of clinical psychology deinstitutionalisation and a transfer of particularly, major depressive disorder and – an essential complement to psychiatry in patient care to community-based initia- various anxiety disorders. Romanian the treatment of mental illness – was tives; a goal made explicit in the health care medical specialists and social workers marginalised to the point where mental reform legislation passed in January 2006. universally associate this increase in health care was almost completely patients with mental illnesses with subsumed by a biological model of care. Regardless, economic shortfalls have increasing unemployment and economic Little or no talk therapy (cognitive or meant that basic medications are stress, particularly since the late-1990s psychodynamic) existed for patients who frequently either in short supply or are when economic reforms began to take suffered from mental illnesses where quickly depleted in these psychiatric hos- their greatest human toll. psychotherapy would be indicated. pitals – a fact that frequently contributes Instead, the liberal use of psychiatric to the relapse of patients under even the This increase in the rate of mental illness medications tended to be the only best physical conditions and medical care. has meant that many of the very services treatment available to patients, leading to The state had traditionally subsidised or that are most essential to those who are out

* In-patient care is limited to 17 days for acute patients and 90 days for chronic patients. Acute patients must wait 24 hours before they can be re-admitted for another 17 days, but they cannot be re-hospitalised in an acute ward, then, for another 30 days. Chronic patients can be continually re-admitted after each 90-day period. In addition, due to a curiosity in the nature of the budgetary system, if a patient is transferred at any point to another hospital, it is the last hospital that sees the patient that will receive reimbursement for the entire period of the patient’s illness. This budgetary oddity means that there is a strong disincentive to transfer a patient even when it might be in his/her best interest.

Eurohealth Vol 12 No 3 37 HEALTH POLICY of work and living with mental illness have the lack of legal reforms and privacy laws At the same time, doctors stressed that been doubly impacted by the increasing continue to undermine these attempts to men are suffering a double-burden population of people with mental illness limit the impact of the stigma of mental connected to economic stress and the and the simultaneous cuts in services. One illness on workers’ employment opportu- increasing threat of downward mobility. point of caution though: the increase in the nities. Ultimately, this problem with the They have historically tended to compose number of people suffering from mental legislation surrounding employment and the heaviest burden on the psychiatric illness reported to me by psychiatrists does mental illness puts one of the heaviest system because they have tended to show not seem to be supported by good strains on the already buckling mental a much higher rate of the most severe, epidemiological data. This is not to say health system because many patients who chronic, and debilitating of the mental that this increase in the number of cases of suffer from an acute mental illness find that illnesses, particularly psychotic disorders mental illness is untrue or inaccurate; they must ‘become’ chronically mentally (especially schizophrenia). In contrast to rather it is, at this point, anecdotal and ill in order to receive enough support this, historically, fewer men have been demands a richer epidemiological foun- through regular state disability payments hospitalised or treated for mood disorders dation to influence policy decisions related just to survive. (especially depression) than would be to mental health service provision. To predicted by epidemiological data. Psychi- address this epidemiology problem, the atrists, however, have stressed that, since January 2006 health reform legislation the late-1990s, they have seen an increase called for the creation of a national mental “stigma means workers in the number of both psychotic disorders health instituted to collect data on psychi- and mood disorders among men. atric illness. tend to find that it is While rich epidemiological data is lacking The third, and perhaps most problematic, impossible to maintain to support some of these claims, if this factor challenging the Romanian mental anecdotal evidence is true, this would seem health system is the problem associated their job after to point to at least three possible explana- with various legislation (or the lack tions. First, for the psychotic disorders, it thereof) related to disability rights, hospitalisation” would seem to support some of the recent workers’ rights, and the ‘mental health medical literature that has pointed to the laws’ in place in the country.* A person increased prevalence of active psychosis with mental illness is multiply challenged among people who suffer from extreme by these institutional inefficiencies. Due to Some early observations social, cultural, and economic marginali- a lack of workers’ rights, any worker who My observations and interviews revealed sation. Second, for mood disorders, this must leave her place of employment for the deeply entwined connection between might suggest that there is an increased rate medical reasons is not guaranteed the experience of mental illness and the of mood disorders associated with the employment upon resolution of that new forms of poverty in Romania. Specif- environmental stressors of unemployment medical problem. While most employers ically, the increasing rate of unem- and increasing poverty. will re-employ workers who have been ployment, particularly among those who Third, the increased rate of mental illnesses physically injured in some way, workers are 40 or older, has taken a catastrophic associated with mood disorders might be who suffer from mental illness are stigma- psychological toll that has, for many, led to a function of both the new forms of tised and tend to find that it is impossible and/or contributed to the emergence of poverty in Romania and how the new to maintain their job after a period of mental illness. In particular, all of the poor are forced to interact with the hospitalisation for mental illness. (The physicians with whom I spoke in Romania disability welfare system. In this case, what only exception to this rule found during stressed the increasingly central place of we might be seeing is a kind of ‘perfor- fieldwork was in the Jiu Valley, where women in their late-30s to their late-50s on mance’ of one’s illness. It is probably most workers who have still been able to hold the burden of illness in psychiatric settings. likely that the real reason for the increased on to their jobs in the mining industry Most of these psychiatrists pointed out rate of mental illness can be found in the have tended to find a more sympathetic that, while, from an epidemiological stand- confluence of all three of these factors; relationship with their employers, such point, this is the key age for women to however, each would demand its own that time spent in treatment for mental begin to experience major depressive policy-orientation to address each of these illness is simply treated as any other period disorders, the increase in the number of factors. of medical leave.) patients in this demographic category Recent attempts to use a medical coding seemed to be more strongly correlated Policy recommendations system borrowed from the Australian with the increased rate of unemployment Romania’s mental health system has medical system have been instituted in among these women rather than appearing suffered terribly from the economic stag- order to address concerns about confiden- as a generalised increased rate of illness nation and government-directed austerity tiality and reporting on disability, medical, among all women in this age range. My measures associated with the need to rein and employment documentation; however, qualitative interviews bore out much of in the inefficiencies of state-controlled these observations.

* A core concern for some scholars and international observers is the nature of ‘involuntary commitment’ legislation. Romania has very strict involuntary commitment legislation; however, this legislation is rarely observed. This is not for lack of interest on the part of most psychiatrists, but is mostly a function of the impossibly over-strained legal system that must be brought in to adjudicate each case of invol- untary commitment.

38 Eurohealth Vol 12 No 3 HEALTH POLICY sectors of the economy and service indus- Romanian society. When people with learn that their loved one does indeed have tries. Cuts in the budget for medical care mental illness are given the same rights as a mental illness. Priests frequently advise have been accompanied by increasing any other citizen, especially in terms of families and patients that it is the devil numbers of patients in need of mental employment, they are less likely to relapse working through them that gives form to health care, frequently stemming from the and are more capable of living a healthy their mental illness. Even within the repercussions of the very economic life. This can help avoid the substantial professional field of social work, young policies that have left these individual burden that mental illness can place on the social worker trainees tend to avoid patients doubly impacted. state sector, as well as in families and choosing the mental health track of social communities. It also implies that the indi- work because they see working with Regardless, many in Romania’s mental vidual can both contribute to the economy people with mental illness as somehow health system recognise the need for through their employment, as well as avoid “dangerous” and “tainting.” These cultural reforms that can both provide the using the limited resources of the mental beliefs must be addressed with a strong necessary services, while doing so in as health system that might better be used to public education campaign in order to efficient and cost-effective a manner as assist low-functioning patients. insure that families, communities, and possible. Several important and broad- professionals alike can provide the support ranging policy suggestions come out of my that a person suffering from a mental preliminary research, some of which have illness might need. become central parts of Romania’s January “Romanians tend to have 2006 health care reform legislation. A final recommendation is that a national institution for gathering, analysing, and One recommendation is an increased a particularly harsh view publishing the findings of mental health commitment to deinstitutionalisation and a of mental illness” statistics be established in order to gain a simultaneous commitment to community better understanding of the epidemio- mental health care. Large psychiatric logical trends in Romanian mental illness. hospitals have proven to be highly ineffi- At this point, there have been almost no cient. While initially designed to take broad-based epidemiological studies of advantage of an economy of scale, the shift A greater commitment is also needed to mental illness in Romania, and, yet, to out-patient care – the least expensive reform the mental health educational everyone from policy makers to type of mental health care – has become system. While psychiatric education is community leaders to religious leaders to almost impossible as large, centralised well-developed and relatively modern in physicians seem to believe that mental hospitals consume all of the resources set Romania, the lack of talk-therapy training, illness is more prevalent today than it was aside for mental health in the state’s the limited availability of specialist mental in the pre-1989 past. If this is the case, budget. health training for nurses, the limited training in basic psychiatry among there needs to be a mechanism in place to Deinstitutionalisation would allow for the primary care physicians, and the lack of a document any trends in mental health establishment of community mental health well-developed core of mental health- epidemiology so that resources can best be centres that can help patients who do not oriented social workers, all undermine the brought to bear on different problems, in need to be hospitalised. It is essential, effectiveness of frontline psychiatrists in different regions – ultimately with an eye however, that any deinstitutionalisation be their battle with mental illness. In addition toward recognising the correlation simultaneously met with a community to these broader professional reforms, a between epidemiological trends and health care* option in order to avoid any greater emphasis must be placed on the various environmental (especially disruption in services to people living with special ethical problems that arise in economic) factors. mental illness. This will keep these people mental health settings. healthy enough to avoid relapse (and the subsequent need for in-patient care) as well Increasing public awareness campaigns to References as concentrating in-patient resources in educate the public about mental illness and to fight the stigmatisation that accompanies 1. Amnesty International. Memorandum to such a way that they will be best used for the Romanian Government Concerning the treatment of those who have chronic, the cultural models of mental illness in Romanian society are also important. Inpatient Psychiatric Treatment. Brussels: severe mental illnesses that demand hospi- Amnesty International, 2004. talisation. People living with mental illness are stig- matised almost everywhere. Romanians, 2. World Health Organization. World A second recommendation is an increased however, tend to have a particularly harsh Health Report 2001. Mental Health: New commitment to reforming the legal system view of mental illness – a cultural under- Understanding, New Hope. Geneva: World to combat institutionalised stigmatisation standing of “madness” that views it as a Health Organization, 2001. of those with mental illness. Improving the combination of evil (in the moral and reli- legislation related to confidentiality and gious sense), genetic weakness (eugenics), 3. Sorel E, Prelipceanu D (eds). Images of privacy, as well as reforming the laws and stupidity (a conflation of mental illness Psychiatry, Romania: 21st Century related to disability eligibility and workers’ with learning disabilities). Romanian Psychiatry. Bucharest: Editura rights, will allow more people with mental Infomedica, 2004. illness to be better integrated into Families are known to simply abandon people at psychiatric hospitals once they

Examples of a few innovative and successful community mental health initiatives can be found in Bucharest, Timis¸oara and Câmpulung Moldovenesc.

Eurohealth Vol 12 No 3 39 Risk in Perspective

RISK COMMUNICATION: A NEGLECTED TOOL IN PROTECTING PUBLIC HEALTH

Davik Ropeik and Paul Slovic

Do we live in riskier times than humans last 40 years, infant mortality has dropped have ever faced? This is a common from 26 per thousand live births, to 7. In question in these days of terrorism, SARS, 1918, the influenza epidemic killed 600,000 “Decision-makers must weapons of mass destruction, climate Americans. In 1999, influenza killed about realise, and accept, that the change, ozone depletion and HIV/AIDS. 36,000 Americans. By major measures, this is a far healthier, safer world than it has The answer is resoundingly equivocal. ever been. dangers of misperception of There is both good risk news, and bad. But risk are real, and pose both a despite the mixed evidence, many people But new risks have arisen. Worldwide say they think the risks we modern more than 22 million people have died of threat to public health and humans face are greater than they’ve ever AIDS since 1984. The postwar industrial/ been. The implications of this appre- technological/information age has given us an impediment to policy hension are immense for public and envi- both the benefits and the risks of nuclear ronmental health and for the global power, pesticides, and many new tech- making that will provide the economy. nologies. Under the burden of a global population that in the last 100 years has We write to offer insight into how human greatest benefit to public exploded from 1.65 billion people to more risk perception is both analytical and than 6 billion people, environmental risks affective, which offers an explanation of health.” such as climate change, water and air why the public’s fears sometimes don’t pollution, and mass extinction of species seem to match the facts. We suggest that, have added to a growing litany of new empowered by such insight, governments perils. can and must do a more effective job of risk communication, through both their On top of this new host of new hazards, policies and what they say about them. we live in a time of unprecedented media Understanding and respecting the analytic availability and information immediacy. and affective ways people make risk judg- Whenever something is discovered that ments can help governments help citizens may even possibly be perilous, we learn of keep their sense of risk in perspective. it, worldwide, within days. It is also a new This, in turn, will not only help individuals phenomenon that a majority of our make wiser, healthier decisions for them- sources of information are owned by a selves. It will also help focus social concern small number of large corporations. on the relatively greater risks. That will Seeking to maximise profits, the media This article is reproduced with allow governments, businesses, and other outlets of these global firms often make permission and was first published as social institutions to invest in optimal new risks sound as dramatic as possible in Risk in Perspective Volume 11, Number 2 protection of public and environmental order to grab attention and attract us to by the Harvard Center for Risk Analysis health with the most efficient use of buy their next newspaper, magazine, or in June 2003. limited resources. television broadcast. These are the modern realities of what Some current risk realities Harvard Center for Risk Analysis, seems like a risky world. But it is not by Just how risky is the world in which we Harvard School of Public Health, careful rational analysis alone that we live? Consider some data from the United Landmark Center, 401 Park Drive, interpret information about the risks our States, which reflect similar trends in PO Box 15677, Boston, modern world presents. Such conscious developed nations worldwide. In 1900, the Massachusetts, 02215 USA. analysis is relatively slow and effortful. In The full series is available at average life expectancy was about 45 years addition we use ancient intuitive processes www.hcra.harvard.edu of age. Today it is nearing 80. In just the

40 Eurohealth Vol 12 No 3 EVIDENCE-INFORMED DECISION MAKING that are instinctive, fast, and often not Choice disease, cancer, or stroke. The other risks completely accessible to conscious weren’t gone, but conscious concern about A risk we choose seems less risky than if awareness. We apply a series of affective them was lower, because awareness of that risk is imposed on us. If you use a criteria to perceive and respond to danger. them had been reduced. mobile phone while driving, you may have Essentially, several decades of research on on occasion noticed a driver next to you, Can it happen to me? risk perception suggests that humans tend using his or her mobile, and felt upset to fear similar things, for similar reasons. Any risk seems larger if you think you or about the risk that other driver was To understand the characteristics of risks someone you care about could be a victim. imposing on you, even while you volun- that trigger these responses is to gain some Consider terrorism in the United States. tarily took the same risk, albeit with less insight into why people are commonly Prior to 11 September 2001, the Americans concern. (Of course, you have control over more afraid of some relatively small risks, who were victims of terrorism were your car, so the factor of control also and less afraid of some that in certain ways “someone else”. Yes, they were Americans. contributes in this example.) cause greater harm. But they were in foreign embassies, or on Children foreign military assignment. After 11 Risk perception factors September 2001, however, Americans at In addition to the genetic imperative to home felt they too were possible targets, Dread survive (which is, after all, the underlying and fear of terrorism grew. impetus of our risk perceptions and What’s worse, being eaten by a shark or responses) humans are genetically driven This helps explain why statistical proba- dying of heart disease? Both kill you, and to reproduce. Survival of the species bility is often irrelevant to people and an heart problems are far more likely to do depends on survival of our progeny. So it is ineffective form of risk communication. you in. But the dreadful death often evokes not surprising that research has found that Imagine that someone hands out one more concern. Despite the fact that heart a risk to children, like asbestos in a school million bottles of water, one of which disease kills roughly 25% more Americans or the abduction of a youngster, seems carries a poison. You get one of those each year, cancer evokes more fear in most worse than the same risk to adults, such as bottles. Now imagine taking a drink from people because cancer is perceived as a asbestos in a workplace or the abduction that bottle. Your risk of dying from that dreadful way to die. This helps explain of an adult. During last year’s sniper water is only one a million, but it still feels why hazards that might cause cancer, such attacks in Washington D.C., after five risky to drink it, because you could be that as radiation and industrial chemicals, adults had been murdered, the sniper one. This helps explain why the acceptable evoke strong fears. Dread is a clear wounded a 13 year-old boy. The local level of risk to many people is zero. example of the more general way we think police chief, tears in his eyes, declared of about risk in terms of our intuitive feelings, The risk-benefit tradeoff the sniper “He’s really getting personal a process that has been labelled ‘The Affect now!” Some risk perception researchers and Heuristic’. many risk analysts believe that the risk- Is the risk new? Control benefit tradeoff is the major factor that At the time bovine spongiform makes us more or less afraid of a given Do you feel pretty safe when you drive? encephalopathy first showed up in threat. If we perceive a benefit from a Most people do. Having the wheel in your Germany, an opinion survey found that behaviour or choice, the risk associated hand gives you the feeling that you can about 85% of the public thought mad cow with it seems smaller. If there is no control what happens. But switch to the disease was a serious threat to public perceived benefit, the risk seems larger. passenger seat and you’re a little more health. But the same poll done at the same When measles and polio were prevalent, nervous because you are no longer in time in the UK, where it had been around the benefits of vaccination were perceived control. This also applies to process. If you for years and killed many more animals to outweigh the risk of the side effects. But feel as though you have some control over and more than 100 humans, found that now, with these diseases rare, the the process determining a risk you will only around 40% of the public thought perception of some parents is that the risks face, the risk probably won’t seem as big mad cow disease was a serious threat. New of those side effects, as low as they are, as if it was decided by a process over which risks, including everything from SARS and outweigh the benefits of vaccines. Many you felt you had no control. West Nile virus to new technologies or American health care workers, ‘first Is the risk natural or is it human-made? products, tend to be more frightening than providers’, are refusing a smallpox vacci- the same risk after we’ve lived with it for a nation because the risk of the treatment, Anthropogenic sources of radiation like while and our experience has helped us put low though it may be, seems larger than nuclear power, mobile phones, or electrical the risk in perspective. the benefit, which is protection from a and magnetic fields frequently evoke disease they aren’t convinced is a threat at greater concern than radiation from the Awareness all. sun, which is a vastly greater risk (1.3 The more aware of a risk we are, the more million skin cancer cases, 7,800 melanoma Trust available it is to our consciousness, and the deaths, per year in the US) but less more concerned about it we are likely to Research has found that the less we trust worrisome to many because it is natural. be. SARS is currently evoking far more the people who are supposed to protect us, This factor helps explain widespread new coverage, attention, and concern than or the people or government or corporate concern about many technologies and influenza, which kills an estimated 36,000 institutions exposing us to the risk in the products, and offers important insights people a year. In the Washington D.C. area first place, or the people communicating to into one key factor in the debate over the last fall, fear of being shot by a sniper was us about the risk, the more afraid we’ll be. ‘Precautionary Principle’. much higher than the greater risks of heart The more we trust, the less concern we’ll

Eurohealth Vol 12 No 3 41 EVIDENCE-INFORMED DECISION MAKING feel. Imagine you’re in a desert, nearly rich diets, fail to take adequate precautions, ences, and public service campaigns. It is dead of thirst, and someone appears and and they too face a greater likelihood of substance, not just spin. offers you two glasses of a clear liquid. She premature death. Lack of appropriate Some call this pandering to irrationality won’t tell you what is in either glass, only caution can be dangerous too. and emotion, and suggest instead that a that one comes from Pope John Paul and At a societal level, elevated concern about benevolent technocracy should be one comes from a tobacco company. relatively low risks, and too little concern empowered to manage societal risk in Which one would you take? about relatively big ones, is also potentially order to ensure intelligent, rational and harmful. People afraid of a risk that effective policies. But this fails to recognise The implications triggers their intuitive fears demand the sensitive and pivotal issues of trust and But what of all this? What is the utility of government protection from that risk, control. Even the most benevolent process, understanding the underpinnings of our though it may not actually be as much of a if removed from the input of citizen values, fears? We suggest that by realising and threat as they feel. Conversely, if a threat will feel like one over which the public has respecting the realities of affect and other is indeed high but does not trigger affective too little control, and will not likely be heuristic processes, and by accepting that alarm, demand for protection will be low. trusted. The policies of such a process are they are apparently deeply rooted and This drives allocation of resources that is more likely to provoke resistance than reflect intrinsic human techniques for suboptimal for public health. Time and support. Further, the very idea of such a survival, policy makers can incorporate money spent protecting people from rela- rationality-based technocracy fails to these values, as well as fact-based analysis, tively low risks are not available to protect accept that risk perception is at least as into their risk management decision people from greater risks. As a result, some much an affective and intuitive process as it making. Further, by understanding the of the people left unprotected from those is analytical, and that fear itself, either too reasons people perceive risk as they do, higher risks will suffer. Some will surely much or not enough, is a significant risk policy makers can communicate with die. that also must be factored into decisions various audiences about these issues in about public and environmental terms and language relevant to people’s Conclusion protection. concerns. Risk communication which One solution to the dangers that arise acknowledges and respects the affective Risk communication, informed by the when the analytic and affective sides of our motivators which underlie people’s insights of risk perception, is a powerful risk perception don’t agree is effective risk concerns, rather than dismissing such yet neglected tool in helping people make communication, informed and empowered perceptions as “irrational” because they more informed and ultimately healthier by an understanding of risk perception. are not solely fact-based, is likely to be choices for themselves. More informed This must become a priority at the highest more successful in helping people make individual decision making will in turn free levels of policy making in government, in more informed choices about the risks the leaders of social institutions to make business, and in international affairs. More they face. reasoned risk management choices that must be done to help people keep their will maximise public and environmental This is directly a matter of public health. sense of risk in perspective. Decision- health with the most efficient use of People who are either too afraid of rela- makers must realise, and accept, that the limited resources. tively low risks, or not afraid enough of dangers of misperception of risk are real, relatively big ones, make dangerous and pose both a threat to public health and FURTHER READING choices. People afraid of flying choose an impediment to policy making that will instead to drive, a much riskier behaviour. provide the greatest benefit to public Slovic P. The Perception of Risk. London: People afraid of terrorism or other crimes health. Earthscan Press, 2000. take the risk of acquiring firearms. In 2001 Effective risk communication requires Slovic P, Finucane ML, Peters E, people afraid of anthrax took antibiotics recognition by policy makers that there are MacGregor DG. Risk as analysis and risk prophylactically, increasing the prolifer- risk perception implications in what they as feelings: some thoughts about affect, ation of drug-resistant bacteria. do, that communication is not just what reason, risk, and rationality. Risk Analysis Further, chronic stress, by altering blood they say and how they say it. Setting a 2004;24(2):311–22. levels of adrenaline and cortisol, impairs threshold for acceptable exposure to a Stern PC, Fineberg HV (eds). Under- the immune system. Worrying too much pollutant, allowing or disallowing a standing Risk: Informing Decisions in a about getting sick may actually increase product or process, requiring or not Democratic Society. Washington D.C.: the likelihood that you will get sick, or requiring labelling – indeed all risk National Academy Press, 1996. sicker, or stay sick longer, or die, from any management decisions – have risk commu- infectious disease. Chronic stress is also nication meaning and impact. At the most Committee on Risk Perception and associated with the likelihood of type-II senior level, government agencies must Communication, National Research diabetes, accelerated osteoporosis, and consider the risk perception and commu- Council. Improving Risk causes decrements in learning and long nication implications of their actions as Communication. Washington D.C.: term memory. Fear is, in itself, a risk. policy choices are being made. Risk National Academy Press, 1989. communication must be thought of as Not enough fear can also be dangerous. Source for health statistics: CDC. more than just press releases, news confer- People unafraid of natural risks like solar radiation, or risks they think they can control like driving, or risks that are asso- ciated with benefits, such as smoking or This essay is based on an article: “How to Cope in a World of Risk”, published in Global alcohol consumption or fat and calorie- Agenda (the magazine of the World Economic Forum) 2003;1(1):158–9.

42 Eurohealth Vol 12 No 3 Evidence-based health care

Delivering Better Health Care 2

“Seeing the wood for the trees. Taking a systematic approach to implementing change in clinical practice.”

The starting point designed for a multi-disciplinary group of about The separate aspects of achieving change are familiar fifteen people from each NHS Trust including clini- to most people in the NHS. Change is a way of life. cians and managers. Ideally, participants would be Michael The terms used form a common language. People drawn from different levels within the organisation. Dunning, talk freely about clinical guidelines, care pathways, An opening session, to present information about clinical audit, critical appraisal, patient involvement the task, was followed by small group discussions Editor, ImpAct etc (see Figure 1). Getting the right connections and on a local implementation issue. The aims were to: balance between these separate activities is essential. – Create groups of people in organisations with Experience has shown that achieving these connec- shared understanding of implementing change in tions and this balance is not easy. In the first paper clinical practice. we identified things that can go wrong. Often this is simply because people do not have a good grasp of – Be practical and draw on real examples to illus- the work overall. They may spend too much time trate the task. on the familiar, such as the preparation of guidelines – Support the development of clinical governance and not enough on the unfamiliar: those they in NHS Trusts and Primary Care Groups. perceive as difficult. Build on work on critical appraisal in the region The work in the West Midlands built on the success There are countless educational opportunities that of the established model for critical appraisal seek to tackle all aspects of implementation and training (CASP) workshops. These short two-hour individual activities such as the formulation of sessions concentrate on getting the fundamentals clinical guidelines or the preparation of project over to participants. We wanted to explore whether plans. We were not trying to replicate these training we could design and deliver a similar short (two opportunities. Our starting point was the belief that hour) session that could plant in people’s mind a most people had some knowledge of managing practical picture of the task of implementing change change, but they would benefit from a better under- in clinical practice. A two-part programme was standing of the overall process. – Pilot trials indicated support for idea behind the Figure 1: Delivering better healthcare – the right connections workshop. On-going evaluation was positive, participants: – Valued having time with other members of their organisation for discussion about clinical issues Evidence Communications including multi-disciplinary approaches. – Felt they gained an understanding of the planning process and time scales for preparation, planning, sustaining and delivering a change Education and training Patient records initiative. – Liked the opportunity to rationalise the ethos of managing change in a less than ideal world. – Reported a better understanding of clinical Guidelines and Clinical audit Service agreements governance and evidence based health care was protocols reported. Nevertheless changes seemed necessary and more Bandolier is an independent monthly journal about evidence-based healthcare, time was needed. The session proved to be too busy written by Oxford scientists. Articles can be accessed at www.jr2.ox.ac.uk/bandolier and too short. We were trying to handle too much detail in the limited time available. We subsequently This paper was first published in 2001. © Bandolier, 2001.

Eurohealth Vol 12 No 3 43 EVIDENCE-INFORMED DECISION MAKING tried a more focused model for the from non-NHS settings but have useful There is little point in encouraging GPs to workshop: this was better received. This lessons. They point to the need for clarity refer patients for physiotherapy if that paper is based on the concise version of the of purpose and a systematic approach. department is already under severe session. The third paper in this series will pressure. A link with planning and budg- Fourth, experience which has been learned describe the more detailed version and be eting timetables and the early engagement by those leading and being involved in based around a series of slides that could of the appropriate managers in the discus- implementation projects. All of these be used in a workshop setting. sions will help. confirm the complexity of the process and The starting point for the session was a set the need for flexibility as the work is taken Making change possible of four questions: forward. People cannot change unless they have What do you need to know? The space and the time to understand and What does all this tells us? knowledge which should influence the absorb the evidence you are promoting. The wealth of material shows that imple- work. Research has shown that (simply) circu- menting change is possible, but it is a lating information is normally ineffective. What needs to be done? A broad picture of complex business that takes time, Design of suitable training and education the range of tasks involved. resources and stamina. The important programme should take account of the points are: How to make it happen? The range of needs of those you seek to change. Do not skills and scale of resources required. – Know where you are starting from. expect people necessarily to attend organised training sessions, unless you Where can you find help? Don’t be alone, – Build on what works, such as educa- have taken action to make attendance easy seek advice and share experiences. tional outreach and reminder systems. for them. It may be more sensible to take – Multi-faceted approaches are more the training to the workplace. Educational What do you need to know? likely to be successful. outreach programmes are well proven. Interest in evidence-based practice has – Good project management is essential. sparked many questions about clinical Finally, it is sensible to be flexible and plan behaviour and the ways to influence for the long term. No matter how well What needs to be done? people. Anyone starting out to implement implementation programmes are planned, Clarity about what needs to change is a change needs to be familiar with the wide they are unlikely to adhere to timetables. pre-requisite for success. Two dimensions range material now available – but not People may not react as expected and require attention. First, an analysis of necessarily all of it! It is sensible to be support may come from unexpected current practice to determine the gap aware of the main points from this liter- quarters. Allow for this. As the process is between what is done now and the practice ature and aim to keep up to date. A costly in terms of time and resources it is indicated by research evidence. Clinical framework of four types of knowledge can important from an early stage to explore audit is the key here but bear in mind that help you recognise what you don’t know! how the changes you are implementing what is needed is a broad understanding of will be sustained in the longer term - after Evidence: from research on changing what needs to change - not extensive detail the project spotlight has faded. Make sure clinical behaviour of current practice. that patients’ records reinforce the changes Theory: models of behaviour change Second, an assessment of the likely atti- you are implementing. How will you hand Lessons: about change management tudes of those you may seek to change: it over responsibility to those charged with will help you decide how best to involve monitoring clinical standards? Experience: from implementation projects and work with them. The Rogers analysis First, evidence from research on questions talks of identifying laggards, innovators about changing professional behaviour. It etc. Others talk of the merit of identifying Delivering better health care: what needs to be is a complex field with many significant barriers or a contextual analysis. The done? research programmes in hand. It is an important point is to determine where to international activity with collaboration start and identify whom is likely to • Be clear what and who needs to change through the Cochrane Collaboration support your initiatives and work with • Tackle resource consequences bringing together people from across the you in the initial stages - and who might • Provide practical training and education globe. This work is starting to point to oppose you! Early success is a good change strategies that have been proven to morale booster. Remember pharmaceutical • Be flexible and plan for the long term work - and importantly those that don’t. companies devote significant resources to understanding their market. This task Second, theories about behaviour change should be much easier for people working and the way people learn. Many people How can you make it happen? in the NHS. may be familiar with is the work of Rogers Choice of project leader is critical and should be guided by the need for someone who suggested a classification of people While the assessment of the people likely with a reputation with his or her peers - such as innovators, early adopters, early to be affected by the work is in hand it is rather than necessarily their position majority, late majority and laggards. Other important to assess how the initiative will within the organisation. It is helpful if they work has explored how people learn and affect current services: will it prompt a have: what motivates them to change. need for more or less of something. Expe- rience has shown that tackling these Third, lessons from studies of change – Experience of managing change in the resource consequences may be as time management and initiatives to improve the health service - an understanding of the consuming as changing clinical behaviour. quality of services. Many of these come range of activities involved.

44 Eurohealth Vol 12 No 3 EVIDENCE-INFORMED DECISION MAKING

Figure 2: Delivering better healthcare. An approach to clinical governance – creating links An approach to clinical governance – creating links The introduction of clinical governance has the potential to streamline the process Clinical management and Libraries and knowledge Clinical standard setting for implementing change in clinical information systems management practice. The experience from managing implementation projects suggests that the key task for organisations is to put in place linked systems covering the monitoring, Education and Patient Service Communications improving and maintaining the quality of training involvement agreements health care. Failure to make the right connections between different strands of work means that people have to spend countless hours working against the – Awareness of the emerging research discussed is essential: asking a team systems. evidence about changing clinical member to take on a facilitation role can Seven linked systems could form the basis behaviour. be helpful. Taking steps to ensure that the for managing clinical governance (see learning is used to influence other local – Knowledge and understanding of local Figure 2): initiatives will ensure that there is a better organisational policies and structures return on costs of initial project. It will also 1. Providing information to enable clinical and working relationships. represent an important contribution to the staff to review, routinely, the quality of Given the complexity of the task and the development of local clinical governance their current practice and identify areas range of activities involved, the systems. where improvement is needed. recruitment of a team with the necessary 2. Providing access to the breadth of skills should be an early task. The analysis knowledge required to establish local of what and who needs to change will Delivering better health care: how can you standards of care. indicate the skills required. It is important make it happen? to assemble the right team rather than 3. Reviewing current practice and setting simply rely on colleagues – people with • Find a suitable leader local clinical standards. whom you feel comfortable. Managerial • Recruit the right team 4. Ensuring that patients are at the centre and clinical skills will be required. • Secure adequate resources of work to develop and monitor local The scale of change required could be a clinical standards. • Take communications seriously reliable indicator of the resources required 5. Providing education and training to to make the change happen. The support • Learn as you go! support the development of individuals and commitment of senior staff within the and clinical teams. organisations will help ensure that suffi- cient people and resources are available to Where to find help? 6. Ensuring that implementation is deliver the project’s objectives. There is growing number of people across managed within service agreements. the NHS who have experience of creating 7. Ensuring that information is communi- Keeping people in touch and leading projects to implement cated promptly and accurately within Communications must be taken seriously. improvements in clinical practice. Most are the organisation. Agree at an early stage a communications keen to share their experiences with strategy to let people involved know what colleagues across the NHS. This sharing And, in conclusion is happening. It’s wise to share responsi- used to be difficult and had to rely on Experience has shown advantages from a bility across the project group so that each personal networks – such as people you systematic approach to the management of member takes on the task of keeping their met at professional conferences. programmes to improve the quality of discipline in touch. Wherever possible The creation of the NHS Learning health care. Not least, because it ensures existing communications systems should Network in 1999 has changed this and that scarce resources to be used to the best be used to avoid the need to create new stimulated a range of activities designed to effect. But don’t adopt a rigid approach meetings and paper work. Clarity about help people share experience and good where adherence to the plan and timetable the message – what are you trying to say? practice across the NHS. ImpAct is one is all-important. – and the role of the messenger is essential. element of that activity; another is the Expect the unexpected and learn to coax For most people involvement in work to network of NHS Beacons. and cajole the different aspects along change clinical behaviour is a learning together. A good analogy is trying to experience. Manage project meetings so juggle several balls at once – difficult but that the collective learning of the group is Delivering better health care: where can you not impossible. Keep trying! captured. Allow time in the meetings for find help? reflection so that those activities that have been a success and those that have not can • Don’t try to re-invent the wheel be discussed. An honest approach where • Share successes and failures successes (and failures) can be openly

Eurohealth Vol 12 No 3 45 NEW PUBLICATIONS

Eurohealth aims to provide information on new publications that may be of interest to readers. Contact Sherry Merkur at [email protected] if you wish to submit a publication for potential inclusion in a future issue.

Health in all policies: prospects and Health in All Policies (HiAP) was the main making. John Kemm, Director of the West potentials health theme of the Finnish Presidency of the Midlands Public Health Observatory, in European Union (EU). This accompanying England, contributes an overview chapter on volume published by the Presidency, under this issue. He notes the critical importance, if Edited by Timo Ståhl, Matthias Wismar, the auspices of the European Observatory on HIA is to become ever more useful, of Eeva Ollila, Eero Lahtinen and Kimmo Health Systems and Policies, aims to high- “strengthening the logic used for predicting Leppo light how and why the health dimension can consequences of decisions so as to improve Finnish Ministry of Social Affairs and and should be taken into account across all estimates of the magnitude of outcomes and Health, 2006 government sectors. As Finnish Minister of to develop forms of participation that meet Health and Social Services, Liisa Hyssalla, the needs of both HIA and policy making.” writes, “HiAP highlights the fact that the risk Other chapters look at the use of HIA in the factors of major diseases, or the determinants EU and provide an illustrative case study. of health, are modified by measures that are often managed by other government sectors, Contents: Principles and challenges of health as well as by other actors in society.” in all policies; Moving health higher up the European agenda; The promotion of heart In his foreword, Robert Madelin, Director- health; Health in the world of work; Public General, Health and Consumer Protection health, food and agriculture policy in the Directorate of the European Commission, European Union; Health in alcohol policies; notes “health is a key foundation stone of the Environment and health; Opportunities and ISBN: 952-00-1964-2 overall Lisbon strategy of growth, competi- challenges for including health components tiveness and sustainable development” and in the policy-making process; Towards closer 279 pages that “a healthy economy depends on a inter-sectoral cooperation; Health impact Freely available at: healthy population.” Particular emphasis is assessment and health in all policies; The use placed on the unique mandate and obligation http://www.euro.who.int/document/ of health impact assessment across Europe; of the EU to protect health in all its policies. E89260.pdf Implementing and institutionalising health Examples from specific areas such as agri- impact assessment in Europe; A case study of culture and workplace are examined. A key the role of health impact assessment in imple- focus throughout is on the potential use of menting welfare strategy at local level; Health Impact Assessment (HIA) in policy Towards a healthier future.

Assisted reproduction in the Nordic After five decades of intermittent attempts, governmental committees or working parties Countries: A comparative study of the Nordic countries still have very different to parliamentary proceedings. It describes policies and regulation policies in the field of assisted reproduction. formative events and debates. The one defin- In the absence of a comprehensive policy itive conclusion that the report reaches is that design Finland has, by default, the most there is no such thing as a Nordic policy on Riitta Burrell permissive regimen of assisted reproduction ART. Nordic Council of Ministers, technology (ART) practices in the Nordic The report ends by identifying some of the Copenhagen, 2006 region, while Norway has the strictest ART factors that have accounted for the diver- regulation in place. The ART policy design gence in ART policies across the five coun- in Iceland and Denmark places those two tries. There are no simple explanations. Some countries in the intermediate category. While factors are related to the timing of decision- the policy design in the other Nordic coun- making, actor beliefs, the policy-making tries has remained relatively constant, arena, and the broader context. This, for Sweden has, through several redesigns, instance, includes scientific developments moved from a rather restrictive policy design such as the impact of in-vitro fertilisation to a more permissive one. and embryonic stem cell research. Cultural What is the nature of these differences and factors also are important, yet countries such ISBN: 928-93-1272-6 how did they come about? This report, by as Denmark, with a tradition for liberalism, do not have the most progressive of Riitta Burrell and commissioned by the 97 pages approaches to ART. Nordic Committee on Bioethics, examines Freely available at the use of ART in the Nordic countries at a Contents: Foreword; Introduction; Sweden; http://www.norden.org/pub/ovrigt/ policy-making level. It traces the policy Norway; Iceland; Denmark; Finland; ovrigt/uk/TN2006505.pdf designing process in each country from Conclusion; References.

46 Eurohealth Vol 12 No 3 Please contact Sherry Merkur at [email protected] to suggest websites WEBwatch for potential inclusion in future issues.

Direction de la recherche, des DREES, or the Department of Research, Studies, Evaluation and Statistics, is a division of the études, de l’évaluation et des French Ministry of Health and Solidarity. It commissions and publishes many evaluations, statis- statistiques (DREES) tical analyses and policy overviews of all aspects of the French health care system. Many of these studies have a strong health economic component. Recent reports include a review of regional http://www.sante.gouv.fr/drees health inequalities and the annual health status of the population. In addition to working papers, there are also several periodical publications, including Etudes et Resultats which publishes two individually themed reports each week. The website is predominantly French only, although there is some limited English content.

European Foundation for the Based in Dublin, the Foundation is a European Union body, one of the first to be established to Improvement of Living and work in specialised areas of EU policy. Specifically, it was set up by the European Council Working Conditions (Council Regulation (EEC) No. 1365/75 of 26 May 1975), to contribute to the planning and design of better living and working conditions in Europe. Its role is to provide information, http://www.eurofound.ie advice and expertise – on living and working conditions, industrial relations and managing change in Europe – for key actors in the field of EU social policy on the basis of comparative infor- mation, research and analysis. The Foundation has explored the area of health, in the broader sense, by examining the physical, mental and social well-being of workers. In relation to work- place health, there are three main issues to be considered: health problems; risk exposure; and work organisation. Foundation studies have identified that the two most frequent work-related health problems are musculoskeletal disorders as well as stress, depression and anxiety problems. The Foundation also looks at the provision of social care: recent research includes a publication on employment patterns in social care across Europe.

Haute Autorité de Santé – French The Haute Autorité de Santé (HAS) was set up by the French government in August 2004 in National Authority for Health order to bring together under one roof a number of activities designed to improve the quality of patient care and guarantee equity within the health care system. HAS activities are diverse. They http://www.has-sante.fr range from assessment of drugs, medical devices, and procedures to publication of guidelines to accreditation of health care organisations and certification of doctors. All are based on rigor- ously acquired scientific expertise. Training in quality issues and information provision are also key components of its work programme. HAS is an independent public body with financial autonomy. It is mandated by law to carry out specific missions on which it reports to government and parliament. It liaises closely with government health agencies, national health insurance funds, research organisations, unions of health care professionals and patients’ representatives. While most of the website is only available in French, there are some English language pages including a catalogue of more than 122 HAS publications available in English.

Institute for Public Policy The Institute for Public Policy Research is a UK based think tank, undertaking research and Research policy innovation across all areas of public policy, including health and social care research. A wide range of reports are produced, all freely downloadable from the website. Recent publica- http://www.ippr.org tions include an analysis of hospital reconfiguration, as well as public expectations and the NHS. Detailed information on current research and flagship areas of work are also provided.

Scottish Medicines Consortium The remit of the Scottish Medicines Consortium (SMC) is to provide advice to NHS Boards and their Area Drug and Therapeutics Committees (ADTCs) across Scotland about the status http://www.scottishmedicines.org.uk of all newly licensed medicines, all new formulations of existing medicines and any major new indications for established products (licensed from January 2002). Assessments consider not only whether it is more effective than existing treatments, but which patients will benefit, what is costs and whether it is worth investing NHS money to prescribe it. The website provides information on on-going and completed assessments, detailed minutes of meetings, press releases and methodological documents.

Eurohealth Vol 12 No 3 47 MONITOR

EUROPEAN MONITOR was WHO Assistant Director- reduce the extent and impact of General for Communicable the commercial promotion of Diseases and Representative of energy-dense food and New WHO Director-General the Director-General for beverages, particularly to Dr Margaret Chan of China was Pandemic Influenza. Anders children, with the development appointed as the next Director- Nordström, who was appointed of international approaches, General of the World Health by the Executive Board as such as a code on marketing to Organization (WHO) on 10 Acting Director-General of children in this area; and the November 2006. In her WHO in May 2006, will adoption of regulations for safer acceptance speech, Dr Chan told continue in this role until the roads to promote cycling and the World Health Assembly that new Director-General officially walking. Other key actions as Director-General she wanted takes up office. needed to encourage healthier WHO performance to be judged diets and more physical activity More information at by the impact its work has on include promoting breast- http://www.who.int/ the people of Africa and on feeding; reducing the amount of mediacentre/news/releases/ women. She also stated that her fat, sugar and salt in manufac- 2006/pr66/en/index.html focus will be on six key issues, tured products; and establishing including health development, opportunities for daily physical European Charter adopted to security, capacity, information activity and for good nutrition reverse the obesity epidemic and knowledge, partnership, and and physical education in On 16 November in Istanbul, at performance. Furthermore, she schools. the WHO European Ministerial emphasised the importance of Conference on Counteracting Earlier, at the opening of the global health security in her Obesity, Dr Marc Danzon, conference, Turkish Prime vision of the Organization’s role WHO Regional Director for Minister Tayyip Erdogan and praised health workers for Europe, and Professor Recep stressed the need for actions their “impressive dedication, Akdag, Minister of Health of across many sectors stating that often under difficult condi- the Republic of Turkey, signed “obesity is an epidemic peculiar tions”. an historic charter on behalf of to this century…comprehensive She also paid tribute to her all of the Member States in the changes to the way we live have predecessor. “We are all here WHO European Region. The led to this problem, and we are because of the untimely death of European Charter on Counter- all aware that action in the field Dr Lee Jong-wook. We are also acting Obesity sets the ultimate of health alone is not enough”. all here because of many goal of curbing the epidemic The charter is available at millions of untimely deaths. I and reversing the current trend http://www.euro.who.int/ know Dr Lee would have in the Region. Document/E89567.pdf wanted me to make this point.

News Dr Danzon said “we are all He will always be remembered More information and access to aware that obesity is one of the for his 3-by-5 initiative. That working papers and background most serious public health chal- was all about preventing documents related to the Minis- lenges facing Europe today. untimely deaths on the grandest terial Conference can be found Evidence exists on what needs scale possible”. at http://www.euro.who.int/ to be done to reverse the trend. obesity/conference2006 Dr Chan obtained her medical This Charter commits Member degree from the University of States to put obesity high on Health Ministers Council calls Western Ontario, London, their political agendas and calls for broad action on health Canada and a degree in public on all partners and stakeholders determinants health from the National to do the same. It is a guide, an On 30 November in Brussels, University of Singapore. In opportunity, and gives us the EU health ministers called for a 1987, she joined the Hong Kong tools to take effective action”. broad package of measures to Department of Health and was The Charter declares that tackle the lack of physical appointed Director of Health in “visible progress, especially activity, smoking, unhealthy 1994. In this capacity she relating to children and adoles- diets and other ‘societal’ health launched new services focusing cents, should be achievable in determinants, as individuals’ on the prevention of disease and most countries in the next 4–5 capacity to control them is promotion of health and intro- Press releases and years and it should be possible sometimes limited. They also duced new initiatives to improve other suggested to reverse the trend by 2015 at adopted conclusions on Health communicable disease surveil- information for the latest”. It notes that specific, in All Policies (HiAP) – the lance and response, enhance future inclusion targeted action across many main priority of the Finnish EU training for public health can be e-mailed to sectors is needed to achieve this. Presidency in the health sector. professionals, and establish the editor Among measures that should be These conclusions call for better local and international included are: the adoption of “broad societal action to tackle David McDaid collaboration. Previously she [email protected] regulations to substantially health determinants, in

Eurohealth Vol 12 No 3 48 MONITOR particular unhealthy diet, lack of mation objective, the Commission will nication were: to protect young people physical activity, harmful use of alcohol, foster the exchange of knowledge and and children; reduce injuries and deaths tobacco and psychosocial stress, since best practice in areas where the EU can from alcohol-related road accidents; the individual capacity to control these provide added-value in bringing together prevent harm among adults and reduce determinants that account for major expertise from different countries, e.g. the negative impact on the economy; public health problems, is strongly asso- rare diseases, children’s health or any raise awareness of the impact on health ciated with broader societal determi- other important area. It will promote of harmful alcohol consumption; and nants of health, for example the level of EU health monitoring and develop indi- help gather reliable statistics. In cooper- education and available economic cators and tools as well as ways of ation with Member States and stake- resources”. disseminating information to citizens, holders, the Commission will develop such as the health-EU portal. strategies aimed at curbing under-age Accordingly, the Council have invited drinking, by exchanging good practice the Commission to set out a work plan Welcoming the agreement, European on issues like selling and serving, for HiAP and to consider related activ- Health and Consumer Protection marketing, and the image of alcohol use ities in the future EU health strategy. Commissioner, Markos Kyprianou, said conveyed through the media. Through The Member States are invited to “improving health is important in its its Public Health Programme, the undertake, where appropriate, “health- own right. But it also plays a key role in Commission will support projects that impact assessment of major government addressing challenges such as population will contribute to reduce alcohol-related policy initiatives with a potential bearing ageing, security threats or labour harm in the EU, and especially the harm on health”. shortages. Health has a role to play in suffered by children and young people, achieving Europe’s full potential for The Council also reached a political as well as gathering and disseminating prosperity, solidarity and security. The agreement on the Commission proposal data. It will support the monitoring of new Health Programme will be instru- for the EU Health Programme 2007– young people’s drinking habits, with a mental in reaching these goals. I look 2013, which aligns future EU health focus on the increased drinking of forward to working with the Council action with the overall EU objectives of alcohol among girls and binge-drinking. and Parliament to help discussions to prosperity, solidarity and security and progress rapidly”. The Commission will explore, in coop- aims to further exploit synergies with eration with Member States and stake- other policies. A formal “common The Council conclusions can be viewed holders, the usefulness of developing position” will have to be adopted by the at http://www.consilium.europa.eu/ efficient common approaches Council in early 2007, and the ueDocs/cms_Data/docs/pressData/en/ throughout the Community to provide Programme will have to go through the lsa/91975.pdf adequate consumer information. Such European Parliament in second reading. Further information on the proposed reflections are particularly important as The Programme sets the framework for work programme can be viewed at some Member States are planning to the Commission’s funding of projects http://ec.europa.eu/health/ph_overview/ introduce warning labels (for example, relating to health between 2007–13 and pgm2007_2013_en.htm on alcohol and pregnancy). It will will be part of a broader EU health support Member States and stakeholders strategy to be put forward by the Commission adopts Communication on in their efforts to develop information Commission next year. The proposed reducing alcohol related harm in Europe and education programmes on the effect budget is €365.6 million. The On October 24, the European of harmful drinking. Through the EU Programme’s objectives are: improving Commission adopted a Communication Research Framework Programme, the citizens’ health security; promoting setting out an EU strategy to support Commission will launch research on health; generating and disseminating Member States in reducing alcohol- young people’s drinking habits in order health information and knowledge. related harm. The Communication to analyse current trends and motiva- Under the first objective, actions to be addresses the adverse health effects of tions for drinking, as well as the wider taken will include developing EU and harmful and hazardous alcohol determinants of youth drinking. Member States’ capacity to respond to consumption in Europe. Fifty-five The Communication also mapped out cross-border threats, including preparing million adults are estimated to drink to actions which Member States are taking, for coordinated EU and international hazardous levels in the EU. Harmful and with a view to promoting good practice, responses to health emergencies. This hazardous alcohol consumption is a net proposed an Alcohol and Health Forum objective will also address patient safety cause of 7.4% of all ill-health and early by June 2007 of interested parties and and EU legislation on blood, tissues and death in the EU. The Commission also set out areas where industry can cells. estimate overall alcohol is the cause of make a contribution, notably in the area the deaths of 195,000 people a year in Under the promoting health objective, of responsible advertising and the EU. Other adverse consequences can the Commission will foster healthy marketing. However acknowledging the include child abuse and neglect, while active ageing and help bridge health role of Member States in this policy area approximately one accident in four can inequalities. It will also continue action the Commission stated that it does not be attributed to alcohol consumption, on the determinants of health such as intend to propose legislation at and about 10,000 people are killed in nutrition, alcohol, tobacco and drug European level. alcohol-related road accidents in the EU consumption as well as the quality of each year. Health and Consumer Protection social and physical environments. Commissioner Markos Kyprianou said The priorities identified in the Commu- Under the third knowledge and infor- of the strategy: “binge drinking, under-

Eurohealth Vol 12 No 3 49 MONITOR age drinking and drink-driving are real alcohol in Europe”. However they obviously expectations on the alcohol public health issues in Europe, especially argued that the final text of the Commu- industry to deliver will be high”. He also among young people. The Commission nication was watered down heavily due stated that there was an ethical obli- is not targeting moderate alcohol to intense industry lobbying. gation on the industry not “to specifi- consumption, but seeks to actively cally target young people through the Andrew McNeill, Honorary Secretary support Member States measures to design of alcoholic beverages, or through of Eurocare said “we regret to see the reduce the harm caused by alcohol advertising, sponsoring and marketing”. industry’s paw prints are all over the abuse”. Communication”, and added “given that The alcohol strategy can be viewed on Mixed reactions to the strategy the industry has made it abundantly line at http://ec.europa.eu/health/ph_ clear that it is opposed to the whole idea determinants/life_style/alcohol/ Responses to the publication of the of a public health strategy on alcohol, documents/alcohol_com_625_en.pdf strategy have been mixed. The alcohol how can it possibly be seen as a main industry have broadly welcomed the Commisioner Kyprianou’s speech to the collaborator in implementing it?” Communication, given its focus on EFRD on 30 October can be viewed at alcohol abuse rather than alcohol Peter Anderson, the author of the recent http://europa.eu/rapid/pressReleases consumption per se. Jamie Fortescue, report Alcohol in Europe, stated that Action.do?reference=SPEECH/06/645& Director General of the European Spirits “the alcohol industry has lobbied to put format=HTML&aged=0&language=EN Organisation (CEPS) welcomed “the their own profits above the needs of the &guiLanguage=en recognition the Communication gives to European people, with commission offi- the role the alcohol industry can play in cials, other than those directly involved reducing alcohol related harm, most with health issues, surrendering to its EUROPEAN COURT NEWS notably in terms of promoting respon- pressure”. He said the proposed EU sible consumption. The priority themes alcohol policy is “much weaker than the proposed are entirely consistent with first draft and has a much greater focus ECJ looks again at duty on alcohol and CEPS’ Charter on Responsible Alcohol on education as the answer to solving tobacco imports Consumption”. the problems of alcohol, when the In the EU, excise duty is chargeable in evidence shows that it does not work”. Alan Butler, Chairman of the Europe the Member State of final destination; He regretted that measures that could Forum for Responsible Drinking however, a provision allows for excise have made a real difference such as a (EFRD), an alliance of leading spirits duty on products “acquired by private “better regulation of the product and its organisations, said that “there is much to individuals for their own use and trans- marketing”, were no longer in the text of be welcomed in this Strategy, in ported by them” to be charged in the the Communication. particular a focus on alcohol misuse Member State of purchase. The issue rather than alcohol per se and the reas- One week after the publication of the under question in the European Court surance that different cultural habits are Communication, Commissioner of Justice centred on where duty on respected through recognition of Kyprianou in a speech in Stockholm to alcohol and cigarettes should be charged, Member State subsidiarity”. He went on the EFRD also expressed his frustration specifically for goods bought for to applaud the Commission for with the attitude adopted towards the personal use over the internet or via mail “rejecting attempts to hijack the strategy strategy by some in the alcohol industry order. In the present case (Staatssecre- by those who advocated a biased view of and challenged them to do more to coop- taris van Financiën v. BF Joustra), a the evidence base and for recognising the erate on alcohol-related harm. He said private individual from the Netherlands positive role that industry can play in “to be frank, I have been disappointed to purchased duty-paid wine in France for being part of the solution to alcohol- see that some senior players in your his own use. He did not transport the related harm”. However, he also said industry have deliberately painted a false wine himself, but engaged a transport that “concerns remain that warning picture of what the Communication is company to do so. The Dutch tax labels and de facto restrictions on about, and about what we are trying to authorities now wish to levy excise duty commercial communications could achieve. Indeed, some of you have used on the wine, and the UK government is surface during the implementation the media to give the impression that the supporting them in their action. phase. We urge the Commission to Commission is hell-bent on spoiling the Advice from Advocate General Jacobs in exercise caution in compiling the pleasure of those who enjoy alcohol in his December 2005 Opinion, confirmed evidence base in support of these policy moderation. You know very well that that the rules should mean that shoppers options and reject such arbitrary this is not the case”. can buy at local excise duty rates when measures”. He went on to say that “it is however ordering from abroad. The Dutch and In contrast some in the public health clear that the alcohol industry must UK authorities wanted the Court to community are disappointed with the make an active and significant contri- reject this Opinion. On 23 November final text agreed. The European Alcohol bution towards measurable progress”. 2006, the European Court ruled that Policy Alliance (Eurocare), an alliance of Referring to the planned Forum on consumers are allowed to buy alcohol fifty-five voluntary and non-govern- Alcohol and Health, he said “I should and cigarettes online at lower duties mental organisations “welcomed the emphasise right from the start that the from abroad, but they will have to strategy and stated that it would Forum will not just be a talking shop. I accompany the goods back themselves. continue to support the Commission in want to see meaningful and verifiable This judgment comes six months after its efforts to reduce the harm done by commitments from all its members – and the European Commission decided to

50 Eurohealth Vol 12 No 3 MONITOR end legal proceedings against the UK for to €14 billion gross current plus €657 poor organisational procedures. The cracking down on shoppers bringing in million gross capital. The Minister said, claims were made in at a conference excessive quantities of alcohol and “the government is again providing for a organised by the Italian Association of tobacco. The UK Treasury crackdown substantial annual increase in public Oncological Medicine (AIOM) and held was triggered by fears that shoppers spending on health, of over €1.1 in Milan on 23 October. In response to were bringing in much more cheap billion”. Eight new units in acute the claims, Ignazio Marino, president of alcohol and cigarettes than was justified hospitals around the country will be the Senate Hygiene and Health by private consumption, then selling it opened at a cost (along with other devel- Commission, underlined that “the figures on and worsening revenue losses. opments) of €75 million. given to the press are alarming and need Furthermore, the British Retail in-depth explanation and have to be The Minister also confirmed that Consortium argued that if the Court had analysed by experts active in evaluating spending on older people would be one taken the Opinion of the Advocate clinical risk inside medical facilities.” of the key priorities in 2007, stating that General, British business could have she wanted to “ensure that our Widely reported in the media, the AIOM been hit hard unless excise duty rates commitment to fully fund the largest report estimated that about 33,000 people were harmonised across the EU. expansion in services for older people is die each year, far higher than the number met in 2007”. She noted that “€110 of people killed on the roads. Speaking to COUNTRY NEWS million was added to services for older the BBC, AIOM spokesman Mauro people in 2006. This funding has been Boldrini said that they were “convinced well-used to treble home care packages, that there is a serious problem that no-one Access to cancer-treatment varies across to expand home help hours, to increase has properly studied. If no-one talks Europe nursing home subvention and to support about it, then it won’t be addressed”. In Access to cancer care, such as surgery palliative care, for example. The €40 response, a health ministry spokesman and radiotherapy, the availability of anti- million required to fund this expansion said that the claim seemed “exaggerated”. cancer drugs and medical training differ in a full year is now provided for. Effec- However Health Minister, Livia Turco, throughout the EU, according to a study tively, this means that these additional said that “whatever the correct numbers published by the Swiss based European services will be provided for the full 12 are...the data given by AIOM confirms Society for Medical Oncology (ESMO) months of the year, rather than 9 months the urgent need to face up to the issue of on 3 October 2006. Even access to infor- on average in 2006, and this will mean errors in medicine in order to guarantee mation is said to vary from country to more older people will receive new maximum safety for citizens who turn to country. support in 2007 than in 2006”. our country’s health services every day”. The Medical Oncology Status in Europe There will also be an additional €8 Around one third of the alleged errors survey studied and compared countries, million in funding to allow the occurred on the operating table. Other for example, on education and training, nationwide rollout of Breastcheck, the areas for errors were patient wards sub-specialisations of oncology, patterns national breast cancer screening (28%), emergency rooms (22%) and of care, national guidelines on cancer programme, while €5 million will be out-patient clinics (18%). The report and clinical research. The study does not made available to help prepare the suggested that many errors involved provide for a clear ranking of the national cervical screening programme. giving patients the wrong medication European countries on the matter, but The National Treatment Purchase Fund, because of the similarities between shows that Iceland, Switzerland, Italy which sources treatment for patients generic and brand names. and Germany have the highest number who have been waiting for more than Media coverage of the event has been of both oncologists and facilities relative three months, will also see its budget to population size, whereas eastern criticised for being sensationalist and not increased by €10 to €88m. Commenting grounded in science. Maurizio European nations have fewer specialist on the Fund the Minister said, “the Fund Maggiorotti, head of the Association of units. ESMO President Håkan Mell- has shortened waiting times and Doctors Unjustly Accused of stedt, hopes that the report, by improved responsiveness for 50,000 Malpractice commented that “this is not providing more information on the public patients. I am very supportive only false but is has no scientific foun- European infrastructure, will help also of its expanding work to provide dation or statistical credence”. Measures reduce some of the inequalities seen in outpatient appointments in areas and to avoid the likelihood of medical errors access to services. specialties where waiting times have in Italy have included the establishment been longest”. The report is available at of a Commission for Clinical Excellence http://www.esmo.org/resources/surveys/ Full information on the 2007 health and the National Centre for Patient mosesII_survey estimates are available at Safety. http://www.dohc.ie/publications/pdf/ Ireland: New hospital units and older estimate_increases.pdf?direct=1 Germany: Parliament votes to ban people priorities in €14.5bn package of tobacco advertising funding Italy: Senate investigates medical The lower house of the German On 16 November the Minister for malpractice claims parliament on 9 November voted over- Health and Children, Mary Harney, The Italian Senate has called for further whelmingly in favour of a ban on announced the agreed estimates of information on controversial claims that tobacco advertising that would finally expenditure on health in 2007. Total as many as ninety people a day die in the bring Berlin in line with European public spending on health will amounts country due to medical malpractice and Union directives. Under the bill, ciga-

Eurohealth Vol 12 No 3 51 MONITOR rette manufacturers will still be able to This would mark a sharp departure from to claim, however, that the abortion was advertise on billboards and on cinema the rest of Germany’s federal states, completely legal. Moreover, the doctor, screens after 7:00 pm. But it will bring an which have to varying degrees resisted who has run clinics specialising in end to tobacco in the print press, on national restrictions on tobacco. A voluntary terminations for 30 years, television and the Internet and at sports previous effort to introduce a underlined that he had rarely practiced events which are broadcast on television. nationwide ban on smoking in restau- abortions on women whose pregnancies rants, cafes and bars, aimed at bringing had gone beyond 30 weeks. The Free Democrats, a free-market Germany into line with other European liberal party, voted against the ban. They The deputy director of the Catalan nations, was blocked in September by claimed that it patronised consumers and health ministry, Lluis Torralba, said his Chancellor Angela Merkel’s Christian forbade advertising for a legal substance. department was now collecting infor- Democrats. Advertisers and publishers also generally mation on the clinic. The case has led to condemned the decision. Newspaper a political outcry on Denmark with the Spain: Investigation into alleged illegal publishers see it as a restriction to their head of the Danish parliamentary late term abortions freedom to advertise, while the German committee on public health, Birthe In October an investigation was Association of Magazine Publishers Skaarup, a member of the far-right launched in Barcelona into allegations (VDZ) said the government capitulated Danish People’s Party which is a key ally made on a Danish television (DR1) with its “overly-hasty” decision. The of the government, saying that she was documentary that doctors in one clinic vote to ban tobacco advertising shows “scandalised and shocked” by what she were providing late terminations, for the increasing influence of the EU over termed the “outright murders”. Oppo- women from all over Europe; in some national questions, the VDZ told news sition MPs also urged the Danish cases as late as eight months into preg- channel Deutsche Welle. government to put pressure on the nancy. Spanish government. A spokesman for Germany has long been considered a According to the documentary, which Denmark’s ruling Liberal Party, Joergen haven for smokers and cigarette manu- used video footage taken in September Winther, said meanwhile it was necessary facturers, while rules on public smoking and also sent to local news agencies, the to “discuss common regulations within and tobacco advertising grew stricter centre is alleged to be systematically and the European Union on abortion”. elsewhere in Europe. The ban was fraudulently using a legal loophole highly controversial and Berlin went to In Spain, abortion was decriminalised in which allows abortions without time the European Court of Justice to fight 1985 for certain cases: up to the first limits in cases of serious mental or the EU directive on forbidding tobacco twelve weeks of pregnancy following physical risk to the mother. advertising. But the government realised rape and up to twenty two weeks in the the challenge was doomed in June when In the documentary, filmed with a case of foetus abnormality or if the preg- an advocate general of the court recom- hidden camera, a DR1 journalist in her nancy represents a threat to the physical mended dismissing it. (See news section eighth month of pregnancy appeared to or mental health of the woman. Inter- in Eurohealth 12 2). be offered a chance to abort her healthy viewed in the documentary, Jesús Silva, foetus for a fee of €4,000. She met with professor of criminal law at the Univer- Consumer Affairs Minister Gerd Müller the director of the centre, who assured sidad Pompeu Fabra in Barcelona stated has also held out the prospect of further her that the procedure was legal and that the application process “was a anti-smoking legislation to protect indi- carried no risks. The director explained theatre, a lie with false tests”, and that “it viduals against the effects of passive before the hidden camera that the foetus was fraudulent in Spanish law and as a smoking; a working group made up of would be injected with dioxin, which whole”, and should – in the cases of representatives from the Social Demo- would make the baby’s heart stop before illegal abortions being carried out – cratic Party (SPD), the Christian Demo- being extracted from the uterus. The imply prison sentences and the disquali- cratic Union (CDU) as well as from the female journalist, who alluded to the fication from practice of those involved. health and consumer protection ministry break-up with her partner being the is currently exploring ways of intro- More information (in Spanish) at reason for the abortion, was asked to fill ducing a Germany-wide anti-smoking http://actualidad.terra.es/sociedad/articu in a questionnaire about her physical and regulation. lo/reportaje_tv_barcelona_1174449.htm mental health. Then she completed three psychological tests, being told that the Berlin to press ahead with local Portugal: Parliament approves abortion only way of having a legal abortion smoking ban referendum (under these circumstances) was to allege Meanwhile, Berlin’s local government On October 19 Portugal’s parliament physical or mental problems, in spite of wants a ground-breaking ban on voted to hold a national referendum the fact that she had already stated smoking in the city’s public buildings as allowing voters to decide on making during an interview that her health was well as in all bars and restaurants, further abortion legal up until the 10th week of ‘good’. stoking debate on outlawing smoking pregnancy. Current Portuguese abortion across the country. Berlin Mayor Klaus Minutes later, the journalist returned to law allows the procedure up until the Wowereit’s Social Democrats and their the clinic to reveal her true identity, 12th week of pregnancy, but only in designated coalition partners, the Left accompanied by a television camera. In cases of rape, foetal abnormality, or risk Party, said in early November that they an interview with the director, he to the mother’s health. Parliamentary are pressing ahead with plans to make claimed that the operation had not been approval of the referendum comes only a the German capital smoke-free as early authorised and that further psycho- month after the ruling Socialist Party as 2007. logical tests were needed. He continued first proposed it. Before a date for the

52 Eurohealth Vol 12 No 3 MONITOR vote is set, both the conservative Pres- pricing and reimbursement and distri- people will have the opportunity to ident Cavaco Silva and the Constitu- bution of pharmaceuticals, as well as the publish photographs or video clips on a tional Court of this very Catholic operation of pharmacies. web site (www.drugsinfo.nl), together country must formally approve it. with a message explaining why they do The Bill contains provisions on the pay- or do not smoke cannabis. Portugal, which has one of the most in obligations of marketing authorisation restrictive abortion laws in Europe, has holders (MAH). A MAH shall pay a Figures published by the Netherlands made several unsuccessful attempts in certain percentage (14% for fixed- Institute of Mental Health and the last ten years to ease restrictions on subsidised products and 16% for non- Addiction show that cannabis is still the abortion, so success is by no means guar- fixed subsidised products) of the total most widely used drug among young anteed. In 1998, a referendum on legal- annual amount of reimbursement for people in the Netherlands. Moreover, ising abortion was declared void due to each product reimbursed by the national data collected by the Drugs Info Line low voter turnout, yet there was a slight health insurance system. In order to show that most of the questions received majority voting against the referendum. cover the overspending of the health by that service concern the use of A second referendum was proposed in budget on the reimbursement of medi- cannabis. Yet four out of five young November 2005, but the Constitutional cines, MAHs shall also comply with a people have never smoked cannabis, Court held that the vote could not be band-based pay-in obligation (up to 9% which contradicts the commonly held held before September of this year, of the overspending, the MAHs shall belief in this age group that at least 80% because the same referendum had been pay jointly with the State, above 9%, the are cannabis users. rejected in the current legislature by the MAHs shall be solely responsible for the The new campaign tackles misconcep- now-former president. A referendum remaining amount). tions about cannabis use. It prompts result can only be valid only if 50% of The bill also permits the temporary young people aged between 14 and 18 to Portugal’s registered voters cast ballots. fixing of pharmaceutical prices for a search for more facts about cannabis. One recent opinion poll conducted by maximum of two years; currently the The campaign was developed by the the firm Marktest suggests that 63% of duration of such a price freeze is nine Trimbos Institute, in cooperation with the population would be in favour. months. The bill would allow for a addiction care institutions and Although affluent Portuguese women review annually to determine whether municipal/regional health authorities, can travel to abortion clinics in Spain, any price freeze was still justified. Such under the auspices of the Ministry of abortion rights groups estimate that factors would include the need to Health, Welfare and Sport. approximately 10,000 Portuguese provide access to a key patented Cash rewards for drug addicts women are hospitalised each year from treatment for a disease or if the costs of complications from failed backstreet manufacturing were in excess of the Meanwhile over the summer there has procedures. Prime Minister Jose Socrates government’s fixed price. Registration been some controversy over a pilot said “we have to end this blight of back- fees with the National Institute of fourteen-month scheme involving hard street abortions, it makes Portugal a Pharmacy for medical sales representa- drug addicts in three Dutch cities, esti- backward country”. The opposition tives will be increased to approximately mated to cost of more than €500,000. Christian Democrats said they would €19,000 with an annual renewal fee of The pilot schemes will give free heroin campaign against the legalisation of almost €4,000. The bill also proposes and cash rewards (up to €56 euros per abortion. “Once again, the Christian that limits on hospitality and spon- week) to heroin addicts if they do not Democrats will be the only party that sorship of conferences per participant be use cocaine at the same time. Partici- will campaign against (it), defending the slashed from 50% to just 5% of the pants will be required to prove that they fundamental right to life,” MP Pedro monthly statutory minimum income. are cocaine-free by taking regular urine Mota Soares told parliament. tests. The Central Commission for the A new authority will be responsible for Treatment of Heroin Addiction believes In Europe, only Poland and Ireland have approving contracts with health service that the experiment is worthwhile, as such restrictive rules on abortion, while suppliers. It will be able to recommend research has shown that cocaine is the Malta forbids abortion altogether. to the National Health Insurance Fund preferred drug for most addicts. Administration to suspend or terminate Hungary: Proposed act on supply and the financing contracts of healthcare Some in the Dutch media have however distribution of medicines and devices service providers. The Bill will also liber- condemned the pilot schemes. In a alise rules concerning pharmacies and written reply to Parliament, Minister of The Hungarian Minister of Health has the sale of medicines and will allow Health Hans Hoogervorst stated that he submitted draft legislation to parliament some over the counter medicines to be fully understood concerns over the use on the Safe and Economical Supply and sold outside pharmacies. of a system of financial rewards, but Distribution of Medicines and Medical stressed that this approach has been Devices. Parliamentary debate began on Netherlands – Drug initiatives effective in the United States. 25 October 2006, and it is proposed that Nonetheless, he acknowledged that this the Bill will enter into force on 1 January Launch of nationwide Drugs Awareness might be seen to send the wrong signals 2007. It will impose new payment obli- Campaign to addicts and as a result he has asked gations on pharmaceutical manufac- On 6 November, Health Minister Hans the Central Commission for the turers and make amendments concerning Hoogervorst officially launched the Treatment of Heroin Addiction to inves- various aspects of pharmaceutical regu- annual nationwide Drugs Awareness tigate suitable alternatives to cash. lation, particularly related to promotion, Campaign. During one month, young Potential options might include the

Eurohealth Vol 12 No 3 53 MONITOR distribution of vouchers for services supplemental medicines programme, and 6,000. The largest number of officially such as personal grooming, health and may arise out of the fierce competition registered people living with sports. to win the next year’s rights to supply HIV/AIDS, 218, is in the capital city medicines to Russians who receive state Dushanbe. Russia: Chief Medical Officer calls for assistance and benefits. In this year’s Although Tajikistan is still considered a state monopoly on alcohol programme three companies were country with low HIV prevalence, the On 14 November, Russia’s Chief awarded 70% of the 29 billion rouble dramatic rise in new cases since 2004 is a Medical Officer, Gennady Onishchenko, fund, with the remainder of the funds cause for concern. In Tajikistan, as in urged the government to introduce a distributed to more than 50 companies. Russia, Ukraine and Belarus, the vast state monopoly on alcohol, amid the Next year’s budget for the fund is majority of new cases are among rising death toll from bootleg vodka in expected to be in the region of 42 billion injecting drug users. The spread of HIV the country. Russia has recently been roubles. in this group has been rapid. They now swept by media reports of large-scale The supplemental medicines programme make up two –thirds of officially regis- outbreaks of alcohol poisoning in several has however been problematic; this year tered HIV-positive cases. regions as bootleg vodka and poisonous running out of funds by July and antici- substitutes have been sold at low prices Financial and technical support from pated to incur a substantial debt of more in the country. Dr Onishchenko noted international donors for HIV prevention than 20 billion roubles by the end of that while “in the 1990s, per capita and improved surveillance increased 2006. The case has also led to calls for consumption of alcohol stood at 7.6 dramatically in 2005, as Tajikistan is one the resignation of Minister of Health and litres by 2005, the figure had reached 9.7 of the countries covered by the Central Social Development, Mikhail Zurabov. litres”. He went on to say that his Asia AIDS Project. The supplemental medicines program is department and the Interior Ministry seen as one of his most important For more information see: were taking active measures to expose projects. It was heralded as the largest http://eng.caap.info bootleg vodka and alcohol substitutes. state social programme and the Dr Onishchenko’s call comes in the beginning of the reform of state social Turkmenistan: Reforms focus on wake of the news that approximately assistance when it was launched. importing medical technology 10,000 cases of toxic hepatitis caused by The official news agency for Turk- At a press conference shown on Russian surrogate alcohol have been registered in menistan reported on 7 November 2006 television on 20 November he said that Russia. He said that toxic hepatitis had that a new contract with Siemens has “our understanding of how events will been seen in eighteen regions, with a been finalised with the Ministry of develop is rather limited at the moment, dramatic surge of alcohol-related cases Healthcare. This will provide a telemed- but it evidently is not a question of addi- in the Irkutsk, Chelyabinsk and icine network across the country. The tional supplies of medicine”. He did not Belgorod regions, where 107 people have government have been collaborating rule out that people were using the been affected. There have been more with the German high-technology scandal to drive him from his job, but he than 400 deaths in recent months, the company Siemens on a number of health said that resigning would be too easy. majority of which appear to be due to care projects and reforms in the country the consumption of sub-standard and Mr Zurabov has courted unpopularity have focussed on the importation of ‘big illegal bootlegged alcohol. ever since his appointment in March ticket’ medical technologies. 2004. He has tried to push through The introduction in July of a new alcohol The flagship hospital is the International reforms to Russia’s pension and health regulation policy, has been criticised for Medical Centre in the capital, systems, seeking to replace many causing widespread confusion leading to Ashkhabad, which specialises in cardi- benefits with a cash payment system. He a shortage of legal supplies of alcohol. ology. The aim has been to provide has faced stiff opposition from doctors clinics and hospitals in Turkmenistan and local officials and there have been Russia: Corruption scandal hits with the equipment to bring facilities up calls for demonstrations from pensioners to ‘western’ standards. Estimated life insurance fund faced with charges for benefits that were expectancy in Turkmenistan was just 60 A criminal investigation into alleged previously free. major corruption at the Federal Medical years in 2003, one of the lowest in the WHO European region. Mandatory Insurance Fund has been Tajikistan: Rapid increase in HIV launched, following the arrest of fund infection rates. While this project constitutes a major director Andrey Taranov and deputy Doctors at Tajikistan’s Republican AIDS investment in health care facilities in director Dmitry Usenko on suspicion of Prevention Centre have reported a sharp Turkmenistan, there are concerns that accepting bribes and misusing funds rise in the number of newly registered investments in technological hardware from the federal budget. Further arrests cases of HIV infection in their quarterly have not been matched by commen- have followed. The Russian Prosecutor bulletin. 121 new cases have been offi- surate investments in human capital and General’s Office has released a statement cially registered in just the first ten training for staff. saying that officials of the agency took months of 2006. This brings the total bribes from regional medical insurance More information at number of officially registered cases to funds, pharmaceutical companies and http://www.turkmenistan.ru/?page_id= 627 as of 1 October 2006, although medicine suppliers. The amounts 3&lang_id=en&elem_id=8810&type= doctors in Tajikistan estimate the total involved have not been disclosed event&sort=date_desc number of people living with The scandal has been linked to the state HIV/AIDS in the country to be over

54 Eurohealth Vol 12 No 3 News in Brief

New HEN report on mobile phone in the production and trafficking of il- oriented approach on the one hand, and use and health licit drugs and still more are touched by a caring and serving approach on the Written by Emília Sánchez from the the devastating social and economic other hand, they want to focus on the Catalan Agency for Health Technology costs of this problem. Partially a conse- possibilities and practices of more effec- Assessment and Research, this new re- quence of its pervasiveness and partially tive combinations of these two sets of port from the WHO Regional Office for a consequence of the illicit and hidden values. The conference seeks to explore Europe's Health Evidence Network nature of the problem, reliable analysis how the clash between value sets can be looks at the use and health effects or and statistics on the production, traffick- addressed. Is it possible to reconcile risks of mobile phones. The study analy- ing and use of illicit drugs are rare. both sets of values and look for a com- ses epidemiological studies in the general mon denominator? The World Drug Report 2006, published population that have looked at the links by the United Nations Office on Drugs The submission deadline is 15 January between mobile phone use and the de- and Crime, endeavours to fill this gap. It 2007. The event will take place in Lyon, velopment of tumours. Although weak provides one of the most comprehensive France on 27–29 June 2007. and inconclusive, most of the evidence overviews of illicit drug trends at the in- More information at available does not suggest that there are ternational level. In addition, it presents http://www.ehma.org/_fileupload/File/ adverse effects on health attributable to a special thematic chapter on cannabis, EHMA_2007_Call_for_papers.pdf long-term exposure to radio-frequency by far the most widely produced, traf- and microwave radiation from mobile ficked and used drug in the world. EC work plan confirmed phones. Recent studies have however re- The European Commission has pub- ported an increased risk of acoustic neu- More at http://www.unodc.org/unodc/ lished its work plan for 2007, listing a roma and some brain tumours in people en/world_drug_report.html range of new initiatives in addition to its who use an analogue mobile phone for ongoing programmes. Health related ac- more than ten years. The report con- Public-Private Partnerships and tions include strategic communications cludes that if there is a risk, it is small, collaboration in the health sector on nutrition, mental health, health care but that there are still gaps in our Written by Irina Nikolic and Harald services and health in all policies. knowledge. Maikisch, this World Bank brief is in- tended to provide an overview of the More information at The report is available at topic of public-private partnerships http://ec.europa.eu/atwork/programmes http://www.euro.who.int/Document/ (PPPs) and public-private collaboration E89486.pdf (PPC) in the health sector, the key types Regions: Statistical Yearbook of PPPs and PPC encountered in prac- Eurostat, the EU statistics body, has Health in Scotland annual report tice, the associated benefits and risks, published the 2006 edition of Regions: A Scotland in which lung cancer is virtu- and good practices for ensuring success. Statistical Yearbook. Covering the 266 ally wiped out is a real possibility in Also included are nine recent case stud- regions of the 27 EU member states years to come if the reduction in deaths ies from experience in Romania, Ger- from 2007, it includes chapters on health speeds up as expected, Chief Medical many, Austria, Denmark, Sweden and and other data. Officer, Harry Burns, said on 6 Novem- Portugal that illustrate these considera- ber in his first annual report. The smok- It is available in paper, CD-Rom or tions under specific project circum- ing ban, which has reduced passive DVD formats from stances. smoking rates and is showing early signs http://epp.eurostat.ec.europa.eu of encouraging more people to quit, will The report is available at reduce lung cancer rates to just a few http://siteresources.worldbank.org/ WHO violence survey hundred cases a year in the future, said HEALTHNUTRITIONANDPOPU- The WHO Regional Office for Europe Dr Burns. The smoking ban and other LATION/Resources/281627- has published a European survey on vio- public health measures outlined in the 1095698140167/NikolicPPP&CintheHe lence and injury levels to better under- report are also having an impact on driv- althSectorfinal.pdf stand how ministries are operating in ing down the incidence of conditions terms of policy frameworks and infra- like heart disease and stroke. EHMA conference – call for capers structures. The European Health Management As- More information at http://www.scot- Further information at sociation's scientific advisory committee land.gov.uk/Publications/2006/10/ http://www.euro.who.int/violenceinjury is now seeking oral presentations and 30145141/0 posters on the theme ‘Managing values in health care’ to be presented at its an- Additional materials supplied by World Drug Report 2006 nual conference. The aim of the confer- Some two hundred million people, or ence is to explore the relationship EuroHealthNet 5% of the global population age 15–64, between values and performance meas- 6 Philippe Le Bon, Brussels. have used illicit drugs at least once in the ures, going beyond the ideological di- Tel: + 32 2 235 03 20 last twelve months. Among this popula- chotomy of public-private, and state tion are people from almost every coun- versus market. Instead of increasing the Fax: + 32 2 235 03 39 try on earth. More people are involved gap between a market and efficiency- Email: [email protected]

eurohealth Vol 12 No 3 2 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

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