vol 12 no 4 - world health organization · 2013-10-10 · contents eurohealth volume 12 number 4...
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EurohealthEvery second counts: Doctors who work at night
Volume 12 Number 4, 2006RESEARCH • DEBATE • POLICY • NEWS
Improving accessto medicines
in the Russian Federation
Is Denmark prepared to meetfuture health care
demands?
A corporate approach to
promoting global health
Pharmaceutical policy in Spain • Armenia: health care access • Ireland's grey vote grows bolderGermany: institutional change or political stalemate? • Norway: economic impact of smoke free hospitality venues
LSE Health, London School of Economics and PoliticalScience, Houghton Street, London WC2A 2AE, United Kingdomfax: +44 (0)20 7955 6090email: [email protected]/LSEHealth
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Published by LSE Health and the European Observatoryon Health Systems and Policies, with the financial supportof Merck & Co and the European Observatory on HealthSystems and Policies.
Eurohealth is a quarterly publication that provides a forumfor researchers, experts and policymakers to express theirviews on health policy issues and so contribute to a constructive debate on health policy in Europe.
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Every second counts
As Roy Pounder writes in this issue of Eurohealth,health care is a 24 hour business. Historically, to ensurethat the demand for services could be met both day andnight, hospitals have relied on resident ‘on call’ juniordoctors, resting and sleeping when not treating patients.While this undoubtedly led on occasion to dangerouslevels of exhaustion, the limits imposed on workinghours under the European Working Time Directive(EWTD) have posed their own set of problems. Notonly has there been a need for significant organisationalchange, but resources have had to be found to pay forthe increased number of staff now needed to deliverservices.
Working patterns continue to change, so that muchmore use is made of a shift-based model. Most typicallythis consists of a simple division between one day andone night shift. Evidence from other sectors indicateshowever, that the risk of adverse events and accidents ismuch greater for night shift workers. Moreover, theserisks are set to become even more pronounced as furtherETWD constraints are introduced.
Pounder calls here for a delay in further implementationof the EWTD, suggesting only as few as four MemberStates are fully compliant with existing regulations. Innovative thinking, he contends, on how to implementchange is required, and he puts forward the notion ofthree overlapping nine hour shifts as one way of countering adverse risks.
Time inexorably marches on, no more so than in theRussian Federation. We also feature an article byKhabriev and colleagues illustrating the initial, andlargely positive, impact of a scheme to increase access toessential medicines across Russia. Additionally, we reflect on global health, by considering to what extent approaches adopted by the business community in Europe and elsewhere might be used to help foster sustainable health improvements in some of the world’smost impoverished regions. Whether thinking abouthospital staffing issues, pharmaceutical reform or savinglives in the developing world, it is abundantly clear thatevery second counts.
David McDaid EditorSherry Merkur Deputy Editor
MENT
EurohealthCOM
Contents EurohealthVolume 12 Number 4
Joan Costa-Font is Research Fellow, LondonSchool of Economics and Political Science, UKand Associate Professor of Economics,University of Barcelona, Spain.
Anne Dempsey is a freelance journalist, Greystones, Ireland.
Gilea Gildeeva is Deputy Head, Dept of Medicines and Medical Devices Registration,Federal Service of Health Care and SocialDevelopment, Moscow, Russian Federation.
Ramil Usmanovich Khabriev is Head, Federal Service of Health Care and Social Development, Moscow, Russian Federation.
Panos Kanavos is Lecturer, London School ofEconomics and Political Science, UK.
Allan Krasnik is Professor, Institute of PublicHealth, University of Copenhagen, Denmark.
Karl Erik Lund is a Researcher, NorwegianInstitute for Alcohol and Drug Research , Oslo.
Marianne Lund is an Adviser, NorwegianInstitute for Alcohol and Drug Research, Oslo.
David McDaid is Research Fellow, LondonSchool of Economics and Political Science, UK.
Kai Mosebach is Health Policy Analyst,Institute of Medical Sociology, JohannWolfgang Goethe University, Frankfurt,Germany.
Mikkel Bernt Nielsen is Research Fellow,Institute of Public Health, University of Copenhagen, Denmark.
Roy Pounder is Lead, EWTD Working Party,Royal College of Physicians, London, UK.
Erica Richardson is Research Officer,European Observatory on Health Systems andPolicies, London School of Hygiene andTropical Medicine, UK.
Martin Strandberg-Larsen is Researcher,Institute of Public Health, University of Copenhagen, Denmark.
Elena Telnova is Deputy Head of the FederalService of Health Care and Social Development, Moscow, Russian Federation.
Karsten Vrangbæk is Associate Professor,Department of Political Science, University ofCopenhagen, Denmark.
Public Health Perspectives22 The impact of smoke-free hospitality venues in Norway
Karl Erik Lund and Marianne Lund
Global Health18 Corporate lifelines: a new approach to making poverty history
David McDaid
Health Policy Developments1 Improving access to medicines in the Russian Federation:
The Programme for Supplementary Pharmaceutical ProvisionRamil U Khabriev, Panos G Kanavos, Elena A Telnova and Gilea N Gildeeva
5 European junior doctors who work at nightRoy Pounder
7 Is Denmark prepared to meet future health care demands?Martin Strandberg-Larsen, Mikkel Bernt Nielsen, Allan Krasnik and Karsten Vrangbæk
11 Institutional change or political stalemate? Health care financing reform in GermanyKai Mosebach
14 Pharmaceutical policy reform in SpainJoan Costa-Font and David McDaid
European Snapshots24 Improving access to health care in Armenia
Erica Richardson
25 Ireland’s grey vote grows bolder Anne Dempsey
Evidence-informed Decision Making 27 “Mythbusters” Managed care = mangled care
29 “Bandolier” What is evidence-based medicine?
Monitor
32 Publications
33 Web Watch
34 European Union News
BackgroundCurrent economic policy in the RussianFederation has become increasinglyfocused on four priority national projects,Health, Education, Housing and Agri-culture.1 As part of ‘Project Health’, a newprogramme enabling prescription drugcoverage for the weaker segments ofsociety commenced on 1 January 2005following Federal Law No. 122-Φ3. ThisProgramme for Supplementary Pharma-ceutical Provision (DopolnitelnogoLekarstvennogo Obespecheniya – DLO)aims to provide prescription drug coverageand free access, at the point of use, to
quality medicines within ambulatory care(polyclinic) level (in part also inpatientcare, up to a limit) to the most vulnerablesocial groups of the Russian Federation,namely those who need extensive pharma-ceutical care because of poor health statusor disability. In this respect, the DLOprogramme is a major step in the directionof modernising publicly funded healthservices in the Russian Federation.
The programme established a mechanismfor the equalisation of the conditionsunder which pharmaceutical care isprovided to the eligible population, in thatit applies throughout the Russian Feder-ation in accordance with uniform prin-ciples (thereby avoiding prior significantregional variations and taking into accountregional differences), provides pharmaceu-tical care in as sufficient a quantity asrequired by medical need and ensures theprovision of pharmaceutical products ofhigh quality.
Programme provisionsThe DLO programme initially enrollednearly sixteen million eligible citizens inthe Russian Federation comprising peopleof all ages (children, retirees and those agedbetween 16 and 60). Eligibility is basedeither on disability status with the‘disabled’ defined as those severely or
chronically ill (more than 90% of alleligible groups), or special social statussuch as war veterans. The key objective hasbeen to enable access to pharmaceuticaltreatments for this population at no cost tothese insurees.
The key actors in the DLO programmeinclude the Ministry of Health Care andSocial Development, which coordinatesthe activities of all other stakeholders, setsthe main rules for programme regulation,including those governing the budget,medications, and flows of funds, as well asestablishing the list of reimbursableproducts. Other actors include the FederalFoundation of Obligatory MedicalInsurance (FFOMI), which holds thebudget from which it pays for pharmaceu-tical products supplied and the FederalService of Health Care and Social Devel-opment (Roszdravnadzor), which super-vises the implementation of the DLOprogramme and is also responsible foroversight, pricing policy and overall policyreform. Physicians, pharmacies andregional warehouses, who prescribe,dispense and store and deliver, respectively,pharmaceuticals to the eligible population,as well as pharmaceutical distributors atthe federal level, who purchase and supplypharmaceutical products in the RussianFederation are also key actors.
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Improving access to medicines inthe Russian Federation: The Programme for Supplementary Pharmaceutical Provision
Ramil U Khabriev, Panos G Kanavos, Elena A Telnova and Gilea N Gildeeva
Summary: In January 2005 the Programme for Supplementary Pharmaceutical Provision(DLO) was implemented in the Russian Federation, enabling, for the first time, uniform,free access to medicines to the most vulnerable social groups in need of extensive pharma-ceutical care due to poor health status or disability (federal eligibles). Attitudes towardsthe programme show increasing levels of satisfaction; utilisation of needed medicines hasincreased several-fold, particularly in under-provided regions and predominantly forexpensive medications, including those for cancer, mental illness, haematology andcardiovascular disease. In order to ensure financial sustainability, further reforms will beimplemented aiming at improving efficiency and cost-effectiveness, whilst maintainingquality and equity.
Keywords: Russian Federation, pharmaceutical policy, health care reform, healthinsurance coverage, access to medicines
Ramil Usmanovich Khabriev is Head,Federal Service of Health Care and SocialDevelopment, Moscow, Russian Federation;
Panos Kanavos is Lecturer, LSE Health,London School of Economics and PoliticalScience.
Elena Telnova is Deputy Head of theFederal Service of Health Care and SocialDevelopment; and
Gilea Gildeeva is Deputy Head of theDepartment of Medicines and MedicalDevices Registration of the FederalService of Health Care and Social Development.
Email: [email protected]
The implementation of the DLOprogramme has required the mobilisationof a substantial number of resources andmanpower including:
– 233,698 participating physicians
– 26,064 polyclinics, hospitals, and otherinstitutions
– 6,000 pharmacies initially, subsequentlyincreasing to 12,813 pharmacies by thebeginning of 2006
– 23 pharmaceutical distributors atfederal level, selected through an initialcompetitive process
– 86 regional warehouses workingtogether with federal level pharmaceu-tical distributors
– 61 national and 110 foreign pharmaceu-tical manufacturers
Evaluating programme performance Undoubtedly, the most importantachievement of the DLO programme isthat, for the first time, it has enabled freeaccess to essential medicines for the mostvulnerable and under-provided segment ofthe Russian population. Patients have beenable to obtain medications on a sustainablebasis, without the necessity of having tomake any out-of-pocket contribution.Provision has remained, therefore, co-payment-free at the point of use for alleligible patients. Figure 1 illustrates thedifference that the DLO programme hasmade to those who needed to make moreintensive use of pharmaceutical care.Prescribed drug provision increased from87% (April 2005) to 99.5% (January 2006),with the share of prescriptions waiting tobe filled decreasing from 11% (April 2005)to less than 1% (January 2006).
The vast majority of medicines (over 75%)consumed by DLO eligible patients in thefirst half of 2006 were contained within themore expensive medicines categories,costing more than 500 roubles each ($US 18); about 50% of these medicineswere very expensive, each costing thesystem in excess of 2,000 roubles ($US 72)(Figure 1). Prior to the implementation ofthe programme, patients would either needto purchase these on the commercialmarket, paying the entire cost out-of-pocket, or obtain some pharmaceuticalcoverage through in-patient settings, or,simply, forego treatment.
There was also a regional reimbursementsystem, which provided drugs to so-called‘regionally eligible citizens’, but the reim-bursement list, eligibility criteria, and the
level of co-payment required differedgreatly from region to region, dependingon budgetary constraints. Moreover, noregional reimbursement list could becompared with the current federal reim-bursement list. The latter is far morecomprehensive, in terms of both thenumber of INNs (international non-proprietary names) and the new and inno-vative medicines reimbursed. By contrast,the commercial market has been domi-nated by lower cost medicines; only about15% fall into the expensive medicines’categories.
Receiving its budget direct from theMinistry, the DLO programme immedi-ately became an important player in asystem dominated hitherto by a com-mercial market that experienced regularprice instability and price hikes. Indeed,the DLO’s total market share increasedfrom 0% in 2004, to 21% in 2005 and 26%by the first half of 2006 (Figure 2).
Satisfaction surveys conducted at the startof the programme in January 2005 and alsotowards the end of that year showedimprovements in the perception of theprogramme by eligible individuals; the
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Figure 1: Expenditure in the commercial and the DLO markets by type of drug(January – June 2006)
Source: Adapted from Kuzin A, 2006..3 Note: 1 US$ = 28 roubles.
Figure 2: Pharmaceutical market structure in 2005 and first half of 2006, at publicprices including VAT (CM:Commercial market + DLO)
Source: Adapted from Kuzin A, 2006..3
proportion of respondents indicating thatthey were very, or generally, satisfied rosefrom 38% to 45% over this time period.This is hardly surprising given that theimplementation of the programme resultedin a significant increase in the number ofprescriptions successfully filled by eligibleinsurees. On average the number ofprescriptions filled in Russia increased twoand a half to threefold in 2005 comparedwith 2004.
In some regions, particularly those whichwere previously under provided, theincreases were even more striking. Theseincluded a fourfold increase in Mordovia,fivefold in Amur, more than sixfold inKaluga and sevenfold in North Ossetia.The average cost per prescription nearlydoubled, from 180 roubles ($6.4) to 340roubles ($12), between the first quarter of2005 and the same period in 2006. This wasnot, however, the result of price hikes, asprices had stabilised and even fallen by10% across 118 molecules, but rather anindication that more expensive medicineswere being prescribed more frequently.
Additionally, in order to monitor andevaluate the programme’s performance, anumber of key indicators to be used asbenchmarks were developed by theRussian Ministry of Health Care andSocial Development and the FederalService. (The most important are shown inBox 1). These tied in with a series ofproblems impacting on patients, physi-cians, pharmacies and manufacturers thatarose during the implementation of theDLO programme.
Patients were mainly concerned about theduration of waiting times to see a physicianor to fill a prescription at a pharmacy, aswell as the shortages at pharmacy level interms of filling the prescription with theprescribed medicine first time, resulting indelay. Government-led surveys suggestedthat 27% of all patient-related complaintsrelated to medicines not being in-stock at aparticipating pharmacy and a further 27%related to (excessive) waiting times in orderto see a physician and receive aprescription. 23% of all complaints relatedto (excessive) waiting times at thepharmacy, whereas in 16% of all cases,patients experienced problems due to alack of information.
Physicians were mainly concerned withhaving an excessive workload, seeing manypatients without necessarily having therelevant supporting infrastructure. Phar-macists were also sometimes overwhelmedby having to service an increased numberof patients, whilst at the same time experi-encing shortages in a number of drugs onthe reimbursement list. An additionalproblem was the requirement to preparedispensing and activity reports; this led toa disproportionate amount of time beingspent on administration.
Efficiency measuresWhile the DLO programme hasundoubtedly had a significant positiveimpact on improving access to essentialmedicines, it has continued to operatewithin a fixed budget determined by thefederal government. This implies thatresources have to be used cost-effectively
to maximise both programme impact andvalue for money. To that end, significantpolicy changes have occurred during thefirst two years of the programme [4].These are intended to ensure that fundingis adequate to guarantee continued accessto medicines. Of particular attention in thesecond half of 2006 was a policy shift fromsimply focusing on the delivery of phar-maceutical products to eligible patients,towards managing resources morerationally.
At the beginning of 2006, INN prescribingwas introduced, although it remains to beseen how the policy will be taken up byprescribing physicians. A further policymeasure, introduced in April 2006, was anew reimbursement list, comprising 2276trade names and which reduced the pricesof 178 trade names. In addition to theseselective price reductions, 103 brandedproducts were excluded while 46 newbranded products added to the list. TheMinistry of Health Care and Social Devel-opment anticipates that the total efficiencysavings from this fine tuning measure willbe in the region of 14% of total spend.
“If manufacturers refused todecrease prices, their productswould be automaticallydelisted”
Subsequent reforms on the operationalside of the programme have included theintroduction of further restrictions to thelist of reimbursable products in October2006. Some 74 INNs and 62 productformulations, mainly products financedfrom other programmes within the healthcare system (HIV, tuberculosis, someoncology drugs), as well as INNs andproduct formulations for in-patient use,were excluded from the list. In addition,prices for the most frequently prescribedINNs were reduced to the level of thelowest generic price, plus a supplement of20%. If manufacturers refused to decreaseprices, their products would be automati-cally delisted. In total, these price cutsaffected 122 individual products. As aresult, a total of 834 positions (both INNsand product formulations) were affected(due to both INN list shortening anddemands for price cuts for individualproducts or product formulations).
A new tender system was announced for
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Box 1: DLO programme – thresholds for satisfactory performance
1. Level of provision of drugs relative to number of prescriptions submitted to pharmacy at firstrequest (needs to be >90%).
2. Proportion of prescriptions filled (within 10 days) relative to monthly average number ofsubmitted prescriptions (needs to be <10%)
3. Proportion of prescriptions waiting to be filled (for more than 10 days) relative to the monthlyaverage number of submitted prescriptions (needs to be <1%)
4. Proportion of inappropriately issued prescriptions (needs to be <1%)
5.Compliance with licensing requirements by organisations participating in the DLOprogramme.
Source: Ministry of Health and Social Development of the Russian Federation, 2006.2
four groups of the most expensive INNs,(three each from oncology, haemophiliaand multiple sclerosis and eight fordiabetes (insulins)). These seventeen INNsput together account for 40% of totalDLO spend. The objective was to decreasewholesale markups from the current per-region fixed rate (35% on average) to asignificantly lower rate. The 2007 tendersare now being published by FFOMI.
Total anticipated savings from thesemeasures, calculated on the basis of nextyear’s projected DLO budget, have beenestimated at 15% of DLO total spend, or$230 million. 7.2% and 7.8% respectivelywill be saved by the exclusion of INNs andbranded products (Figure 3). This isexpected to be achieved without adverselyaffecting the level of access to medicines,or the quality of products supplied. Itshould also allow room for innovativeproducts to be included in the 2007 DLOprogramme.
Future policy directionsWhile the Federal Government remainscommitted to providing continued accessto essential medicines and improving thehealth status of the population, it must alsoensure that the DLO programme providescoverage in a rational and cost-effectiveway. In order to do this, a number ofreforms are necessary. In addition to thealready existing INN prescribing, theFederal Government has requested thatoptions such as internal reference pricingand cost-sharing also be considered.Reference pricing would imply thatpatients would have to pay out-of-pocketif a medication’s price were in excess of thereference price. This might encouragephysicians to prescribe cheaper, butequally efficacious alternatives.
“There has been an increase inthe confidence of patients in thehealth care system”
While some of these reforms, such as INNprescribing and, if introduced, referencepricing, are aimed at rationalising bothphysician prescribing habits and patientutilisation patterns, others are aimed atrationalising the programme’s type ofcoverage. To date, the DLO programme,being a prescription drug insurancescheme, covers both outpatient and someinpatient use drugs. However, proposals
are already in place to shift certain cate-gories of medications to otherprogrammes. For instance, HIV and tuber-culosis drugs, which were included in theDLO controlled list until September 2006,and available to patients with doctors’(specialists or heads of polyclinics) autho-risation, will now be shifted to other partsof ‘Project Health’ and reduce the burdenon available DLO funds.
In addition, products for oncology,psychiatry, diabetes and hypertensionpatients intended for in-patient care, maybe shifted, for example, to the ‘FederalDedicated Programme’, which aims toprovide integrated care for patientsrequiring these interventions; this will alsoinclude pharmaceutical care. Finally, the‘High Technology Medical Care’ project,being part of the President’s ‘ProjectHealth’, is intended to improve access tohospital and high technology medical care,including hospital drugs reimbursed underthe project.
Suppliers will compete to provide medi-cines via a tendering mechanism. Thismeasure should reduce the demands placedon DLO resources. It should also providean opportunity for the programme toexpand its outpatient coverage and tacklethe potential under-use of medications inkey diagnoses, whilst at the same time,generally enhancing access to improvedpharmaceutical care.
To date, the DLO programme hasprovided free access and comprehensivecoverage to the federally eligible popu-lation. Its first two years have been accom-panied by an increased confidence in thesystem from a patients perspective whilethere has also been an accumulation ofexpertise in terms of establishing infra-structure, administering the programme,addressing its shortfalls and initiatingpolicy changes aimed at a rational and efficient use of resources.
REFERENCES
1. World Bank. Russian Economic Report.Moscow: Economic Unit, World BankMoscow Office, April 2006.(http://www.worldbank.org.ru)
2. Ministry of Health and Social Devel-opment of the Russian Federation. Resultsof DLO programme implementation in2005. Moscow: Federal Service for HealthCare and Social Development, 2006.
3. Kuzin A. DLO and Commercial Market– Mutual Influence (presentation).Moscow: DSM Group, 15 October 2006.
4. Telnova EA. Expected Future Implemen-tation of DLO Programme and its Impacton the Pharmaceutical Market in Russia in2005–2006. Moscow: Federal Service ofHealth Care and Social Development,2006.
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Figure 3: Expected savings on 2007 DLO budget due to product delisting, as apercentage of market share
Notes: INN = international non-proprietary name; TN = trade name
Source: The authors based on data from the DSM Group, 2006.
Health care is a 24-hour business in everyEuropean general hospital. There are rolesand responsibilities that can only beperformed by a licensed doctor, and theseskills may be required on demand, andimmediately. Thus, there is a need to havedoctors present in hospitals day and night.
Until 2004, most hospitals had juniordoctors resident in the building, who wereresting and sleeping when not activelycaring for patients. This ‘on call’ system, ifunregulated, could result in exhausteddoctors, but it provided a pool of doctorsavailable at short notice. The EuropeanWorking Time Directive is a health andsafety measure designed to protectworkers, but it has made life more difficultfor many junior doctors.
The Directive was applied to all Europeanjunior doctors in 2004, and it will beapplied with increasing stringency in thecoming few years. In 2007, the regulationsexpect every junior doctor to work amaximum of 13 hours in every 24, andconsequently have 11 hours rest in thesame period. In addition, each traineedoctor may only work an average of 56hours each week. But there are 168 hoursin every week, and it is clear that devisinga roster of junior doctors, all of whomhave the relevant skills and training is quite
a challenge. A group of seven to twelvedoctors is needed just to provide thepresence of a single trainee doctor,available 24 hours every day, throughoutthe year.
The SiMAP judgement* of the EuropeanCourts of Justice has caused the greatestproblem – because it decided that a juniordoctor sleeping on call in a hospital is stillworking – that is, every hour is deductedfrom the weekly average of 56 hours. Thisis not only an economic disadvantage forthe employer – that is, paying for essen-tially no output – but these are traineedoctors, and whilst losing working hoursduring sleep, they are also losing theirtraining.
The implementation of the Working TimeDirective has driven a sudden change inthe pattern of work of European juniordoctors from working on call, to full-shiftworkers – there is no other way to staff ahospital 24/7. Thus, if they obey theDirective, a hospital has one team ofdoctors working in the day and evening,and an entirely new team coming on thelate evening to work the night shift untilthe morning.
My evidence, from informal surveys in2005 and 2006 of colleague gastroenterol-ogists throughout Europe, is that theDirective is only being followed inSweden, Denmark, the Netherlands and
the United Kingdom. All the other EUMember States appear to disobey the rules,by rostering their doctors to work contin-uously for 24 to 36 hours.
What’s so bad about a night shift?1
Working at night is harder than workingduring the day, because this is the timewhen the human body is programmed tobe asleep. It also results in loss of sleep andincreased fatigue, which directly impactson performance. Working at night involvestrying to function when one’s alertness,vigilance and cognitive reasoning are all attheir lowest, making it easier to makemistakes without noticing. Tired juniordoctors in the USA and Denmark didexactly this, and were shown to loseconcentration more often and make moreclinical errors compared to when theywere able to get more sleep.2-4 Ofparticular relevance to junior doctors intraining, exhaustion also impairs recentlearning and can decrease their ability tomake correct diagnoses and perform tech-nical procedures.5
Importantly, because working a night shiftinvolves trying to sleep in the day, the lackof sleep can quickly become excessive.Sleeping during the day is much harderthan sleeping at night, because it is notwhat humans are designed to do. Brightsunlight, temperature, and noise can allkeep night workers awake during the day,
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European junior doctors whowork at night
Roy Pounder
Summary: In 2007, the Working Time Directive expects every junior doctor to work amaximum of 13 hours in every 24 and have 11 hours rest, with a weekly average of 56hours. This has driven European junior doctors from working on call to becoming shiftworkers. Shift working at night increases errors, but the length of shifts and thenumber of shifts worked in succession are also safety factors. Preparation for shiftwork, in terms of sleep patterns and design of rotas, improves safety. Only fourEuropean countries comply with the existing regulations, and ministers should considerdelaying further implementation.
Key words: European Working Time Directive, junior doctors, rotas, safety, shift work.
Professor Roy Pounder is Lead for theEuropean Working Time Directive, Royal College of Physicians, London. Email: [email protected]
* Sindicato de Médicos de Asistencia Pública (Simap) v Conselleria de Sanidad y Consumode la Generalidad Valenciana, ECJ Case C303/98 Judgment of 3 October 2000.
but perhaps most importantly, the body’sinternal clock, which regulates sleep-wakepatterns, acts to maintain alertness andwakefulness. This means that daytimesleep is not of such good quality orduration as sleep at night;6 shift workerswho work several consecutive night shiftscan become progressively more tired overthe course of their duty. Inevitably this canthen lead to further reductions inperformance and an increased likelihoodof accidents or mistakes.
Night shifts and safetyWhile working at night does contribute toan increased risk of making errors, it is notthe only factor to consider. Evidencecollected from a range of industries whereshift work is common shows that thelength of individual shifts and the numberof shifts worked in succession are also veryimportant (see Figures 1 and 2).7,8 Themore shifts that are worked consecutively,the greater the relative risk compared tothe first shift worked. Likewise for thelength of each shift – the longer each shift,the greater the chance of an accident. Inter-estingly, if two otherwise identical shifts interms of length and number of previouslyworked shifts are compared, the risk of anaccident is always greater on the night shiftthan during the day.
Shift length and the number of consecutiveshifts must always be considered whendesigning new rotas. Furthermore, becauseof the increased risk with working at night,it is essential to remember that what is anacceptable rota for working during the daymay not be sensible when planning nightshifts.
Getting home after a night shiftDesigning safe rotas does not just involveconsidering the doctor at work. After theshift, doctors must also be able to travelhome safely, and often this will meandriving. Just as with performance on duty,driving ability is strongly affected byfatigue and lack of sleep. There is clearevidence that this is a particular hazard forAmerican junior doctors working verylong hours.9 While this should be less of aproblem if doctors work two or threeshorter night shifts at time, appropriatenapping and preparation are nonethelessnecessary. Driving while tired becomes anincreasing potential hazard as shift lengthand the number of nights worked insuccession rise, particularly if the recom-mendations in ‘Working the night shift:preparation, survival and recovery – Aguide for junior doctors’1 are not followed.
Shift patterns that don’t work, and somethat shouldWhen the Working Time Directive Regu-lations were implemented in the UnitedKingdom in August 2004, the mostcommon pattern of shift work was for anindividual doctor to work a 13-hour nightshift for seven nights in succession. Thismade design of the roster easy – one weekof nights, followed by some leave forrecovery and then some weeks of dayshifts. It also seemed to ‘get rid’ of thestressful period in one sharp, unpleasantweek of nights. But it meant that the indi-vidual worked seven 13-hour shifts in oneweek – that is, a 91-hour week, whichwould be daunting if worked in the day-time, and clearly wrong if associated withan acute change of diurnal body rhythm.
A working group from the Royal Collegeof Physicians has published a documentthat discusses different solutions to thisrostering problem; it recommends an inno-vative pattern of three overlapping nine-hour shifts to provide cover across the 24hours.10
What’s the future for European juniordoctors?In 2009, the average working week isscheduled to be reduced from 56 to 48hours, to come into line with all otherworkers in the European Union. Thisdemands an approximate 20% increase indaytime productivity (daytime, becausemost hospitals already roster the absoluteminimum number of juniors at night, andno more reductions can be achieved at
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Figure 1: The estimated risk of accidents in shift workers, related to length of shift.7,8 An 8-hourshift has been set to have an estimated risk of 1.0, with all other shifts relative to this
Figure 2: The estimated risk of accidents in shift workers, related to the number of successive shiftsand whether they are day or night shifts7,8 The first day shift has been set to have a relative riskof 1.0 and all other shifts are relative to this
IntroductionThe predominantly tax-based Danishhealth care system has traditionally beenhighly decentralised politically, financiallyand operationally; public regional andlocal authorities are responsible for theprovision and delivery of health careservices. The system has also been charac-terised by strict expenditure controls and ahigh level of patient satisfaction.1 Oneconsequence of decentralisation however,has been the somewhat uneven access tohealth care resources across the country.Danish politicians have, until now, givenmore weight to the importance of local selfgovernance (and its potential to achieveinnovation) than geographical equity. Thishas led to differences in waiting times, theavailability of medical technologies andrates of specific diagnostic and curativeactivities, such as systematic breast cancerscreening or the use of expensive drugs forovarian cancer.1
The demands for ever more compre-hensive primary care services, in additionto highly specialised secondary health careservices, have not always been helped bythe fragmented structure within thisdecentralised system. It has been arguedthat this structure with three political/administrative levels has led to suboptimaldecision-making and management. As aconsequence, a series of interventions togradually strengthen the coordination andcentralised control of the system have beenintroduced during recent decades, culmi-nating in a major reform of administrativestructures that came into effect on 1January 2007.
The reform measures radically change theadministrative and geographical bound-aries of the health care system. Simultane-ously, a centralisation and decentralisationprocess has been initiated, where both thestate and the municipalities obtain newresponsibilities and tasks. One of the goals
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Is Denmark prepared tomeet future health caredemands?
Martin Strandberg-Larsen, Mikkel Bernt Nielsen, Allan Krasnik and Karsten Vrangbæk
Summary: One consequence of the decentralised nature of the Danish health caresystem, characterised by a high degree of patient satisfaction and expenditurecontrol, has been the somewhat uneven level of access to health care resourcesacross the country. A series of interventions to gradually strengthen coordinationand centralised control of the system have been introduced in recent decades,culminating in major structural reform being implemented from January 2007.This article presents a brief analysis of this reform process, its policy goals, keyelements and potential to prepare the system to meet future health care chal-lenges.
Keywords: Health care reform, administration, decentralisation, recentralisation,health care financing, Denmark.
Martin Strandberg-Larsen is a doctoral research student, Mikkel Bernt Nielsen isResearch Fellow and Professor Allan Krasnik is Director of the MPH-programme,Institute of Public Health, University of Copenhagen, Denmark. Karsten Vrangbæk isAssociate Professor, Department of Political Science, University of Copenhagen,Denmark.
night). This increased productivity isneeded for not only work output, but alsotraining. Only four countries haveachieved compliance with the existingregulations, and it seems sensible forMinisters to consider a delay in furtherimplementation.
REFERENCES
1. Horrocks N, Pounder R, RCP WorkingGroup. Working the night shift: prepa-ration, survival and recovery – a guide forjunior doctors. Clinical Medicine2006;6:61–67. Also freely available athttp://www.rcplondon.ac.uk/pubs/books/night shift/night shiftbooklet.pdf
2. Lockley SW, Cronin JW, Evans EE et al.Effect of reducing interns’ weekly workhours on sleep and attentional failures.New England Journal of Medicine 2004;351:1829–37.
3. Landrigan CP, Rothschild JM, CroninJW et al. Effect of reducing interns’ workhours on serious medical errors amonginterns in intensive care units. NewEngland Journal of Medicine2004;351:1838–48.
4. Eastridge BJ, Hamilton EC, O’Keefe GEet al. Effect of sleep deprivation on theperformance of simulated laparoscopicsurgical skill. American Journal of Surgery2003;186:169–74.
5. Stickgold R. Sleep-dependent memoryconsolidation. Nature 2005;437:1272–78.
6. Knauth P, Rutenfranz J. Duration ofsleep related to the type of shift work. In:Reinberg A, Vieux N, Andlauer P (eds).Advances in the Biosciences, Vol 30. Nightand shift work: biological and social aspects.New York: Pergamon Press, 1980:161–8.
7. Folkard S, Tucker P. Shift work, safetyand productivity. Occupational Medicine2003;53:95–101.
8. Folkard S, Lombardi DA, Tucker PT.Shift work: safety, sleepiness and sleep.Industrial Health 2005;43:20–23.
9. Barger LK, Cade BE, Ayas N et al.Extended work shifts and the risk of motorvehicle crashes among interns. NewEngland Journal of Medicine2005;352:125–34.
10. Horrocks N, Pounder R, RCP WorkingGroup. Designing Safer Rotas for JuniorDoctors in the 48-hour Week. London:Royal College of Physicians, 2006. Freelyavailable athttp://www.rcplondon.ac.uk/pubs/contents/09446ffc-7f46-4f18-a1d0-fb5b8607b0c4.pdf
of the reform process is to ensure equalstandards of care throughout the countryby increasing the power of state bodies inplanning and quality management.Another goal is to improve the structuralconditions needed for primary careservices that better meet needs, with anemphasis on preventive services and healthpromotion, in addition to the provision ofhigh quality specialist secondary healthcare services.2,3 This article presents a briefanalysis of this reform process, policygoals, key elements, and potential toprepare the system to meet future healthcare challenges.
Changing structure The health system has been characterisedby path dependent and incrementalchanges since major administrativereforms created the decentralised (county-based) system in the early 1970s. As aresult of the growing debate on thestructure of the public sector, thegovernment appointed a Commission onAdministrative Structure in October 2002.This Commission was charged with thetask of assessing the “advantages anddisadvantages of alternative models for thestructure of the public sector and on thisbasis to make recommendations forchanges that would remain sustainable fora number of years”.4–6
In January 2004, this Commissionconcluded that reforms to public sectorstructures were required. This conclusionwas partly based on the assessment thatcounties and municipalities were of insuf-ficient size for proper task performanceand also because the distribution of tasksin the public sector was inappropriate. TheCommission presented six different alter-native public sector models, describingtheir advantages and disadvantages butwithout making any recommendation.4–6
After a public hearing, the centralgovernment proposed large scale structuralreform that deviated somewhat from themodels put forward by the Commission,particularly in regards to financing mech-anisms and the number of regional units.The government proposal, which becamethe basis for the final political decision,maintained the three political/adminis-trative levels but introduced new divisionsof labour. The larger regions would retainresponsibility for most treatment-relatedhealth tasks, while the municipalitieswould gain a greater role in terms ofprevention, health promotion and rehabil-itation. The agreement also included
financing and resource allocationmeasures, with the regions losing the rightto finance health expenditure via regionaltaxation, instead relying on a combinationof state block grants, activity-based contri-butions as well as municipal co-financing(see section on key elements of newsystem).
“One of the goals of reform isto ensure equal standards ofcare across the country”
Free choice of hospital remains a keyfeature of the system. The reform reducessome of the administrative issues related tochoice of services across regional borders.They are also expected to increase theadministrative and legal capacity of theregions to enter into contracts with privateproviders. This is likely to become moreimportant, as the government intends tolower the general waiting time guaranteefrom referral to treatment from twomonths to one month as of 1 October2007. Patients will have access to a range ofprivate contracted providers if the regionsare unable to offer treatment within thistime limit.
The legislation for reform passed throughparliament in 2005 and was implementedin January 2007; 2006 being a transitionyear. The reform bill was passed by a smallmajority; this is unusual in Denmark,
where typically major structural reformshave achieved a broad consensus betweenthe government and opposition parties. Inthis case, two of the parties behind thereform, including the ruling Conservativeparty, had been in favour of dismantlingthe counties for a number of years.2
Policy goals and principles behindreformThe main arguments in favour of reformwere broadly related to a reduction inbureaucratic costs and taxation levels. Thegovernment further stated that the purposeof the reform was to maintain and developa democratically governed public sector ona sound basis for continued developmentof the Danish welfare society. Therefore,the decentralised public sector needed tobe designed in such a way that it couldmeet future requirements by creatingsustainable structures with a clear respon-sibility to provide high quality welfareservice to the population. Larger munici-palities were expected to be able to providemore specialised and integrated solutionsfor welfare tasks, whilst maintaining localdemocratic accountability.
The government also set out two under-lying principles governing reform.The firstwas that funding should be linked to tasks.This meant that the authorities taking onnew tasks would be compensated by thoseauthorities relinquishing these activities.The parties behind the reform measuresagreed that this should not result in highertaxes nor increased public expenditure.
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Figure 1: Post reform structure of the statutory health system in Denmark
State level
ParliamentGovernment
Ministry of the Interior and HealthNational Board of Health
Danish Regions* National Association of Local Authorities*
Regional level
5 RegionsRegional Councils
Municipal level
98 MunicipalitiesMunicipal Councils
Subcommittees
* The Danish Regions and the National Association of Local Authorities are not part of theformal political and administrative system. They are interest groups for the municipalitiesand regions. They represent the decentralised authorities in discussions and negotiationsbetween regional and municipal politicians, professional organisations and centralgovernment but cannot enter into legally binding agreements on behalf of their members.
The second linked principle was that whilethese structural measures, in general,should be neutral in terms of expenditure,this did not mean that there would be nocosts involved in merging municipalitiesand creating new regions. These costshowever, would very much depend onhow the individual municipalities andregions planned the process. The munici-palities had to bear these costs, which thegovernment argued would ultimately beoutweighed in the long run because ofpotential synergy effects and economies ofscale.3,6
Key elements of the new system
Organisation
Structural measures within the reformhave changed the political and adminis-trative landscape by dramatically reducingthe number of regional and local units andchanging their division of responsibilities.The number of regional authorities havebeen reduced from fourteen counties tofive regions (0.6-1.6 million inhabitants)and the number of municipalities from 271to 98 (37% of the new municipalities havemore than 50,000 inhabitants, 38% have30,000-50,000, 18% 20,000-30,000 and 7%have less than 20,000). Both administrativelevels are governed by directly electedpoliticians.2,6 (See Figure 1 for an organi-sational overview of the new adminis-trative structure).
The purpose of establishing larger unitswithin the health care sector is to improvethe quality of patient care, as well as healthpromotion and preventive services, bycreating opportunities for grouping treat-ments and services, thus exploiting theadvantages of specialisation which ensuresthe best possible utilisation of resources.2,6
With reform, municipalities have gainedoverall responsibility for rehabilitationthat is not provided during hospitalisation.Previously, this responsibility was sharedwith the counties. In addition, the munic-ipalities now have primary responsibilityfor prevention and health promotion, withthe goal of integrating these activities intoother local responsibilities, i.e. day care,schools, centres for the elderly, etc.Treatment of alcohol and drug abuse, aswell as specialist dental treatment forpeople with learning difficulties, arelikewise now the responsibility of themunicipalities.2,6
The chief responsibility of the regions is torun hospitals, including psychiatric andprenatal care centres. Environmental and
regional development tasks have also beenmaintained at this level. Most other taskshave been moved to the state or munici-pality level.2,6 In order to ensure coordi-nation between regional and local activitieswithin the health care system, regions andmunicipalities will have to enter intobinding partnerships within health coordi-nation committees. Furthermore, theymust make health agreements on proce-dures for the discharge of frail and elderlypeople from hospital, social services forpeople with mental disorders as well aspreventive treatment and rehabilitation.2,6
“Co-financing may incentivisemunicipalities to invest inprevention”
The role of the central government is almost exclusively concentrated on regulating, supervising and financing.Following reform, the influence of theNational Board of Health on hospitalplanning has been strengthened, with theintention of ensuring more equal provisionof hospital treatment across the country.2,6
Financing
Until 2007, the Danish health care systemwas financed through progressive generalincome taxation at the national levelsupplemented by proportional income andproperty taxes at the regional level.National level tax revenue was redis-tributed to the counties via block grantsbased on objective criteria and someactivity-based financing for hospitals. Thesystem was designed to support solidarityin financing and equity in coverage.7.8
With reform, several important financialchanges have been implemented. The inde-pendent right to raise taxation at regionallevel was abolished. Health care activitiesare now financed largely through anational earmarked health tax (8% ofincome), redistributed in terms of blockgrants to regions and municipalities. Theearmarking of health taxes is a new featurein Denmark and is intended to creategreater transparency within this sector.However, it also reduces the potential forredistribution between health and othersectors.
80% of all health care activities in theregions are financed through these blockgrants in addition to some activity-based
payments (approximately 5%). The size ofthese block grants are calculated using aformula where expected need for healthcare in the population is a centralcomponent. This level of need is assessedby combining the distribution of age andsocioeconomic status in the region. Thepurpose of activity-based payments is toencourage the regions to increase activitylevels within hospitals.
The remaining funding comes from acombination of per capita and activity-based payment contributions by munici-palities. Co-financing it is thought willincentivise municipalities to invest inprevention activities, as their activity-related contributions will primarily reflectthe number of hospitalisations and out-patient treatments at hospitals, as well asthe number of services from general prac-titioners. In this way, municipalities thatare successful in reducing the need forhospitalisation will be rewarded.2,6
DiscussionOne key argument for reform has been thecost of bureaucracy and the multiple tiersof taxation. However, it is not clearwhether it will lead to any major reductionin administrative costs. Moreover, signif-icant implementation costs are beingincurred. With the continuation of threeadministrative/political levels, now withjust two tiers where taxes are levied, thestage is set for a blame-game between thenewly empowered state and the regions.Some observers question the sustainabilityof the new organisational structures andpredict that the regional tier of adminis-tration will in turn be removed due to theseparation of funding from the provisionof services. This could lead to a newstructure, with the state also responsiblefor the provision of hospital services.
Another key driver behind reform was theperceived need for larger catchments areasto support future specialisation andsustainable structural adjustments. Manyobservers have pointed to the ambiguousevidence on economies of scale andspecialisation in health care, while severalindependent observers have pointed outthat the former counties were alreadyperforming well in terms of controllingexpenditure, increasing productivity andmaking gradual structural adjustments.Most observers agree that strengtheningthe role of the municipalities is beneficial;however, there is some fear that they lacksufficient competence to plan andimplement their newly acquired responsi-
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bilities and that they might instead givepriority to activities directly reducinghospital admissions rather than long-termprevention programmes.
The challenges imposed by fragmentationin the system have probably not beensolved through these measures. The newlyestablished formal tool for achieving coor-dination between the different adminis-trative levels of health care has been shownto be inadequate.9 The fragmentation ofthe system is further challenged by theincreasing use of public-private partner-ships.9
To date, no independent experts havespoken out in favour of the financingchanges.1,2 Municipal co-financing forregional health services, for example,hospital admissions and consultations withgeneral practitioners, have been based ontwo assumptions. First, that incentivestructures will only be effective if use ofregional health services can in fact beprevented. This is not likely for a largeamount of hospital services. Second, thatprevention or alternative services offeredby the municipalities have to be lessexpensive than the municipalities’ contri-bution to the total costs of the givenservice otherwise provided by the region.
This is also not very likely due to the rela-tively limited municipal co-financingcontributions. Since many municipalitiesare currently developing substituteservices, one unintentional consequence ofthe new financial system could be that thetotal cost of municipal and regional healthservices will increase, especially in theshort run.
Another important radical change in thefinancial arrangements is that the level ofactivity-based financing in hospitalbudgets will increase from 20% in 2006 to50% in 2007.10 The government hasactively sought to use activity-basedfinancing to create incentives for increasedactivity when redistributing funds.2 So far,the relative limited use of activity-basedfinancing seems to have led to increases inactivity level at hospitals, but possibly alsobias against some areas where activitylevels are harder to measure and influence(for example, geriatrics or internalmedicine).11,12
The implementation of such large scalereform will not be without obstacles and asignificant challenge still lies in ensuring asystem that all groups of patients and theirfamilies can access and navigate easily.Careful ongoing evaluation of thesereform measures, such as those by theSundhedsreform network will be required(See Box).
However, if these challenges can behandled appropriately, the structuralchanges will likely make the Danish healthcare system better prepared to meet thefuture demands of modern health care. Onthe other hand, the changes in financingarrangements are not without their diffi-culties and the likelihood of unintentionalconsequences is present. With the neworganisational structures in place, thelogical next step would be to go deeperinto the core of problems that have muchto do with the need to strengthen theculture of trust between health profes-sionals within the system. This mightpossibly be achieved through skilled stew-ardship at all levels, with an emphasis on awhole-system approach towards healthcare services.
References
1. Pedersen KM, Christiansen T, Bech M.The Danish health care system: evolution –not revolution – in a decentralised system.Health Economics 2005;14(Suppl 1):S41-S57.
2. Strandberg-Larsen M, Nielsen MB, et al.Health Systems in Transition: Denmark.Copenhagen: European Observatory onHealth Care Systems, unpublished work.
3. Ministry of the Interior and Health.Agreement on a Structural Reform.Copenhagen: The Ministry of the Interiorand Health, 2007. Available athttp://www.sundhedsministeriet.dk/publikationer/agreement/index.html
4. The Commission on AdministrativeStructure. Analysis of the health care sector[In Danish]. Copenhagen: Ministry of theInterior and Health, 2003.
5. The Commission on AdministrativeStructure. Recommendation of theCommission on Administrative Structure,Vol.III, Recommendation no. 1434.Copenhagen: Ministry of the Interior andHealth, 2004. Summary available athttp://www.im.dk/publikationer/struktur_uk/SummaryGB.pdf
6. The Ministry of the Interior and Health.The local government reform – in brief.Copenhagen: Ministry of the Interior andHealth, 2005. Available athttp://www.im.dk/publikationer/government_reform_in_brief/Kommunal_UK_screen.pdf
7. Gundgaard J. Income-related equality inutilization of health services in Denmark:Evidence from Funen County. Scandi-navian Journal of Public Health 2006;34(5):462–71.
8. Wagstaff A, van Doorslaer E, van derBurg H, et al. Redistributive effect,progressivity and differential tax treatment:Personal income taxes in twelve OECDcountries. Journal of Public Economics1999;72(1):73–98.
9. Strandberg-Larsen M, Nielsen MB,Krasnik A. Sundhedsaftaler som nytstyringsredskab til at sikre sammenhæng isundhedsvæsenet [Health plans as a newmanagement tool]. Tidsskrift for DanskSundhedsvæsen 2006;82(10):334–37.
10. The Ministry of Finance. Agreement onthe municipal and regional economy 2007[in Danish]. Copenhagen: Ministry ofFinance, 1 June 2006.
11. Ankjær-Jensen A Rath MB. Takst-styring af sygehuse. Copenhagen, DSI -Institut for Health Services Research, 2004.Available in Danish athttp://www.dsi.dk/publikationer/DSI-rapporter/2004.08/Rapport_2004_08.pdf
12. Ministry of the Interior and Health.Evaluering af takststyring på sygehusom-rådet. Copenhagen: Ministry of theInterior and Health, 2005. Available inDanish at http://www.im.dk/publika-tioner/eva_takststyring/Evaluering.pdf
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Box: Reform research initiatives inDenmark
The structural reform measures to theDanish health care system are highlycomplex which makes evaluation of theireffects challenging.
However, health services research initia-tives have been initiated in order todisseminate empirical findings on theirimpact to policy-makers and healthsystem planners in Denmark andabroad.
Such research initiatives have beenestablished within a Danish multi-institu-tional research network.
The network is assessing the impact ofthis reform, with a focus on adminis-trative and managerial changes, impacton the health economy, influence oncoordination of care, and the redistrib-ution of activities regarding healthpromotion, preventive services, andrehabilitation
See www.sundhedsreform.ku.dk
On 24 October 2006, the Germangovernment agreed a proposal that wouldalter the structure of both statutory (SHI)and private (PHI) health insurance, ifapproved by the the lower (Bundestag)and upper house (Bundesrat) of parliamentin 2007. The parties representing theGrand Coalition between the ChristianDemocrats (Christlich DemokratischeUnion – CDU), their sister party theBavarian Christian Social Unionist(Christlich-Soziale Union in Bayern –CSU), and the Social Democrats(Sozialdemokratische Partei – SPD)struggled to get their diverse factions tosupport this proposal. Moreover, thesereforms have been faced by nearly unan-imous opposition from the sickness funds,physicians, pharmacists and hospitalmanagers, as well as the media and public.
As a result of lengthy rounds of negotia-tions, the original draft proposal, the SHI-Competition-Strengthening Act (GKV-Wettbewerbsstaerkungsgesetz, SHICS-Act) has been revised, thus making itextremely difficult to assess what the finaloutcome will be prior to the conclusion of
parliamentary deliberations in March2007.1 However, this overwhelming levelof dissent and ongoing debate obscures thefact that an evolutionary process of healthsystem change is already under way; themost recent health care reform proposalsare a further step in that direction.
‘Back to the future’: regulated compe-tition and managed care in GermanySince the early 1990s, German health carepolicy has been changing course. In 1992,the governing CDU/CSU and the FreeDemocrats (Freie Demokratische Partei –FDP) agreed, in consensus with the oppo-sition SPD, the Health Care Structure Act(HCS-Act). In hindsight, the mostimportant structural change that the HCS-Act introduced was the implementation ofregulated competition between, what bythen had become, regionally and/orbranch-organised sickness funds.Following the implementation of a risk-adjustment mechanism, from 1997,insurees could choose between mostsickness funds. One consequence of thisnew policy of ‘choice’ was that the young,male, healthy and wealthy insured inparticular, changed sickness funds, leadingto rising levels of redistribution betweenfunds.2
The notion of regulated competition meantthat sickness funds could offer differentpackages of service provision. Initial steps
in this direction were taken under the twoStatutory Health Insurance RestructuringActs (SHIR-Acts) by the CDU/CSU andFDP government in 1997. These Actsenabled sickness funds and health careproviders to contract selectively for thefirst time. However, due to the politicallinks between doctors and the FDP, as wellas factions of the CDU/CSU, selectivecontracting still depended on the approvalof regional physicians’ associations.
This obstacle was overcome by the SHIModernisation Act (SHIM Act), enactedby the first red-green SPD/Greengovernment with support from the oppo-sition CDU/CSU in 2003. From 2004,sickness funds could contract selectivelywith individual or groups of individualhealth care providers without requiring theformal approval of a physicians’ associ-ation. Furthermore, to overcome financialconstraints on selective contracting, theSHIM-Act decided to fund integratedhealth care at the expense of collectivereimbursement schemes for physicians andhospitals. Ever since, the number of newforms of health care provision making useof selective contracting has risenconstantly. These new ‘networks of care’range from gate-keeping models anddisease management programmes to inte-grated care – the German model ofpreferred provision, integrating providersfrom different health care sectors.
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Institutional change orpolitical stalemate? Health care financing reform in Germany
Kai Mosebach
Summary: After its inauguration in Autumn 2005, the second Grand Coalition inGerman post-war-history announced a major reform of health care financing. Thepublic and the media were curious to see how the governing CDU/CSU and SPDcoalition would overcome their differences on health care financing. To date, theparties have not fully agreed on the final institutional design of the future system.However, the Grand Coalition will introduce some institutional innovations thatnonetheless will alter the overall structure of health care financing in the country.
Key words: Germany, health care financing, health policy, regulated competition,health insurance
Kai Mosebach is a Health Policy Analyst,Institute of Medical Sociology, JohannWolfgang Goethe University, Frankfurt,Germany.Email: [email protected]
All these developments have meant that anew regulatory model has been emergingsince the 1990s; one that, in line with inter-national trends, focuses on regulatingincentives instead of relying on cost-containment alone.3 The new shape of thehealth care system has been labelled‘competitive corporatism’. This combinescompetition between sickness funds andamong health care providers with thepreservation of a common regulatoryframework through corporatist bargainingprocedures.4 However, the politicaldynamics of competitive corporatism areboth contradictory and conflict-driven. Inessence, a dual structure has emerged,placing selective contracting into an envi-ronment where traditionally blockcontracts have been the norm.
Debating health care financing reform:red-green agenda and beyondOne motivation behind the introductionof regulated competition has been thedesire for efficiency gains, which conse-quently would imply lower socialinsurance contributions. This would helpsupport the international competitivenessof the German economy. This policy hasbeen accompanied by higher levels of co-payment first introduced through theSHIR-Acts at the end of the CDU/CSUand FDP government in 1996. This wasthe only significant change in health carefinancing after the introduction of openenrolment in the 1990s.
Eventually, the red-green coalition puthealth care financing reform onto itspolitical agenda in summer 2003. It estab-lished an expert Commission on SocialInsurance Financing, which laid theconceptual groundwork for the ongoingpolitical debate seen today. Whilefocussing on several pillars of the Germanwelfare state, the Commission’s recom-mendations regarding health care financingrested on two commonly shared premises.4
First, that the financial foundations of theincome-related health care insurance hadbeen eroding because of economic global-isation, European integration and risingunemployment. Second, in order topreserve the international competitivenessof the German economy, health careinsurance contributions must not riseexcessively. However, due to a lack ofconsensus, the Commission’s reformproposals ended up consisting of twocompeting models of health care financing:a nation-wide citizen’s health insurance(ending the co-existence of SHI and substi-tutive PHI by integrating the latter into the
former), or alternatively a flat-rate healthinsurance limited to the SHI.
From a political perspective, the SPD andGreens favoured the citizen’s insurance,while the CDU/CSU (the latter by nomeans unanimous) preferred a flat-rateinsurance. This citizen’s insurance wouldsubject all individuals and all forms ofincome to health insurance contributions.By preserving the income component ofthe SHI, the citizen’s insurance would leadto a significant increase in funds for healthcare. Additionally, it would make redistri-bution within the health care system moreprogressive.
However, the federal SPD/Green govern-ment had to contend with a CDU/CSU-led majority of state governments in theBundesrat. Their conservative model ofhealth care financing would imply acapital-funded health care insuranceshifting the mechanism of income redistri-bution out of health insurance and towardstax based subsidies. As a consequence ofthis political stalemate, health carefinancing reforms were postponed, leavingonly a new system of co-payments inplace.5
After the end of the red-green governmentin early autumn 2005, the newly estab-lished Grand Coalition, under ChancellorAngela Merkel (CDU), agreed to bring inhealth care financing reforms. Theproposed SHICS-Act will strengthen therole of the federal state in regulating thehealth care system at the expense of thetraditional (corporatist) regulatory system.With regard to health care financing, thismeans on the one hand the introduction ofa federal fund to pool financial flows, andon the other, a change in the relationshipbetween SHI and the (substitutive) PHIsystem.
‘Bringing the state in’: federal fund,sickness funds and competitionCurrently, sickness funds compete throughdifferent health insurance contributionrates paid by employers and employees.From 2009, the federal government will set(on an annual basis) income-related anduniform (for all sickness funds) healthinsurance contribution rates through legalregulation. The resulting revenues will bepooled centrally into a new federal fund onhealth care financing, managed by theFederal Insurance Office (Bundesver-sicherungs-amt). This federal fund will alsoreceive tax subsidies which should risefrom €1.5 billion (2008) to €3.0 billion in2009. However, due to political pressure
from the Federal Ministry of Finance thecurrent (2006) tax subsidy of €4.3 billionwill be reduced by €1.8 billion to €2.5billion in 2007.
The proposals to channel funds from thePHI into the SHI and to construct a stan-dardised reimbursement scheme for SHIand PHI were debated, but eventuallyabandoned. The SPD (especially its leftwing) favoured both measures, but theCDU and CSU blocked these proposals,thereby reflecting their close links withPHI-companies and physicians that havethe option of billing their services forprivate insurees at rates several timeshigher than those for statutorily insuredpatients. Furthermore, the implementationof the already concluded (SHIM-Act)morbidity-based and standardised reim-bursement system for SHI physicians hasbeen postponed to 2011.
After pooling the revenues, an amount ofmoney consisting of a per capita amount,plus a risk-adjusted extra payment whichbalances the different risk structures ofsickness funds, will be directed to the indi-vidual sickness funds. In contrast to thecurrent risk-adjustment mechanism, in thefuture the total sum of health and adminis-trative expenses of one sickness fundshould be balanced with all others. Inaddition, the new system will redistributehealth care expenditures according to thesickness fund’s relative burden ofmorbidity.
At the start of the new health care financingsystem in 2009, sickness funds will berelieved of (recently accumulated) debt. Ifrevenues are not sufficient to pay theirhealth care expenditures, an individualsickness fund will be obliged to charge anadditional levy on their members (but nottheir employers) – either through income-related or flat-rate payments. These chargesshould help incentivise funds to makefurther efficiency savings through theexpansion of selective contracting. Thereforms also aim to support selectivecontracting through strengthened out-patient and integrated care.
The federal government will alsodetermine (by legal regulation) the overalldistribution rate of funding from healthinsurance contributions, as well as the levelof additional funding to be raised by indi-vidual sickness funds. In 2009, the share offunds from the income-related healthinsurance contribution will be 100%.However, the scale of additional chargescould rise to as much as 5% of the overall
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health care costs in the SHI, possiblyreducing the share from health insurancecontributions to 95%. Consequently, thelevel of additional charge should act as asignal of the efficiency of the sicknessfunds’ operations.
However, due to a proposed hardshipclause, sickness funds with anunfavourable risk structure (for example,many chronic ill and low-income insurees)may face funding problems. Under theterms of the hardship clause additionalcharges are individually limited to amaximum of 1% of the income of themember. The charge will in fact becollected without respective income testingup to an amount of €8, meaning that poorand low-income households (i.e. theworking poor) will suffer the most if thisadditional charge is applied by theirsickness funds.
Funds with a high concentration of lowincome households may face the additionalproblem of having to charge their moreaffluent members at a much higher levelthan low income members because of therestrictions on charges set by the hardshipclause. One scenario where this might bethe case would be if the governmentdecides to raise the scale of any additionalcharges to more than 5% of total healthcare costs. Therefore many, but by nomeans all sickness funds, fear that iffinancial pressure on the SHI persist, infuture the hardship clause might lead to aloss of competitiveness in some funds incomparison to those with a morefavourable ‘risk structure’. Eventually,many funds may face bankruptcy and/orhave to merge with their competitors; thelatter is in fact a political goal of the currentreform proposals.
Regulating the boundaries betweenvoluntary SHI and PHIIn Germany, the structure of health carefinancing currently consists of both SHIand (substitutive) PHI. High incomeearners above a specific income ceiling canchoose between SHI and (substitutive)PHI. In fact, competition exists (albeitlimited) between SHI and PHI for highincome earners. Since the early 1990s, thenumber of privately insured individualshas continuously risen. There are howeverincreasing restrictions for solidarity relatedreasons. These for example, prevent highincome earners who are privately insuredfrom insuring their children without anycost through the SHI contributions oftheir low paid spouses, thereby pulling
insurance contributions out of the SHI-system and shifting the health care costs ofchildren onto the solidarity based systemof SHI. Moving from SHI to Moving fromSHI to PHI will now also be more difficultthan in the past.
Consequently, while the regulation of theboundaries of SHI and PHI has been thesubject of contention, there has never-theless been some covergence, leading firstto the introduction of a standardised healthinsurance scheme within the PHI, coveringmainly low income older people (Stan-dardtarif) in 2000. In addition, some PHI-measures were implemented into SHI, forexample deductibles and no-claim refundschemes if insurees did not make use ofhealth insurance benefits within a givenperiod. The SHICS-Act will also expandthe scope of PHI-type regulations in theSHI by enabling all SHI-insurees to choose(reduced) health insurance schemes withdeductibles and to opt for reimbursementschemes instead of benefits-in-kind.
Although the ‘Great Coalition’ did notagree to integrate the PHI into the SHI asproposed by the Social Democrats, theSHICS-Act will change the rules of thegame for (substitutive) PHI. In order toestablish a more competitive framework,the SHICS-Act will introduce new regula-tions. First, the federal government willoblige PHI to offer a (revised) standardisedinsurance scheme, similar to SHI, which isprohibited from applying individual healthrisk-adjusted premiums (Basistarif). Theoriginal draft regulation which requiredPHI funds to accept every insured personfrom SHI and PHI schemes to this stan-dardised insurance scheme (as favoured bythe Social Democrats) was however aban-doned during consensus negotiations inearly January 2007. This was due topressure from PHI companies channelledthrough the CDU/CSU.
Now SHI-insured individuals can switchto PHI (probably to the Basistarif) if theyhave an income in excess of a specifiedincome ceiling for at least three years. Thewindow of opportunity for those alreadyPHI-insured individuals to change to thenew standardised insurance scheme (Basis-tarif) will now been limited to a six monthperiod in 2009.
The government will also make old agereserves in the PHI transferable in order toestablish a higher level of competitionwithin PHI. At the moment, capitalfunded old age reserves are not transferableeven if the privately insured would like to
change their PHI provider. Competitionbetween PHI companies has thus beenseverely limited for this group until now.
Finally, as a step towards counteracting therecently growing numbers of the non-insured, the government wanted tointroduce a regulation stating that every(legal) resident will have the legal right toreturn to the system from whence he/shehad been insured previously, beforebecoming ineligible for health careinsurance (be it either SHI or PHI).Concerning this regulation, the Associ-ation of PHI Companies has highlightedthe potential perverse incentive thatprivately insured persons could decide toopt-out of health insurance and return tothe Basistarif if they were to become ill andneed expensive health care (Vorteil-shopping – health-insurance-free-riding).To counter this would require additionalfunds within the PHI through compara-tively higher insurance premiums, becauseit would be possible that especially highincome earners would opt-out of PHI. Inorder to avoid such health-insurance-free-riding the Grand Coalition has decided tomake health insurance compulsory forSHI and PHI.
Institutional change: health carefinancing at the crossroadsThe SHICS-Act will introduce severalinnovations into the German health caresystem. Most prominently, will be theestablishment of a federal fund, thusreducing the power of sickness funds.Furthermore, the boundaries between SHIand PHI will be both more closed andmore open. While it will be more difficultto switch from SHI to PHI, the probableimplementation of a standardised healthinsurance scheme (Basistarif) as well as thetransferability of capital funded old agereserves will intensify competition withinthe PHI system and between (voluntary)SHI and PHI. However, both the originalproposals and final agreed regulationsunderline the highly contested boundariesof SHI and PHI. In addition, most reformproposals within the SHICS-Act(concerning health care financing) are to beimplemented only in 2009.
Furthermore, the basic problems of healthcare financing are still to be addressed. Theproposed reform will not counteract theerosion of the financial foundations ofhealth care insurance, nor will it preventthe social insurance contribution fromrising steadily. Therefore, critics argue thatin effect there has been no health care
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financing reform at all, only the extensionof a political stalemate.
Nevertheless, it is clear that some initialsteps that will change the institutionalfoundations of health care financing havebeen taken. The introduction of the federalfund and the (however limited andcontested) convergence between SHI andPHI point to an evolutionary change fromcompetitive corporatism to the marketi-sation of health care (financing), accom-panied by a changing role for stateregulation. However, the SHICS-Act alsorepresents a political stalemate in respect ofthe final design of health care financing (beit citizen’s or flat-rate-insurance) inGermany. Health care financing reform, nodoubt, will be a key issue in the electoralcampaign of 2009.
REFERENCES
1. Mosebach K. Money for Nothing?Discourse, Power, and the Politics of HealthCare Financing Reform in GermanyDuring the Governmental Period of theGrand Coalition of CDU, CSU and SPD(2005–2007). Frankurt: Institute of MedicalSociology at the Hospital of the Johann-Wolfgang-Goethe-University, Frankfurt,Discussion Paper 2/2007
2. Busse R. Risk adjustment in socialinsurance systems. Risk structure compen-sation in Germany’s statutory healthinsurance. European Journal of PublicHealth 2001;11:174–77.
3. Saltman R. Regulating incentives: thepast and the present role of the state inhealth care systems. Social Science andMedicine 2002;54:1677–84.
4. Gerlinger T. Vom korporatistischen zumwettbewerblichen Ordnungsmodell? UeberKontinuitaet und Wandel politischerSteuerung im Gesundheitswesen. [From acorporatist to competitive model? Beyondcontinuity and change in the steering ofhealth policy] In: W Gellner, M Schön,Markus (eds). Paradigmenwechsel in derGesundheitspolitik? [A Paradigm Shift inHealth Policy?] Baden-Baden: Nomos,2002.
5. Mosebach K. Transforming the welfarestate. Continuity and change in socialpolicy since 1998. In: S Beck, F Klobes, CScherrer (eds). Surviving Globalization?Perspectives for the German EconomicModel. Dordrecht: Springer, 2005.
6. Mosebach K. The politics of health carefinancing reform in Germany. EuroObserver 2005;7(1):3–6.
Pharmaceutical policyreform in Spain
Joan Costa-Font and David McDaid
Summary: There are many deficiencies in the operation of pharmaceutical policyin Spain. This article provides a brief overview of the way in which the marketfunctions and highlights some structural problems. We describe and provide someinsights on the main economic policy problems to be faced in the regulation of theSpanish market. Key measures introduced as part of new 2006 legislationintended to address some of these deficiencies are then discussed.
Keywords: Spain, pharmaceutical policy, generics, reference pricing, medicines, regulation
Spain has traditionally faced seriousproblems in containing pharmaceuticalexpenditure. Compared to other EuropeanUnion countries, she has historically reliedheavily on pharmaceutical treatments.1
The pharmaceutical market has struggledwith a number of deficiencies related toquality and performance including vari-ability in clinical practice and limited useof clinical guidelines in prescribing. Thereare also inefficiencies at the provider level,including limited use of generics with fewincentives to switch to generics, while atconsumer level there is a high level of selfmedication and limited impact of co-payments.
Traditionally mark-ups to reimburse thepharmaceutical distribution chain haveneither fostered cost-containment norgeneric substitution; instead there havebeen subtle incentives including non-transparent discounts that benefit retailersand wholesalers but do little for the taxpayer. The mechanism for distributingpharmaceuticals also heavily restrictscompetition between retail pharmacists,for instance by requiring the owner of thebusiness to have a degree in pharmacy.Wholesalers are also linked to groups ofpharmacies, rather than subject to wider
competition. This system, compounded bystrict price regulation based on unclearindexation and costs-plus formulae, leadsto low average prices and explains why thecountry is involved in the parallel exportof drugs.2
Physicians traditionally have had very fewincentives to prescribe efficiently.Moreover generic prescriptions do notguarantee that the cheapest generic will bedispensed; economic incentives are not inplace. There is also only a very limited rolefor cost-effectiveness analysis in guidingdrug reimbursement and pricing.
While the responsibility for healthgenerally has been decentralised to the 17Autonomous Communities (ACs), phar-maceutical policy and regulation remainsone the few areas much less affected bythis process; although some steps havebeen taken to involve the ACs in quasi-federal decision making boards that lookat pricing and coordinate some policies.Consequently, pharmaceuticals are a highpriority for health policy reform.
There have been some recent attempts tobreak the cycle of stagnation in the phar-maceutical market through modestreforms that strive to accommodate all
Joan Costa-Font is Research Fellow in Health and Pharmaceutical Economics, LSEHealth, London School of Economics and Political Science and Associate Professor ofEconomics, University of Barcelona. David McDaid is Research Fellow, LSE Health andEuropean Observatory on Health Systems and Policies, London School of Economics andPolitical Science. Email: [email protected]
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Table 1: Pharmaceutical expenditure in Spain (1990 –2005)
1990 1995 1996 1997 1998 1999
Drug Expenditure
NHS Drug Expenditure (€m) 2,524 4,389 4,887 5,155 5,700 6,268
NHS Share of Total Drug Expenditure 68% 72% 73% 73% 73% 72%
Drug Expenditure Per Capita (€) 63.3 110.6 123.2 129.9 143 155.9
Drug Expenditure Drivers
Price per NHS prescription (€) 5.63 9.17 9.68 9.99 10.99 11.88
Number of prescriptions 532,231 525,316 551,696 562,716 561,716 569,526
Population per pharmacy 2,172 2,101 2,098 2,084 2,073 2,068
% Patients who make co-payments 13.00% 8.90% 8.50% 8.20% 7.70% 7.30%
% Drug expenditure for older people 61.50% 68.30% 68.90% 69.30% 70.10% 71.00%
stakeholders’ interests involved. Onesignificant measure implemented from July2006 was the introduction of a law guar-anteeing the rational use of pharmaceu-ticals and health care products (Ley deGarantías y Uso Racional de Medica-mentos y Productos Sanitarios – Ley29/2006). This law replaces the old 1990Pharmaceuticals Act and contains anumber of ambitious measures. This shortarticle looks at the context for this legis-lation and highlights some of the recentinnovative steps taken.
Pharmaceutical expenditurePharmaceutical expenditure has continuedto grow between 1990 and 2005 (see Table1). The price per prescription rather thanthe number of prescriptions has beenresponsible for much of this increase. The
market strategy of the industry has been toconcentrate their promotional efforts onnew and sometimes highly innovativeproducts that command higher prices. Thisis one reason for the increasing share ofpharmaceutical revenues enjoyed bymanufacturers (see Table 2). On the otherhand, from the turn of the millenniumthere has also been some increase in thenumber of prescriptions; this may be dueto greater penetration by generics, as wellas the introduction of a reference pricesystem; this might foster the expansion ofmore intensive treatment. This also openedup the market to competition betweengenerics.
The data also indicate that there have beenfew changes in the geographical concen-tration of pharmacies. This is consistent
with the protected and highly regulatedretail pharmacy market. Co-payments formedications have reduced; older peoplewho are exempt from such payments andrepresent 18% of the population accountfor 72% of drug expenditure.4
Market structurePrescription drugs account for approxi-mately 85% of total volume and 92% oftotal sales in the pharmaceutical market.Generics only represented 9% of totalvolume in 2003. Locally based industrieshave only a limited research and devel-opment capacity. Research and devel-opment expenditure relative to salesdeclined from 8.6% in 1987 to 7.9% in2001. Only 10% of employees work in thisarea compared with 43% engaged inmarketing.5
2000 2001 2002 2003 2004 2005
Drug Expenditure
NHS Drug Expenditure (€m) 6,800 7,462 7,996 8,962 9,530 10,075
NHS Share of Total Drug Expenditure 72% 73% 73% 74% 74% 75%
Drug Expenditure Per Capita (€) 167.9 181.5 191.1 209.8 220.6 228.4
Drug Expenditure Drivers
Price per NHS prescription (€) 12.26 12.9 13.36 14.08 14.43 14.55
Number of prescriptions 596,891 621,593 661,402 706,737 728,722 764,884
Population per pharmacy 2,062 2,080 2,082 2,099 2,111 2,143
% Patients who make co-payments 7.10% 6.90% 6.80% 6.80% 6.40% 6.20%
% Drug expenditure for older people 71.90% 72.20% 72.10% 72.00% 72.10% 72.40%
Source: Consejo General del Colegio de Farmacéuticos, 20063 and own calculations.
The share of revenues from pharmaceu-ticals for each of the principal stakeholdersis shown in Table 2. Interestingly, whilstreforms that were put in place in the early1990s did not have any significant impact,those introduced after 1996 under conser-vative administrations appear to indicatethat a greater share of revenues haveaccrued to product manufacturerscompared with distributors, both retailand wholesale.
Generics marketThe market for generic drugs in Spain hasbeen practically nonexistent over the lasttwo decades. Until 1992, the country onlyrecognised process (rather than product)patenting. The 13/1996 General BudgetAct and the 66/1997 Regulation Act,which opened the door to the introductionof generic drugs, modified the 1990 Phar-maceuticals Act. The first generic brandswere registered for commercial distri-bution in July 1997 and generic pene-tration has risen steadily (althoughleisurely) ever since. In 2000, genericsaccounted for just 3% of total nationalhealth service sales. This increased to 6.4%by 2003 and 7.5% (13.8% in volume) by2005. This compares with an average 27%shares of sales volume across the EU as awhole, although this varies markedly withrates well over 40% reported in theNetherlands, Poland, Slovakia, Sloveniaand the UK.6
The market for generics is typically domi-nated by local manufacturers, with fewinternational players operating in themarket. This implies that there are veryfew incentives for competition. Genericprescriptions depend heavily on infor-mation being provided to general practi-tioners and patients; initiatives in thisregard remain small. In 2001 whereas12–15% of total prescriptions (8–10% ofsales) in Madrid and Catalonia were for
generics, in Galicia the figure was less than3%.7 Policies to promote the greater use ofgenerics have taken the form of promotionand advertising campaigns for physicians,as well as subsidies and requirements toonly dispense generics when theprescription is based on such an activeingredient. Since the approval of the mostrecent General Health Act reforms (socalled Cohesion and Quality Act), phar-macists should play a wider role in thepromotion of the rational use of drugs byworking in collaboration with other healthprofessionals to promote generics.However, both the enforcement of theserequirements and incentives to promotegeneric substitution fall short comparedwith other European countries such asFrance.
Key reforms A number of measures set out in the newpharmaceuticals law are intended toaddress some of the deficiencies in thecurrent system. In some areas there is aparadigm change, but in others the regula-tions offer the prospect of reform ofmeasures that have already worked in thepast.
A new system of reference pricing willcome into operation from March 2007.This is slightly more transparent than itspredecessors though it in essence followssimilar rules. It essentially brings togetherall off patent drugs financed for more thanten years by the national health service.These are grouped by form and activeingredient and include at least one genericequivalent. The reference price for eachgroup of drugs is computed as the averageof the three cheapest products regardlessof market share. This is an improvementon previous requirements which weredependent on the market share obtainedby these products or the overall cost oftreatment.
To improve the efficiency of the referencepricing system, the new system has slightlyexpanded the number of therapeuticgroups to 135. No significant reformthough has been introduced to promotecompetition with innovative drugs.Indeed, drugs that are considered to be‘innovative’ can be exempted from thesystem. Reference prices can be revised asregularly as every year. All, in principle,must be revised every three years.
“incentives to promote genericsubstitution fall short comparedwith other European countries”
To promote generic competition, the newlaw also has put in a place a 20% reductionin the price of products that after ten yearsof registration have a generic equivalent inanother European country. The so-called‘bolar provisions’ will also be imple-mented. Clinical trials for the developmentof new generic drugs will be able to starteight years after drug authorisation.
One paradigm change has been the intro-duction of a contribution, in the form of atax on manufacturers based on their salesvolume. This will be used to help fund thenational health service. Through thismechanism, the system ensures that someof the proceeds of pharmaceuticalcompanies are shared with the state andthus stands as a form of ex-post regulation.
The new law does not, contrary to someexpectations, have a significant impact onthe way in which pharmaceuticals aredispensed. As a concession to pharmacistsit introduces the concept of ‘pharmaceu-tical care’ services that are to be provided
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Table 2: Average share of revenues for pharmaceuticals 1991–2005
1991–1992 1993–1994 1995 –1996 1997–1998 1999–2000 2001–2003 2004–2005*
Ex-factory price 58.2 59.9 59.3 61.7 62.7 63.3 64.2
Wholesaler’s margin 7.9 8.2 8.1 7.6 6.6 6.5 5.9
Retailer’s margin 28.2 29 28.8 26.8 26.8 26.4 26.1
VAT 5.7 2.9 3.8 3.9 3.9 3.8 3.8
Source: Farmaindustria, 20045
* After 1 March 2005 a non-linear margin system is in place so that products with a price below €89.62 had a wholesale margin of 8.62%and a retail margin of 27.9%. Products priced above €89.62 had a wholesale margin of €8.43and a retail margin of €37.94.
within pharmacies. The law also permitsdrug substitution by pharmacists in somecircumstances and prohibits the sale ofmost drugs without a prescription. Highlevels of self medication have been aparticular problem in the country.8 Underthe new law penalties of up to €90,000 canbe imposed on those pharmacists whoignore this prohibition. At the same time,the law permits electronic prescriptions forpeople living with chronic conditions; thiswill reduce their need to travel to a healthcare centre in order to obtain aprescription.
The new regulation has also sought toreform the distribution system byenforcing a product traceability systemthroughout the whole product distributionchain (at the manufacturer, wholesale andretail level). The main rationale for this hasbeen to eliminate the shortages that haveoften been commonplace in pharmacies inthe past and reduce the continuingexpansion of the parallel trade market.9
Agreement was reached after one companyproposed setting up its own distributionnetwork so as to avoid the further devel-opment of a parallel distribution chain.Spanish wholesalers argued that theyshould still have a right of access to manu-facturers’ products. The new regulationsenshrine this right and in exchange theindustry will have some control over thedistribution network and most likely willbe able to apply differential prices; that is adiscounted price upon justification of localsale and a European price for all others.
Discounts on products from wholesalershave also been banned, other than thoserelated to early payment or sales volume.They can no longer be used to encouragethe purchase of any one specific product.Prior to the law, discounts that effectivelymeant ‘buy one get one free’ (and variantsthereof) were commonplace. However,from prior experience, the interpretationof the law always ends up allowing someflexibility to maintain discounts of somesort. Indeed, one of the problems ofSpanish decision making is the frequentrecourse to the courts to interpret policyset out in legislation. This is alreadyhappening in respect of discounting. Newobligations have also been imposed uponthe pharmaceutical industry with respectpharmacovigilance; in addition to main-taining the system they must report anyadverse events to the Ministry of Health,thus enhancing the information systemwith regards to medicines.
DiscussionGiven the nature of the pharmaceuticalmarket in Spain and the extent to which itis subject to regulation, changes in theregulatory environment are critical toachieving improvements in practice. Themarket in Spain has been shown to reactsignificantly to changes in incentives;however until now there was no significantparadigm change. The shape of regulatorymeasures have always been an issue forbargaining and lobbying between thedifferent stakeholders, the Ministry ofHealth and the ACs. Such measures arethen typically enshrined in law, as in thecase of the new Act and resemble a rent-seeking process where the final equilibriumtypically implies only modest change.
“Another key issue to beaddressed is the lack of transparency in the way drugs are initially priced and reimbursed”
The new legislation has undoubtedlyintroduced reforms intended to improvethe efficiency of the distribution system aswell as foster competition in the genericsmarket. However, how this regulation isfinally implemented will be the key to itssuccess. Careful evaluation of the reformswill in time be required but clearly limita-tions remain. Retailers, nonetheless,continue to control roughly 70% of thewholesale market, limiting competition.While there are now some incentives inplace to promote the use of generics, aswell as support for innovative products,one continuing challenge will be to designa system that makes, once and for all, thereference price efficient. This impliesdevoting particular attention to preventingunjustified substitutions from productsincluded in the reference price to thoseexempt from the system.10
Co-payments can be an obvious way ofcontaining drug expenditure, yet the use ofsuch cost sharing measures in Spain hasnot changed in the last twenty years;possibly due to a lack of political supportand the unpopularity of such reforms. Anincreasing share of total drug expendituresnow fall on groups that are exempt fromsuch co-payments, which creates signif-icant equity concerns (a rich older personwill be exempt from co-payments whilst a
poor middle age woman with childrenwould have to pay 40% of their costs).This may be an issue for further reform,whilst being mindful of efficiency andequity concerns. Another key issue yet tobe addressed, and one which is a bone ofcontention for the European Commission,is the lack of transparency in the way thatdrugs are initially priced and reimbursed.Ultimately, the best way to reduce rent-seeking behaviour and preventgovernment from being captured by vestedinterests of any sort is by defining clearrules and enforcing them.
REFERENCES
1. Costa-Font J, Puig J. The pharmaceuticalmarket regulation in Spain is drug cost-containment under question? Journal ofPharmaceuticals Finance, Economics andPolicy 2004;13(4):33–49.
2. Kanavos P, Costa-Font J. Pharmaceuticalparallel trade in Europe: impact on stake-holders and competition effects. EconomicPolicy 2005;20(44):753–98.
3. Consejo General del Colegio de Farma-céuticos. Informacion Estadistica [Statis-tical Information]. Consejo General delColegio de Farmacéuticos, 2006. Availablevia http://www.portalfarma.com
4. Puig-Junoy J. Incentives and pharmaceu-tical reimbursement reforms in Spain.Health Policy 2004;67:149–65.
5. Farmaindustria. La industria Farma-céutica en Cifras [The pharmaceuticalindustry in statistics]. Madrid: Farmaindustria, 2004.
6. Perry G. The European generic pharma-ceutical market in review: 2006 andbeyond. Journal of Generic Medicines2004;4(1):4–14.
7. Asociación Española de Productores deGenéricos, Madrid. Data provided formannual reports. Websitehttp://www.aeseg.es
8. Costa-Font J, Kanavos P, Rovira, J.Determinants of out-of-pocket pharmaceutical expenditure and access todrugs in Catalonia. Applied Economics2007 (in press).
9. Costa-Font J, Kanavos P. Drug parallelimports: the case of Simvastatin inGermany, Netherlands and the UnitedKingdom [in Spanish] Gaceta Sanitaria,2007 (in press).
10. Puig-Junoy J. The Impact of GenericReference Pricing Intervention in the StatinMarket. Barcelona: Departamentd’Economia I Empresa, UniversitatPompeu Fabra, 2005.
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Eurohealth Vol 12 No 4 18
GLOBAL HEALTH
Making poverty historyMuch has been said about the need toeradicate poverty and avoidable disease toimprove the life chances of all those livingin the developing world. The first of theUnited Nations’ eight Millennium Devel-opment Goals (MDG) agreed in 2000 wasto halve extreme poverty and hunger by2015. Responding to the world’s maindevelopment challenges and to the calls ofcivil society, the MDGs also promoteeducation, maternal health, genderequality, and aim to combat childmortality, HIV/AIDS and other diseases.They are the most visible indication of aglobal partnership that has developed fromcommitments and targets established atvarious world summits in the 1990s.
Certainly some progress has been made interms of poverty reduction. The mostrecent estimate from the World Banksuggests that 21.7% of developing countrypopulations were living on less than $1 perday in 2002 compared with more than29% in 1990; they project this will reduceto 10.2% by 2015, thus attaining the MDGtarget on poverty.1 This still leaves anenormous number of people in abjectpoverty, while others who may see some
growth in income will have very limitedaspirations beyond their daily struggle tosurvive.
Governments, civil society organisationsand others recognise the need to do muchmore. One immediately can think of the‘Make Poverty History’ campaign and thelobbying at the 2005 G8 Summit inScotland by the Live 8 coalition on theneed for more debt relief and a levelplaying field for international trade. It isalso clear that positive actions were takenin response both by the G8 and thebroader international community.
For instance, the G8 pledged a further $50billion in aid to developing countries,including the doubling of aid for Africa to$25 billion by 2010. It also agreed to cancelall $40 billion in debts of some eighteeneligible heavily indebted poor countries tothe International Development Associ-ation, the International Monetary Fundand the African Development Fund. Afurther twenty countries would alsobecome eligible for debt cancellation ifthey met certain structural conditions andmade progress to tackle corruption.
The need to drive growth and boostincomes across the world has also beenrecognised as a necessary element of workto reduce global poverty; trade distortions,the G8 concluded, need to be reduced and,in the case of agriculture, eliminated bysome as yet to be determined credible end
date. At the United Nations WorldSummit later in 2005, further commit-ments were given on attaining the MDGsand “promoting the development of theproductive sectors in developing countriesto enable them to participate more effec-tively in and benefit from the process ofglobalisation.”2
Trade not aidTraditionally, there has been a heavyreliance on governmental development aid,supplemented by the actions of non-governmental organisations (NGOs) of allshapes and sizes, to help in global effortsto address the need to promote betterhealth, tackle some of the terrible buteminently treatable diseases that arecommonplace in low income countries andalleviate poverty. This model of aid hascome under increased scrutiny in recentyears; there have been questions about themerits of donations rather than efforts tocreate self-sustaining solutions – asperhaps best captured by the slogan ‘tradenot aid’. Some have suggested that NGOsbased in developed countries might not bethe most efficient way of helping indi-viduals to get out of poverty.
Certainly the 2005 UN General Assemblyrecognised that intervention must not beconfined to the NGO and public sectorsalone but that “the private sector can playa vital role in generating new investments,employment and financing for devel-
Corporate lifelines: a newapproach to making povertyhistory
David McDaid
David McDaid is Research Fellow, LSEHealth and European Observatory onHealth Systems and Policies, LondonSchool of Economics and Political Science.Email: [email protected]
Summary: Traditionally government aid, supplemented by the actions ofnon-governmental organisations, have been the mainstay of actions totackle global poverty and improve health. Some argue that there areinefficiencies in this model and advocate for a more business orientatedapproach to the promotion of sustainable development. This article looksat some of the issues raised and highlights some of the development workundertaken by the commercial sector.
Keywords: Poverty, economic development, foreign aid, private sector
opment.”2 Further recognition of theimportance of private sector involvementwas also forthcoming in the award of the2006 Nobel Peace Prize to MuhammadYunus and the Grameen Bank for theirwork in providing access to micro-creditto help individuals lift themselves out ofpoverty. Some of the limitations in thetraditional approach to aid and devel-opment, as well as examples of innovativeapproaches undertaken by the businesscommunity to tackling global poverty,which in turn can have a positive impacton health, are illustrated in this article.
Does the aid community have all theanswers? NGOs have undertaken much valuablework to both save and improve the qualityof life across the world; in some cases, asfor instance can be seen in the ongoingtragedy in Darfur, aid workers have ulti-mately paid with their own lives for theirefforts.3 In some instances however, it isnot always clear that the NGO modelalone can best alleviate poverty. Part-nership with business may have merit, yetmany in the aid community have histori-cally been distrustful of the private sector.
Kurt Hoffman, director of the Shell Foun-dation, an independent London basedcharity that adopts a business orientatedapproach to promoting sustainable devel-opment, has called for reform in the aidcommunity. He wants it to apply funda-mental business principles to enhanceperformance and accountability.4 He notesthat “big injections of official aid (forexample, nearly $600 billion to sub-Saharan Africa since 1960) have notgenerated economic growth in the past. Sowithout fundamentally changing the aidindustry’s ‘business model’ why wouldpast failures miraculously morph intosuccesses?”
While there was a quadrupling of aid as apercentage of gross domestic product(GDP) in Africa between 1970 and 2000,he observes that GDP decreased onaverage by 0.6% every year over the sameperiod. It is perhaps unsurprising thereforethat he has been critical of the G8’sdecision to give more money to the aidcommunity, calling this “apparentlythrowing good money after bad” andsomething that “paradoxically leads not tothe support of initiatives that will makepoverty history, but to the creation of avastly inefficient delivery system ofoutcomes that have at best, limited short-term benefit.”
Clearly there are issues about the ways inwhich the performance of NGOs are eval-uated. To what extent are there sufficientincentives to ensure that funds are investedin such a way as to generate maximumsocial benefit? Criticisms can also be madeof governmental partners. One recentParliamentary report in the UK, looking atprivate sector development, also wascritical of the UK’s Department for Inter-national Development for not havingspecialist expertise in property rights.Having property rights guaranteed isessential to help promote businessinvestment and more might be done onthis.5
Clearly there are challenges, widelyacknowledged, in terms of corruption andpoor governmental infrastructures withincountries, that will undoubtedly hamperNGO and government performance; thesecannot be ignored – but are NGOs doingenough to overcome these obstacles? Howwould any performance assessmentmeasures, if used, affect the donating pref-erences of those living in the high incomeworld.
Perhaps more importantly who shoulddetermine how such donations should beused? NGOs, which may be restricted tovery specific types of investment andproject under their terms of incorporation,or might a better alternative be to involveindividuals in low income countries in amuch more pro-active way in this resourceallocation process? If one was thinkingabout funding health policy prioritiesusing public money, good practice wouldinvolve making use of mechanisms such asneeds assessment as well as involving localstakeholders in this process.
Hoffman draws attention to the fact that,unlike aid agencies, investors in newbusiness ventures are careful to look at thetrack record of any entrepreneur seekingcapital, as well as the market potential ofany product, before making anyinvestment decision. Those seekinginvestment will need to their homeworkcarefully, to make a strong business casefor any proposed project; such incentivesdo not necessarily exist for those seekingmoney from NGOs. Moreover becauseentrepreneurs are willing to share in therisk, investors may be more confident thatthey will also take steps to ensure that theventure is a success.
Reform of aid agencies, Hoffman argues,should therefore allow those in the devel-oping world to have a genuine choice over
the providers of aid financed services;introduce targets and incentives thatreward those agencies that createsustainable pro-poor enterprises; andincrease accountability among aid actorsby getting those agencies on the ground tobear some of the risk and invest their ownpersonal resources in projects. He also hascalled for the same standards of riskassessment and due diligence seen in thebusiness community to be applied toinvestment decisions taken by NGOs.Such measures are more often seen in char-itable organisations that have been influ-enced by business practices. Take, forexample, the Bill and Melinda Gates Foun-dation, which has a system of keyperformance indicators for all its projects.
Enterprise solutions Business solutions do not need to bedriven by the profit motive alone; it ispossible to create social business entrepre-neurs seeking to achieve social objectivesthrough the creation and support ofsustainable business enterprises.6 They canhelp introduce a greater level of compe-tition and choice into the market helpingto foster innovation and drive down prices.The performance of such businesses mightultimately be assessed.using some set ofobjective criteria, thus helping potentialinvestors/donors decide which initiativesare likely to generate a good social return.
Such social business can benefit enor-mously from advice and support from thebusiness community in the developedworld. This support may be vital tonurturing business to survive and competewith developed country competitors.Completing the World Trade Organi-sation’s Doha round and promoting fairtrade will be insufficient to allow southernbusiness to flourish. Getting products toconsumers is critical; capacity in devel-oping countries in this respect may belimited, but there is much expertise inmanaging the supply chain in companies inthe developed world.
Here again Kurt Hoffman has argued thatnew initiatives in developing countries willnot simply appear if trade barriers comedown; they are unlikely to have thebusiness acumen to compete against longestablished competitors. “What can’t befixed is what does not exist, the widespreadpresence of scalable, self-sustaining enter-prise that forms the backbone of a diver-sified growing economy. Poor countriesneed to create more enterprise of all kindsif they are to escape poverty and take
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GLOBAL HEALTH
advantage of freer trade. But enterprisedoesn’t just pop up; it has to be nurtureden masse…. Success or failure will bedetermined by how good enterprise is atproducing, delivering, distributing,managing and innovating. This is themissing half of trade justice.” 7
Emergence of new playersHow have business sector approachesdeveloped? Looking at Hoffman’s ShellFoundation, (www.shellfoundation.org)this was set up in 2000, as an independentcharity, initially receiving an endowmentof some $250 million from Shell, theenergy company. This has been investeduntil 2012 after which time the annualincome is projected to be sufficient tosustain the Foundation’s activities.Currently it is receipt of an annual grant ofapproximately $12 million from Shell.
Working in partnership with local Africanbanks, it has provided a mixture ofcommercial and development expertise toover 120 pro-poor small and medium-sized enterprises (SMEs), together with thefinance and business support needed tohelp them grow. Projects are also beingdeveloped in India and Eastern Europeexploring how community enterprises canaccess national and international marketsand adapt to the rigours of competition.
Sustainability and scalability of projects isimportant. According to the Foundation’sCommunications Advisor, Simon Bishop,“if the Foundation invests in a project, it isinvesting in a model which should becapable of being replicated. The modelneeds to be proved to work, so that others,including the private sector will also buyin to this approach elsewhere.” He pointsto one of its current investments in clean,smokeless cooking technology to replacethe old wood burning stoves used in manyhomes.
Smoke in the home, it has long beenknown, can have a major detrimentalimpact on health. NGOs and governmentshave, however, largely failed to come upwith sustainable answers to this problem,or have simply given away clean tech-nology to small population groups. Theprivate sector may be interested in productdevelopment, but only if there is acommercially viable market, somethingnot really achieved to date. As Bishop says,“our solution is to bring the two sectorstogether, with a part commercial approach,which may need some seed capital to get itgoing.” NGO partners and communitygroups might then play a key role in the
distribution of new stoves, selling them ataffordable rates at a local level.
Similar ventures are developing all thetime. Well known players include theGrameen Bank and its sister GrameenFoundation, helping to provide loans,financial services and technology to helpthe poor develop self-sustaining businessesto escape poverty. The work of this Foun-dation on microfinance alone reaches 2.7million families in 22 countries.
The founders of the internet search engineGoogle, have also recently set up a foun-dation, Google.org, providing an endow-ment of some $1 billion and charged witha mandate to tackle poverty, disease andglobal warming. Their approach isdifferent from many existing foundations,in that it will be a for profit enterprise. Itwill help budding entrepreneurs and maywork in partnership with that muchmaligned element of capitalism, theventure capitalist. The for profit status ofthe company it is argued allows greaterflexibility, but says executive directorLarry Brilliant, the “emphasis is on socialreturns, not economic returns.”7 AlreadyGoogle.org has made over $7 million ingrants and investments across a range ofprojects including support for research inwestern Kenya to identify ways to preventchild deaths caused by poor water qualityand to better understand what works inrural water supply and literacy initiativesin India.
Google.org is also one of a number ofcorporate foundations that support theAcumen Fund, a not for profit organi-sation that amongst its activities looks formarket solutions to help improve access tohealth care products and services. TheFund, like many structures that make useof business expertise, seeks to reduce coststructures, making health care productsmore affordable or alternatively may lookat new pricing structures involving micro-financing or cross subsidisation of healthcare products. Improved mechanisms fordistribution can also help improve theaccessibility of health care products.
For instance, this Fund has invested in Ato Z Textile Mills, a Tanzanian manufac-turer that produces bednets impregnatedwith a long-lasting insecticide, makingthem effective for up to five years insteadof the usual six months, with no need forre-treatment.8 The Fund claims that A toZ has already found a more cost-effectiveway to weave the bednet, which isexpected to decrease the cost of production
from $7 to $5 and provide even moreaccess to the life-saving bednets. Expertisefrom the Fund is also being used to help inthe distribution of this net.
The impact is significant: these nets alreadyprotect more than five million people inthe country, with more than ten thousandnets sold privately. Moreover the mill hascreated over two thousand better paid jobsprimarily for women, helping to raise thestandard of living living for these workersand their families. Other investments madeby the Fund include support for acompany producing low cost solarpowered hearing aids across the devel-oping world and a retail micro-franchisedistribution network promoting betteraccess to essential drugs and basic healthservices in Kenya.
ConclusionsThere is potentially much to be gainedfrom ensuring that development policyputs more emphasis on economic growth,alongside traditional developmental aid.Historically there has been some distrustof private sector involvement; this appearsto be changing with genuine partnershipsbetween the public and private sectorsdeveloping.
Business must however also be moreproactive in recognising its social respon-sibilities, and making use of what it knowsbest – i.e. logistics and the supply chain tohelp promote economic development.Good examples can be seen, for instancethe Accenture Development Partnership,a non profit organisation whereconsultants from Accenture take time offfrom their core business and a substantialpay cut in order to work with internationalagencies such as UNICEF and the WorldBank. Despite such examples, theinvolvement of the business communityremains all too limited.
The European Union can play animportant role in terms of fostering greatercontributions from the European businesscommunity. In March 2006, the EuropeanCommission published a new Communi-cation on Corporate Social Responsibility(CSR), and through it, launched theEuropean Alliance for CSR – an umbrellanetwork for discussion and debate on newand existing CSR initiatives by largecompanies, SMEs and their stakeholders.9
This Communication recognises theimportance of the international dimensionof CSR and has a goal of maximising thecontribution of enterprises to theachievement of the UN Millennium
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GLOBAL HEALTH
Development Goals. The Commission willalso strengthen its cooperation with theInternational Labour Organisation topromote decent work, including through apilot project on trade and decent workindicators in developing countries.
One other recent positive developmentwas the first EU-Africa Business Forumunder the Finnish Presidency inNovember 2006. As Aapo Pölhö, DirectorGeneral, Department for Africa and theMiddle East, Ministry for Foreign Affairs,Finland, said in closing the conference,“from the perspective of broad-baseddevelopment as well as business, it is ofutmost importance to involve Africancountries so that they are genuinely able toparticipate in and benefit from the interna-tional commerce. We should supportAfrican countries in strengthening theiroverall trade capacity both in their North-South and South-South commerce.”10
Not all private sector involvementhowever is to be encouraged. Oneunwelcome development has been theemergence of so-called ‘vulture funds’.These are private sector companies thatbuy up the debt of poor nations cheaplywhen this is about to be written off andthen sue for the full value of the debt plusinterest – which might be many timesmore than what they paid for it. There aregrowing concerns that such funds arewiping out the benefits which internationaldebt relief was supposed to bring to poorcountries. One recent court action saw oneof these vulture funds suing Zambia for$42 million for a debt that the fund boughtfrom Romania for less than $4 million. TheEnglish High Court ruled in favour of theapplicant, although it is expected that the
judge will order Zambia to pay no morethan half of what was demanded.Nonetheless, this is still equivalent to halfof all the debt relief received by Zambia in2006.11 Coordinated international actionsto promote partnership with business tohelp make poverty history, while curtailingthe activities of the unwelcome elements ofcapitalism, are urgently needed.
REFERENCES
1.World Bank. Global Monitoring Report2006. Washington D.C: International Bankfor Reconstruction and Development/World Bank, 2006. Available online viawww.worldbank.org
2. United Nations General Assembly.Resolution adopted by the GeneralAssembly. 60/1 World Summit Outcome.New York: United Nations, 2005.Available at http://daccessdds.un.org/doc/UNDOC/GEN/N05/487/60/PDF/N0548760.pdf?OpenElement
3. Nichols M. UN says surge in attacks onDarfur aid workers. AlertNet, 5 February2007. Available at http://www.alertnet.org/thenews/newsdesk/N05476653.htm
4. Hoffman K. Aid Industry Reform andthe Role of Enterprise. London: ShellFoundation, 2005. Available athttp://www.shellfoundation.org/news_rel/Aid_industry_reform_and_the_role_of_enterprise.pdf
5. House of Commons InternationalDevelopment Committee. Private sectordevelopment. Fourth report of session2005–2006. Volume 1. London: TheStationery Office, 2006, HC-921-I.Available at http://www.publications.parliament.uk/pa/cm200506/cmselect/cmin
tdev/921/921i.pdf
6. Yunus M. Social business entrepreneursare the solution. Washington D.C:Grameen Foundation, 2006. Available athttp://www.grameenfoundation.org/pubdownload/~pubid=26
7. Hoffman K. Trade Your Way Out ofPoverty. London: Shell Foundation,September 2004. Available athttp://www.shellfoundation.org/index.php?articleID=28
8. Hafner K. Philanthropy Google’s way:not the usual. New York Times, 14September 2006.
9. Acumen Fund. A to Z Textile Mills –Long Lasting Anti-malaria Bednets.Acumen website, 2007. Available athttp://www.acumenfund.org/Work/HealthTechnology/Investments.asp
10. Commission of the European Commu-nities. Implementing the partnership forgrowth and jobs: making Europe a pole ofexcellence on corporate social responsi-bility. Brussels: Commission of theEuropean Communities, 2006 COM(2006) 136. Available at http://eur-lex.europa.eu/LexUriServ/site/en/com/2006/com2006_0136en01.pdf
11. Pölhö A. Connecting Two Continents:Opportunities for the EU’s Africa Strategy.Speech to EU-Africa Business Forum, 17November 2006. Available athttp://formin.finland.fi/public/default.aspx?contentid=83700&nodeid=15317&contentlan=2&culture=en-US
12. Jones M. Vulture Fund Threat to ThirdWorld. BBC Newsnight. London: BBC, 14February 2007. Available athttp://news.bbc.co.uk/1/hi/programmes/newsnight/6362783.stm
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GLOBAL HEALTH
International trends highlight the confluence ofeconomics, politics and legal considerations inthe health policy process. HEPL serves as aforum for scholarship on health policy issuesfrom these perspectives, and is of use toacademics, policy makers and health caremanagers and professionals.
HEPL is international in scope, and publishesboth theoretical and applied work. Considerable
emphasis is placed on rigorous conceptual development and analysis, and onthe presentation of empirical evidence that is relevant to the policy process.
The most important output of HEPL are original research articles, althoughreaders are also encouraged to propose subjects for editorials, reviewarticles and debate essays.
HEPL invites high quality contributions in healtheconomics, political science and/or law, withinits general aims and scope. Articles on socialcare issues are also considered. The recom-mended text-length of articles is 6–8,000 wordsfor original research articles, 2,000 words forguest editorials, 5,000 words for review articles,and 3,000 words for debate essays.
Instructions for contributors can be found atwww.cambridge.org/journals/hep/ifc
All contributions and correspondence shouldbe sent to: Anna Maresso, Managing Editor, LSE Health, London School of Economics andPolitical Science, Houghton Street, LondonWC2A 2AE, UK. Email [email protected]
Health Economics, Policy and Law
Eurohealth Vol 12 No 4 22
PUBLIC HEALTH PERSPECTIVES
After sixteen years of exemptions fromsection six of the Act on the prevention ofthe harmful effects of tobacco, anamendment to this so-called ‘Tobacco Act’introduced a smoke-free regime to allhospitality venues in Norway from 1 June2004.1 The previous regulations regardingthe provision of smoke-free areas withinbars, pubs, cafes and restaurants werethereby superseded by an absolute ban onsmoking indoors. The authorities’ mostimportant reason for revoking theseexemptions was to afford employees in thehospitality industry the same protectionagainst passive smoking as otheremployees had enjoyed since section six ofthe Tobacco Act came into effect in 1988.Furthermore, hospitality venues, nightclubs and the like were seen as animportant recruitment arena for smokingamong young people. Importance was alsoattached to the fact that numerous indi-viduals with asthma and allergies could notmake use of hospitality venues because ofthe problems they suffered as a result ofthe smoky atmosphere. Moreover, thehospitality industry was having difficultycomplying with existing regulations onsmoke-free areas.
The Standing Committee on Health andSocial Affairs in the Storting (Parliament)augmented by subsequent parliamentarydebate, expressed a desire for an evaluationof the smoking ban. The ban had beencontroversial and there was doubt withregards to the economic consequences forthe hospitality industry, as well as uncer-tainty associated with the general public’scompliance and satisfaction. The evalu-ation was to present results within threeyears and the Norwegian Institute forAlcohol and Drug Research (SIRUS)charged with its conduct. This would belinked to a broader evaluation of the State’stobacco prevention work in Norway.
Commercial impact on the hospitalityindustryAccording to the evaluation, value-addedtax (VAT) collected from the hospitalityindustry (restaurants, pubs and bars)increased by 5% in the first sixteen monthsafter the ban compared with same periodprior to its introduction.2 In the restaurantsegment of the industry, sales went up by6%, while typical taverns such as bars andpubs, which have significantly lower salesthan the restaurant industry, reported asmall downturn of 1%. VAT registrationshave seasonal variations, but there is aslight upward trend in taxes collected(Figure 1) in the period from 2003 to 2005.
The impact of smoke-freehospitality venues in Norway
Karl Erik Lund and Marianne Lund
Summary: In June 2004, Norway introduced an absolute ban on smoking in all hospitalityvenues. The main purpose of the ban was to protect employees in the hospitality businessfrom harmful exposure to tobacco smoke. This article focuses on the economic conse-quences of this policy for the hospitality industry and the public’s attitudes towards smoke-free hospitality venues. Evaluation suggests that the smoking ban has had a small positiveeffect on business. In addition, employees in the industry report better compliance withthis total ban on smoking compared with previous regulations which required theprovision of smoke-free areas. Among the general public, three quarters now support theban, with the most rapid increase in support observed in smokers.
Keywords: Smoking ban, hospitality industry, economic impact, public attitudes, Norway.
Karl Erik Lund is a Researcher andMarianne Lund an Adviser at theNorwegian Institute for Alcohol andDrug Research (SIRUS), Oslo, Norway.Email: [email protected]
Figure 1: Reported VAT from the hospitality industry, 2003–2005
Source: Statistics Norway. One term = 2 months.
No major changes have been observed inthe breweries’ sale of beer to food retailersfollowing the ban. This may indicate thatthe small decline in the licensed sale ofalcohol has not led to more consumptionof beer in private settings. Nor was anypattern observed regarding regional differ-ences in the sale of beer between thenorthern and southern parts of thecountry. The decline in beer sales washowever somewhat higher during thecoldest periods of the year.
Many conditions can affect the volume ofbeer served to guests at hospitality venues.These include price, customers’ purchasingpower, the weather, the price of beer fromalternative sources (retail price) and avail-ability (number of bars and businesshours). The Norwegian MeteorologicalInstitute reports that the first summer withsmoke-free dining was colder and wetterthan normal – except in the northernmostregions of the country. On the other hand,the summer before was warmer than usualin large parts of the country. It is thereforesurprising that the sales in the hospitalitybusiness went up. This may indicate thatthe ban on smoking has had a morepositive impact on sales than shown in ourresults.
In addition to sales statistics, data are alsoavailable from surveys (undertaken beforeand after the ban) on the public’s frequencyof patronage at hospitality venues. Nosignificant differences were observed inself-reported frequency of patronageamong smokers or non-smokers duringthe periods before and after the ban.
A longitudinal survey among hospitalityindustry staff indicated that no less than70% were of the opinion that the ban hadled to no (39%) or minor change (31%) inthe frequency of patronage at their place ofwork. Thus, these responses do not quitesupport what the sales statistics indicated,i.e. an increase of 5%. In fact, nearly one-third of the employees contended that theban had meant far fewer customers. Theresponses to this question were howeverstrongly influenced by the attitude ofemployees to smoke-free hospitalityvenues prior to the ban. Thus, similar toinformation on frequency of patronage,such data have limited validity. This surveyalso reported that the perception that jobswould be endangered were correlated withattitudes towards the ban.3
The number of bankruptcies in the hoteland restaurant industry increased moder-ately during the first two quarters after the
ban and then subsided. This increaseoccurred during a season in which thenumber of bankruptcies had already beenrising over previous years. Accordingly, itis not clear whether the observed increasewas related to the introduction of smoke-free hospitality venues. Employment in thehospitality industry displays seasonal vari-ations. A slight decrease in the number ofemployees was observed in the finalquarter of the year in which the ban wasintroduced, compared with the samequarter in the two preceding years.Employment has however since returnedto its normal level. It is also difficult to saywhether the temporary dip can be relatedto the ban.
A 5% increase in the revenues of theNorwegian hospitality industry subse-quent to the ban is however in line with theresults of a number of foreign surveys. Theliterature has consistently shown that theintroduction of smoke-free hospitalityvenues has had positive or little impact onretail sales in the industry. Most of thesesurveys have, nonetheless, been performedin locations (countries, states, cities) wherethe percentage of smokers has been lowerthan in Norway and where the climate iswarmer. With the somewhat lessfavourable starting point, it was thereforeperhaps rather surprising that the ban onindoor smoking has had such a limitedimpact on the revenues of the Norwegianhospitality industry.
Changes in satisfaction with hospitalityvenuesOne reason for the increase in sales may bedue to the fact that smokers failed to expe-rience their anticipated reduction in satis-faction. Prior to the ban, of those whosmoked on a daily basis, 69% and 55%respectively felt that their satisfactionwould be reduced when visiting smokefree pubs/bars and restaurants. Only amere 38% and 32% respectively, reportedan actual reduction in satisfaction eighteenmonths after the introduction of the ban.This indicates that the ban did not turn outto be as bad as smokers initially feared.The results must be seen in the light ofmoves by many in the hospitality industryto pave the way for outdoor smokingthrough several initiatives to raise satis-faction levels. Among non-smokers, 81%and 82%, respectively, reported a higherlevel of satisfaction with pubs/bars andrestaurants after the ban. One year afterthe ban, no fewer than three out of fourrespondents stated that they would retainsmoke-free hospitality venues if given a
hypothetical choice.
Changes in attitudes The general public’s attitude to passivesmoking has changed since the TobaccoAct was implemented in 1988, effectivelybanning smoking in all workplaces (butnot the hospitality business) and enclosedpublic areas. By the time hospitalityvenues became smoke-free in 2004, farmore people perceived passive smoking asa health hazard compared to the situationin 1988. Support for the ban has increasedsteadily. The most recent survey (June2006) indicated that three out of fourpeople were positive towards smoke-freehospitality venues.
The views of smokers and non-smokerswere largely in harmony about theTobacco Act in 1988, but by 2004 thereappeared to be considerable differences inviews on smoke-free hospitality venues. In2005, 84% of non-smokers were positivetowards smoke-free hospitality venues,while just 45% of those who smoked on adaily basis shared the same opinion. Twoyears earlier, however, only 25% ofsmokers were positive towards the idea, sosupport for smoke-free hospitality venueshas grown quickly, not least among thosein the most sceptical group. Steadilygrowing support for smoke-free hospi-tality venues has also been observed in anumber of international attitudesurveys.4–6
Changes in air qualityWhile just one out of ten guests reportedvery good indoor air quality in pubs/barsprior to the ban (when smoke-free areaswere provided), six out of ten reportedvery good air quality after its introduction.Similarly, the percentage reporting verygood indoor air quality at restaurants hasincreased from about 40% to 75%.Employees in the hospitality industry alsoreport a significant reduction in air qualityproblems at work, with reported problemsdue to second-hand smoke declining from44% to just 6% five months after the banwas enforced.7
Compliance and enforcementBefore it came into force, smokers hadalready suggested that they would have ahigh degree of compliance with the ban.Subsequently customers have not observedmany problems with the new smoke-freehospitality venues. Among those indi-viduals with the highest frequency ofpatronage to pubs/bars, a mere 3%observed any serious enforcement
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PUBLIC HEALTH PERSPECTIVES
problems during the regulation’s firsteighteen months. The comparable figurefor restaurants was just 2%. Even amongsmokers, only a very small percentage hadobserved or experienced any type ofenforcement problems. Staff reportedfewer unpleasant incidents and bettercompliance in enforcing a total smokingban compared with smoke-free areas.3
Other consequences Nearly half of all employees contendedthat one consequence of the ban was morenoise outside premises. However, this hasnot led to more complaints from neigh-bours. There were also reports of morecigarette butts on the street near the frontentrance to premises, but it was not clearwhether this represented a serious andunexpected problem. Employees pointedout that the advantages of the ban includedeasier cleaning of premises, a better state ofhealth, better air quality and work clothesthat did not reek of smoke.7
The evaluation has however shown thatsince the ban, the hospitality industry hasbecome a sales channel for snus (a Scandi-navian type of moist smokeless tobacco)and an arena for its use. It is likely that theban has accelerated the use of snus inNorway. It is also likely that the ban hasaccelerated the decline in the percentage ofsmokers among the general public,although it is difficult to isolate oneparticular effect. Among smokers, nearlyhalf those between the ages of eighteen totwenty reported that the ban had causedthem to cut back on cigarettes, but theresponses were biased by the attitudeyoung people had to the ban on smokingand are thus not entirely valid. However, asurvey from the USA showed that theprogression from experimentation tobecoming a regular smoker was signifi-cantly lower in regions with a ban onsmoking in hospitality venues.8 Our dataare however, not appropriate for deter-mining whether the ban has contributed tothe reduction in taking up smokingobserved in Norway in recent years.
REFERENCES
1. Directorate of Health and Social Affairs.Ot.prp.nr.23 (Proposition to the Odelsting)2002–2003. Concerning act regardingchanges in Act No.14 of March 1973relating to Prevention of the HarmfulEffects of Tobacco. (Smoke-Free Food andDrink Establishments). Oslo: Directorateof Health and Social Affairs, 2003.Available at: http://www.shdir.no/vp/multimedia/archive/00000/Whitepaper_
Proposition_655a.pdf
2. Lund KE. The introduction of smoke-free hospitality venues in Norway. Impacton revenues, frequency of patronage, satis-faction and compliance. Oslo: NorwegianInstitute for Alcohol and Drug Research(SIRUS), 2006: Series 2 (updated version).Available at: http://www.sirus.no/cwob-jekter/SIRUSskrifter0206eng.pdf
3. Hetland J, Aarö LE. Smoking habits,attitudes to and enforcement of the ban onsmoking in eating and drinking establish-ments – a prospective panel study. Oslo:Norwegian Institute for Alcohol and DrugResearch (SIRUS), 2005: Series 2. Availableat http://www.sirus.no/cwobjekter/SIRUSskrifter0205eng.pdf
4. Friis RH, Safer AM. Analysis ofresponses of Long Beach, California residents to the smoke-free bars law. PublicHealth 2005;119(12):1116–21.
5. Kottke TE, Aase LA, Brandel CL, et al.
Attitudes of Olmsted County, Minnesota,residents about tobacco smoke in restau-rants and bars. Mayo Clinic Proceedings2001;76(2):121–23.
6. Miller C, Wakefield M, Kriven S,Hyland A. Evaluation of smoke-freedining in South Australia: support andcompliance among community and restau-rateurs. Australian and New ZealandJournal of Public Health 2002; 26(1):38–44.
7. Hetland J, Aarö LE. Smokefree restau-rants and pubs: Air quality, self reportedhealth and job satisfaction. Oslo:Norwegian Institute for Alcohol and DrugResearch (SIRUS), 2005: Series 3. Availableat: http://www.sirus.no/cwobjekter/SIRUSskrifter0305eng.pdf
8. Siegel M, Albers AB, Cheng DM, BienerL, Rigotti NA. Effect of local restaurantsmoking regulations on progression toestablished smoking among youth. TobaccoControl 2005;14(5):300–6.
Eurohealth Vol 12 No 4 24
EUROPEAN SNAPSHOTS
Improving access to healthcare in Armenia
Erica Richardson
An increasing body of research indicatesthat ongoing health care reforms in thecountries that have emerged from theSoviet Union have had an impact on accessto health care in some parts of the region,including Armenia.1 Despite a declaredpolitical commitment and policy efforts toimprove access to health care for thosemost vulnerable groups, a recent survey bythe Armenian National Statistical Serviceindicates that there are still significantfinancial barriers to access for poor house-holds.2 According to household surveydata, only 40% of individuals from house-holds in the poorest quintile on the incomescale consult a doctor anywhere in thehealth system when they are very ill,compared with 80% of households in the
richest quintile.2 This low level of accesshas remained stable since independencewas gained in 1991.3
Falling utilisation ratesHealth care utilisation rates in Armeniaremain some of the lowest in the post-Soviet region, with only Georgia experi-encing lower levels of utilisation.Inequalities in health service utilisation aresignificant. Estimates in 2001 indicate thatthe poorest 20% of the populationconsumed just 16% of primary health careservice resources and 13% of hospital careresources, compared with 28% and 43%respectively by the wealthiest 20%.3
Before independence, when Armenia wasstill a part of the Soviet health care system,it is likely that there was significant over-utilisation of health services, becauseexcessive use of inpatient care was onefeature of the Semashko system – withfunding dependent on a high level ofactivity and bed occupancy. However,
Erica Richardson is Research Officer,European Observatory on Health Systemsand Policies, London School of Hygieneand Tropical Medicine. Email: [email protected]
current utilisation rates in Armenia arenow significantly lower than in the rest ofEurope, for example, in 2002 outpatientcontacts per person per year in Armeniawere 2.06, while the Commonwealth ofIndependent States (CIS) average was 8.84and that of the EU 6.68.4 This wouldsuggest that the low utilisation rates aredue to problems in accessing servicesrather than merely a ‘balancing out’following reforms to the Semashkosystem.5
Provisions for vulnerable groupsArmenia suffered acute economicproblems following the collapse of theSoviet Union. State funding for health careall but ceased and service provision wasessentially privatised as hospitals anddoctors were allowed to generate revenuesby selling services to the public.5 The fee-for-service nature of the system wasformalised in 1997 with the introductionof social health insurance with a statefinanced Basic Benefits Package (BBP) tocover most health care for vulnerablegroups (such as military or labourveterans, orphans, lone-parents or largefamilies, disabled children, etc.) as well asspecific public health concerns includingtuberculosis, sexually transmitted infec-tions and HIV/AIDS).3
However, the BBP does not yet functionas an adequate safety net for thesevulnerable groups, partly because eligi-bility criteria have not remained stable;moreover the means of demonstratingeligibility has also changed on an almostannual basis.3 This confusion meant thatneither patients nor providers knew whowas covered or for what, so charges werelevied on patients anyway, particularly asthe BBP does not cover the full servicecosts for providers.3
The problem of informal paymentsIn Armenia approximately 65% of healthcare expenditure is made through out-of-pocket payments.3 These can be formal co-payments, from which especiallyvulnerable groups are exempt or straight-forward fee-for-service charges for‘private’ care. However, many out-of-pocket payments in Armenia take the formof informal payments, including bribes andgratuities, which are levied at all levels ofthe system and by the full range of healthcare personnel.
Informal payments have arisen from aspecific set of circumstances, which are byno means unique to Armenia. In addition
to costs not being fully reimbursedmeaning that patients pay the difference,medical personnel receive such low wagesas to necessitate supplementary income.The informal payment system has grownout of the common practice in the Soviethealth care system of giving gratuities –partly as an acknowledgement of this lowpay of health care personnel, but also as asimple way of thanking staff.
Greater political commitment neededThere is evidence that the introduction ofthe BBP and subsequent changes toimprove coverage have had a positiveimpact on the level of out-of-pocketpayments – both formal and informal –that very poor families have to pay.However, this has not significantlyimproved access rates as out-of-pocketpayments for services are only part of thefinancial burden; the cost of pharmaceu-ticals at all levels of the system is alsoprohibitively expensive for the very poor.5
There is no shortage of policy documentsto address the problem of access to healthcare and there has been considerable inter-national assistance in developing pro-poorstrategies.3 However, policy implemen-tation remains a serious problem. Forth-coming elections for both the Parliament
(May 2007) and the Presidency (February2008) are likely to mean that the attentionof political actors will be elsewhere.
REFERENCES
1. Balabanova D, McKee M, Pomerleau J,Rose R, Haerpfer C. Health serviceutilization in the Former Soviet Union:evidence from eight countries. HealthServices Research 2004;39(6):1927–50.
2. National Statistical Service of theRepublic of Armenia, World Bank. SocialSnapshot and Poverty in Armenia. Yerevan:National Statistical Service of the Republicof Armenia, 2006. Available at:http://www.armstat.am/Publications/2006/PV_04/index.html
3. Hakobyan T, Nazaretyan M, MakarovaT, Aristakeysan M, Margaryants H, NolteE. Armenia: health system review. HealthSystems in Transition 2006;8(6):1–180.Available at: http://www.euro.who.int/Document/E89732.pdf
4. World Health Organization. Health forAll Database. Copenhagen: WHORegional Office for Europe, 2006.
5. Angel-Urdinola DF, Jain S. Do Subsi-dized Health Programs in ArmeniaIncrease Utilization Among the Poor?Washington: World Bank, Policy ResearchWorking Paper 4017, September 2006.
Eurohealth Vol 12 No 425
EUROPEAN SNAPSHOTS
Ireland’s grey vote growsbolder
Anne Dempsey
The run up to the May 2007 generalelection in the Irish republic has galvanisedmany of the usual suspects into action.Both sitting and aspiring parliamentarianshave been jostling for media space,constituency clinics are being assiduouslymanaged, and candidate leaflets aredropping on hall mats round the country.
Amidst this traditional clamour, a newvoice has emerged. The ‘Older & Bolder’campaign, launched in November 2006,brings together a number of organisationswho work in the ageing sector, aiming toseek from all parties and candidates acommitment for a National Strategy forOlder People.1 It is the first such coordi-nated campaign, and a timely one whenolder people in Ireland, as elsewhere, areliving longer than ever before, providingopportunity and challenge in equal parts.
While Ireland is normally portrayed as ayoung, thrusting country, our ageingfigures are compelling. According to the
Anne Dempsey is a writer and journalistspecialising in health and social issues. Shealso a counsellor and a trainer in healthpromotion and is based in Greystones, Co Wicklow, Ireland. Email: [email protected]
2002 Census,2 there are 436,000 peopleaged 65 and over, representing 11% of thepopulation. The National Council onAgeing and Older People (NCAOP)predicts this will rise to 15% by 2021,3
with other research anticipating the over-65s being one in four by 2050. Set againstthe 1900s when older people in Irelandnumbered one in 25, this represents a hugedemographic change in 100 years.
This increased longevity is a result ofimproved living conditions and medicaladvances. However, many people see thegreying population as a demographic timebomb rather than demographic bounty.Ireland is no different from other westerncountries in being ageist.
Ageism characterises older people as aproblem to be solved, rather than aresource to be celebrated. Ageism assumesthat somehow people are worth less asthey age, and is based on fear, myth andinaccurate assumptions about what it maybe like to be older. One of ageism’s mostworrying aspects is that it is sociallyacceptable. Discrimination on the basis ofage is rarely challenged because manypeople either don’t think about it, orregard it as the natural order of things.
Age-related barriersSuch ageist attitudes are translated intopublic policy in terms of income,employment, discrimination and, ofcourse, in access to health services. Whileholistic health at all ages is also affected byliving conditions, income levels, socialconnectivity and feelings of being valued,the NCAOP’s 2005 ‘Perceptions ofAgeism in Health and Social Services inIreland’4 identified a series of age-relatedbarriers. These include:
– The upper age limit of age 64 for accessto Breastcheck, a cancer-screeningservice, despite the fact that post-menopausal women may be more atrisk of contracting breast cancer.
– The lack of stroke rehabilitationservices for the over 65s in some HealthService Executive (HSE) areas – whenagain strokes are more prevalent in theolder population.
– The limit of age 82 in one health area foraccess to cardiac services, while inothers, the suspicion of rationing byage.
– An unwritten policy of prioritisingyounger people for intensive care.
– An absence in one health area of
aggressive oncology treatment for olderpeople with cancer.
CampaignOlder & Bolder is spearheaded by fivenational organisations – Age ActionIreland, Age and Opportunity, the IrishHospice Foundation, the Irish SeniorCitizen’s Parliament and the Senior HelpLine – coming together under a unifiedbanner. The campaign began with anational billboard initiative. It showed thehead and shoulders of an older personpictured large, with a similar figure of ayounger person in the background. Theslogan reads ‘Ageism: We’re both gettingolder. But which one of us have you justwritten off?’
A key campaign aspect is giving olderpeople a voice. Accordingly, awarenessmeetings were organised round thecountry with groups of older people.Thousands of postcards were distributedinviting them to sign, stamp and return tocampaign headquarters for presentation tothe Irish parliament – another media eventin early January which made the frontpages. Older people have received mediatraining supporting them to talk publiclyabout their own experiences and concerns.
During winter 2007 a series of publicmeetings are being held between groups ofolder voters and their public representa-tives, with mutual listening and discussion.In a particularly imaginative move, alaminate card with questions for canvasserswho call to the door looking for votes havebeen made available to householders.Sample questions include:
1. What are your views on the rights ofolder people?
2. What are your party’s policies in relationto older people?
3. What do you plan to do for older peoplein this constituency?
4. Will you consult with older people ontheir issues?
5. Will your party support the devel-opment of a National Strategy for OlderPeople if you get into government?
Position paperIn a position paper commissioned by thecampaign, Professor Eamon O’Shea, of theIrish Centre for Social Gerontology,National University of Ireland at Galway,5
set out a sense of what a New Strategy forOlder People in Ireland might look like.An important goal should be to increase
healthy life expectancy for the over 65s,with an expanded role here for a proactivehealth promotion programme aimed atolder people.
Prevention and early disease protection inprimary care settings would include actionon falls prevention, pain relief for arthritissufferers, early intervention for peoplewith sensory disabilities, early diagnosis ofdementia, support for carers, and equalaccess to relevant screening programmes.
Specifically, he suggested it should ensurethat:
– All government policies are age-proofed to remove discriminationagainst older people.
– Clear and consistent legislation on therights and entitlement of older people isdeveloped.
– Equality legislation is developed andstrengthened.
– A proactive programme of informationand provision is put in place to ensurethat older people know what theirrights and entitlements actually are.
A central aim of the Strategy should be topromote independent living of olderpeople in their own communities for aslong as possible, with the consequentimplications for social care provision,access to public transport, social connect-edness, and more research on technologysupported-housing.
REFERENCES
1. Older and Bolder website:http://www.olderandbolder.ie
2. Central Statistics Office. Census 2002:Volume 2, Ages and Marital. Dublin:Stationery Office, 2005.
3. National Council on Ageing and OlderPeople. An Age Friendly Society: A PositionStatement. Dublin: National Council onAgeing and Older People, 2005.
4. National Council on Ageing and OlderPeople. Perceptions of Ageism in Healthand Social Services in Ireland. Dublin:National Council on Ageing and OlderPeople, 2005.
5. O’Shea E. Towards a National Strategyfor Older People in Ireland. Position Paper.Galway: Irish Centre for Social Gerontology, National University ofIreland, Galway, 2006.
Eurohealth Vol 12 No 4 26
EUROPEAN SNAPSHOTS
Mention managed care to a Canadian,and he may tell you that it’s one of thebest reasons to stick with publicmedicare. Large, impersonal health main-tenance organisations (HMOs) loomlarge in the Canadian imagination, andAmerican style managed care oftenbrings to mind only the bad — reducedchoice of physicians, limits on whatservices are covered, and delays in ordenial of care being prime examples.
But it turns out managed care is getting abit of a bad rap. While no health caresystem is perfect, some Americanmanaged care organisations have madestrides in many areas, such as improvingchronic and preventive care, reducinghospital use, and improving physicianpractice.
Managed care 101Managed care refers to a wide variety ofhealth care systems, some of whichcontrol costs largely by contracting withphysicians for reduced fees and byrestricting the patient’s choice of physi-cians. Managed care includes healthmaintenance organisations, which eitherdirectly employ doctors or contract withgroups of clinicians to provide services.
Patients are usually required to have oneprimary care physician or physiciangroup to pre-authorise tests, visits tospecialists, and other services for care tobe covered by insurance. Particularly inHMOs, savings achieved through moreefficient use of services like hospitals andmagnetic resonance imaging (MRI) testscan be shared with the clinicians.
Managed care organisations often put a
strong focus on managing chronicillnesses and providing preventive care, inthe hope of avoiding costly acute carelater on. For example, in 1996 KaiserPermanente, the largest health mainte-nance organisation in the United States,1
created an integrated diabetes caremanagement programme. Kaiser used thebest evidence available to developtreatment guidelines and, working collab-oratively with its physicians, implement aplan that improved screening and controlof blood sugar levels for its diabeticpatients.2
Another innovation that is becomingwidely used is the ‘chronic care model’developed by Group Health Cooper-ative, a non-profit HMO based in Seattle.The model identifies six ‘pillars’ of goodchronic care, including having health careorganisations link with communityresources and teaching patients good self-management skills. Studies of health careorganisations that have implementedcomponents of the model show improve-ments in the care provided to chronicpatients.3,4
Finally, studies of the American VeteransAffairs health system have founddramatic improvements in treatment forchronic care since it reorganised itselfalong the lines of a managed care organi-sation in the mid-1990s. Examplesinclude treating diabetes and high bloodpressure and screening for and treatingdepression.5–7
Some managed care organisations also dowell in preventive care. Studies havelooked at health maintenance organisa-tions, the Veterans Health Adminis-tration, and Medicare’s managed careoption, which allows senior citizens touse their Medicare benefits to enrol in amanaged care health plan and typicallyreceive more benefits than they wouldunder the traditional fee-for-serviceoption. They show higher levels of
Mythbusters
Eurohealth Vol 12 No 427
Myth: Managed care = mangled care
Mythbusters are prepared by Knowledge Transfer and Exchange staff at theCanadian Health Services Research Foundation and published only after review bya researcher expert on the topic.
The full series is available at www.chsrf.ca/mythbusters/index_e.php. This paper was first published in 2005. © CHSRF, 2005.
Eurohealth Vol 12 No 4 28
A series of essays by the Canadian HealthServices Research Foundation on the evidencebehind healthcare debates
preventive services, such as vaccinations,counselling to quit smoking, screeningfor various cancers, and regular bloodpressure checks.6–11
Show me the moneySince a hospital is usually the mostexpensive place to treat someone,managed care organisations (and indeedall health systems) look for ways to carefor patients in non-acute settings whilestill giving them the best care possible.While it is always difficult to comparedifferent hospital populations, theVeterans Affairs system reduced bed-dayrates by 50% over four years after itsreorganisation, with no change in patientmortality, and bed-day use in the EnglishNational Health Service is three and ahalf times that of Kaiser’s rate.12,13
Finally, an extensive study of theAmerican health system found moreinappropriate hospital admissions amongfee-for-service patients than amongpatients of Group Health Cooperative.14
Improving performanceOne final aspect of managed care that isworth noting is its focus on providingdoctors with feedback on theirperformance. While this information isused to determine which physicians costthe system the most (in terms of orderingtests, sending patients to specialists, etc.)and for bonus payments, it is also usedfor quality management. Doctors know ifthey are meeting benchmarks for theproportion of patients screened forcancer or given a flu vaccine, forexample.2,15 Those working in managedcare organisations are far more likely toreceive this information than physiciansin other types of practice.16
ConclusionManaged care organisations want to getthe most out of every dollar, as dopurchasers in other health care systems.While this can sometimes result in undesirable strategies that are well-documented in the popular media, it also
means managed care organisationsprimarily offer services that have strongevidence of effectiveness. While require-ments to see only one physician orphysician group and less hospital use areseen as negatives by many patients, inno-vative managed care organisations findcreative and effective ways to preventillness and complications, enhancing theirpatients’ health while at the same timebeing financially responsible.
REFERENCES
1. Baumgarten A. California HealthcareMarket Report 2005. Oakland: CaliforniaHealthCare Foundation, 2005. Availableviahttp://www.chcf.org/topics/download.cfm?pg=hospitals&fn=CAHealthCareMar-ketRep2005%
2. Stiefel M, Rothert K, Crane, R, CaplanW, Pettay H. Kaiser Permanente’s nationalintegrated diabetes care managementprogramme. In: Informing judgment:Case studies of Health Policy andResearch in Six Countries. New York:Milbank Memorial Fund, 2001. Available athttp://www.milbank.org/2001cochrane/010903cochrane.html
3. Bodenheimer T, Wagner EH, GrumbachK. Improving primary care for patientswith chronic illness. Journal of theAmerican Medical Association2002;288(14):1775–79.
4. Bodenheimer T, Wagner EH, GrumbachK. Improving primary care for patientswith chronic illness: The chronic caremodel, part 2. Journal of the AmericanMedical Association 2002;288(15):1909–14.
5. Kerr EA, Gerzoff RB, Krein SL, et al.Diabetes care quality in the VeteransAffairs health care system and commercialmanaged care: The TRIAD study. Annalsof Internal Medicine 2004;141(4): 272–81.
6. Jha AK, Perlin JB, Kizer KW, DudleyRA. Effect of the transformation of theVeterans Affairs health care system on thequality of care. New England Journal ofMedicine 2003; 348(22):2218–27.
7. Asch SM, McGlynn EA, Hogan MM, etal. Comparison of quality of care forpatients in the Veterans Health Adminis-tration and patients in a national sample.Annals of Internal Medicine2004;141(12):938–45.
8. Rizzo JA. Are HMOs bad for healthmaintenance? Health Economics2005;14(11):1117–31.
9. Weinick RM, Beauregard M. Women’suse of preventive screening services: Acomparison of HMO versus fee-for-serviceenrollees. Medical Care Research andReview 1997;54(2):176–99.
10. Wilson NJ, Kizer KW. Oncologymanagement by the ‘new’ Veterans HealthAdministration. Cancer 1998;82(10supplement):2003–9.
11. Landon BE, Zaslavsky AM, BernardSL, Cioffi MJ, Cleary PD. Comparison ofperformance of traditional Medicare vsMedicare managed care. Journal of theAmerican Medical Association2004;291(14):1744–52.
12. Ashton CM, Souchek J, Petersen NJ, et al. Hospital use and survival amongVeterans Affairs beneficiaries. NewEngland Journal of Medicine2003;349(17):1637–46.
13. Ham C, York N, Sutch S, Shaw R.Hospital bed utilisation in the NHS, KaiserPermanente, and the US Medicareprogramme: Analysis of routine data.British Medical Journal2003;327(7426):1257–61.
14. Newhouse JP, Insurance ExperimentGroup. Free for all? Lessons from theRAND Health Insurance Experiment.Cambridge: Harvard University Press,2003.
15. Kizer KW. The ‘new VA’: A nationallaboratory for health care qualitymanagement. American Journal ofMedical Quality 1999;14(1):3–20.
16. Rittenhouse DR, Grumbach K, O’NeilEH, Dower C, Bindman A. Physicianorganisation and care management in California: From cottage to Kaiser. HealthAffairs 2004;23(6):51–62.
Evidence-Based Medicine (EBM) is the processof systematically reviewing, appraising and usingclinical research findings to aid the delivery ofoptimum clinical care to patients.2
Increasingly, purchasers are looking to thestrength of scientific evidence on clinical practiceand cost-effectiveness when allocating resources.They are using this information to encourageGPs and NHS trusts to adopt more clinicallyeffective and cost-effective practices.
EBM forms part of the multifaceted process ofassuring clinical effectiveness, the main elementsof which are:
– Production of evidence through research andscientific review.
– Production and dissemination of evidence-based clinical guidelines.
– Implementation of evidence-based, cost-effective practice through education andmanagement of change.
– Evaluation of compliance with agreed practiceguidance and patient outcomes – this processincludes clinical audit.
The logic behind EBMTo make EBM more acceptable to clinicians andto encourage its use it is best to turn a specifiedproblem into answerable questions by examiningthe following issues:
– Person or population in question.
– Intervention given.
– Comparison (if appropriate).
– Outcomes considered.
For example: Is an elderly man given nicotinepatches more likely to stop smoking than asimilar man who is not?
Next, it is necessary to refine the problem intoexplicit questions and then check to see whetherthe evidence exists. But where can we find theinformation to help us make better decisions?The following are all common sources:
– Personal experience, for example, a bad drugreaction.
– Reasoning and intuition.
– Colleagues.
– Bottom drawer (pieces of paper lying aroundthe office, etc).
– Published evidence.
It is only by concentrating on the final categorythat ineffective, dangerous or costly interventionscan be reduced.
Analysing informationIn using the evidence it is necessary to:
– Search for and locate it.
– Appraise it.
– Store and retrieve it.
– Ensure it is updated.
– Communicate and use it.
Every clinician strives to provide the bestpossible care for patients. However, given themultitude of research information available, it isnot always possible to keep abreast of currentdevelopments or to translate them into clinicalpractice. One must also rely on published papers,which are not always tailored to meet the clin-ician’s needs.
Forms of evidenceEvidence is presented in many forms, and it isimportant to understand the basis on which it isstated. The value of evidence can be rankedaccording to the following classification indescending order of credibility:
I. Strong evidence from at least one systematicreview of multiple well-designed randomised
Eurohealth Vol 12 No 429
What is Evidence-Based Medicine?
The primary purpose of the English NHS is “… to secure, through resources available, the greatestpossible improvement in the physical and mental health of the [population]“.1 To achieve this,decisions about the delivery and provision of healthcare are increasingly being driven by evidenceof clinical and cost-effectiveness as well as systematic assessment of actual health outcomes.
Evidence-based health care
Bandolier is an independent monthly journal about evidence-based healthcare,written by Oxford scientists. Articles can be accessed at www.jr2.ox.ac.uk/bandolier
This paper was first published in 2001. © Bandolier, 2001.
Jonathan Belsey,
Independent
Medical Adviser
and
Tony Snell, Medical
Adviser, East Kent
Health Authority
controlled trials.
II. Strong evidence from at least oneproperly designed randomised controlledtrial of appropriate size.
III. Evidence from well-designed trialssuch as non-randomised trials, cohortstudies, time series or matched case-controlled studies.
IV. Evidence from well-designed non-experimental studies from more than onecentre or research group.
V. Opinions of respected authorities, basedon clinical evidence, descriptive studies orreports of expert committees.
Critical appraisalFor any clinician, the real key to assessingthe usefulness of a clinical study and inter-preting the results to an area of work isthrough the process of critical appraisal.This is a method of assessing and inter-preting the evidence by systematicallyconsidering its validity, results and rele-vance to the area of work considered.
The Critical Appraisal Skills Programme,based at the Oxford Institute of HealthServices, helps health service professionalsand decision-makers develop skills inappraising evidence about clinical effec-tiveness. Its process uses three broad issuesthat should be considered when appraisinga review article:
– Are the results of the review valid?
– What are the results?
– Will the results help locally?
Meta-analysesSometimes research findings maycontradict each other and obscure the truepicture – this is particularly the case withsmall trials. However, by pooling togetherall the results of various research studies,the sample size can, in effect, be increased.This is known as meta-analysis.
Although pooling together the results of anumber of trials will provide a greaterweight of evidence, it is still important toexamine meta-analyses critically:3
– Was a broad enough search strategyused? MEDLINE, for instance, coversonly about a quarter of the world’sbiomedical journals.
– Do the results all or mostly point in thesame direction? A meta-analysis shouldnot be used to produce a positive resultby averaging the results of, say, fivetrials with negative and ten trials with
positive findings.
– Are the trials in the meta-analysis allsmall trials? If so, be very cautious.
Practical examples of EBMEBM is not a purely academic or financialexercise – its implementation has majorclinical implications that can save lives.
1. Deep vein thrombosis and pulmonaryembolism
Deep vein thrombosis (DVT) of the lowerlimb and pulmonary embolism are majorcauses of death and disability; clinicallyrecognised DVT and/or pulmonaryembolism occurs in about 2/1,000 personseach year. It is estimated that postsurgicalDVT and pulmonary embolism cost theNHS in excess of £200m each year. Despitethe fact that the major risk factors for DVT(age, immobility and certain forms ofsurgery) are well known, only 46% ofhigh-risk patients receive any form of peri-operative prophylaxis.4
Subcutaneous heparin has, in recent years,become the prophylactic treatment ofchoice for surgical procedures, based inpart on the findings of a systematic reviewof the evidence.5 By comparing resultsfrom over 70 clinical trials of heparin, theauthors were able to demonstrate asubstantial benefit in patients undergoinggeneral, orthopaedic and urologicalsurgery. Based on this calibre of evidence,the Thromboembolic Risk Factors(THRIFT) Consensus Group6 recom-mends the following measures for prophy-laxis:
All hospital inpatients: should be assessedfor clinical risk factors and overall risk ofthromboembolism; should receiveprophylaxis according to degree of riskbefore discharge.
Low-risk patients: should be mobilisedearly.
Moderate- and high-risk patients: shouldreceive specific prophylaxis; should bemobilised early.
Clinicians, units and hospitals: shoulddevelop written policies for prophylaxis;should include prophylaxis in clinical auditand patient care plans.
Efficacy of prophylactic methods: should beassessed in outpatients; more recently,studies have suggested that the use of lowmolecular weight heparin (LMWH) couldbe associated with an improved outcome,compared with unfractionated heparin.The higher unit cost of LMWH, however,
means that healthcare purchasers havequeried whether this benefit is real and itsmagnitude sufficiently great to warrant theadditional investment.
A further systematic review7 hasconfirmed not only that LMWHs areeffective prophylactic agents in postoper-ative thromboembolic disease but thatthey are significantly more effective inpreventing DVTs than standard forms ofheparin. Indeed, an economic evaluation ofthe use of one LMWH (enoxaparin) inelective hip replacement8 estimates that anet saving of £20 could be made for everypatient treated prophylactically with theLMWH. This increased efficacy, combinedwith ease of administration on an outpa-tient basis, promises considerable savingsin secondary care expenditure.
2. Influenza vaccination
Significant hospitalisation and 3–4,000deaths are attributed to influenza each yearin the UK. More than 85% of these deathsare people over 65 years, and in epidemicyears the death toll is even higher. Inaddition, people with underlying chronicconditions are at higher risk of seriousillness or death through influenza.
A comprehensive review,9 based on acomparison of 8,000 vaccinated and 20,000unvaccinated patients, indicated that theinfluenza vaccine is highly effective andthat cases of respiratory illness, pneu-monia, hospitalisations and mortality werereduced by over 50% in institutionalisedelderly people. It recommends that peopleover 65 should be considered for influenzavaccination and that, in particular, thosewith chronic disease and resident innursing and residential homes should betargeted.
Sources of informationThere are many sources of information toinform clinical practice, and a full referencepack has been produced by the NHS Exec-utive.10 Some sources are listed here:
The Cochrane CollaborationAn international endeavour in whichpeople from many different countriessystematically find, appraise and reviewavailable evidence from randomisedcontrolled trials (RCTs). There are twocomponents of the Cochrane Collabo-ration: Cochrane Centres (currently tenworldwide) and Collaborative ReviewGroups. The UK Cochrane Centre issuesfour regularly updated databases on CD-Rom, available from BMJ Publishing: TheCochrane Database of Systematic Reviews
Eurohealth Vol 12 No 4 30
EVIDENCE-INFORMED DECISION MAKING
(CDSR); The York Database of Abstractsof Reviews Of Effectiveness (DARE); TheCochrane Controlled Trials Register(CCTR); The Cochrane Review Method-ology Database (CRMD).
The NHS Centre for Reviews andDisseminationCRD is based at the University of York,produces:
– Effective Health Care bulletins, basedon a series of systematic reviews andsynthesis of research on clinical andcost-effectiveness.
– Effectiveness Matters bulletins,summarising the results of importantsystematic reviews of research onspecific clinical topics.
– Systematic Reviews of ResearchEvidence – CRD reports.
The National Research Register A database of information about researchand development projects relating to theNHS. Available to all through theDepartment of Health and on the DHwebsite.
The NHS R&D Programme standinggroup on Health Technology Assessment This group reports on the effectiveness ofthe latest health technologies. Eachregional office has a brief to set upadvisory groups and implement the R&Dpriorities identified as part of the national
programme.
The Centre for Evidence Based Medicineat the University of Oxford, the ClinicalEffectiveness Group for Wales based inCardiff and the Clinical Resources andAudit Group (CRAG) at the ScottishOffice in Edinburgh provide advice onvarious effectiveness matters.
MEDLINE and EMBASEElectronic databases drawing data fromkey publications worldwide. Available atmost medical libraries, on CD-Rom or viathe internet.
An increasing range of journals and periodicalsThese include Bandolier, British MedicalJournal, Journal of Evidence BasedMedicine and Health Trends.
The National Primary Care Research andDevelopment Centre Based in Manchester, this is a collaborationbetween the Universities of Manchester,Salford and York disseminating researchon primary care policy and practice.
REFERENCES
1. Department of Health. PromotingClinical Effectiveness: A Framework forAction in and through the NHS. London:Department of Health, 1996.
2. Rosenberg W, Donald A. Evidence-based medicine: an approach to clinical
problem solving. British Medical Journal1995;310(6987):1122–26.
3. Oxman AD et al. Users’ guides to themedical literature, VI. How to use anoverview. Journal of the American MedicalAssociation 1994;272(17):1367–71.
4. Griffin J. Deep Vein Thrombosis andPulmonary Embolism. London: Office ofHealth Economics, 1996.
5. Collins R et al. Reduction in fatalpulmonary embolism and venous throm-bosis by perioperative administration ofsubcutaneous heparin. New EnglandJournal of Medicine 1988;318:1162–73.
6. Thromboembolic Risk Factors(THRIFT) Consensus Group. Risk of andprophylaxis for venous thromboembolismin hospital patients. British Medical Journal1992;305:567–74.
7. Leizorovicz A et al. Low molecularweight heparin in prevention of perioperative thrombosis. British MedicalJournal 1992;305:913–20.
8. Drummond M et al. Economic evalu-ation of standard heparin and enoxaparinfor prophylaxis against deep vein throm-bosis in elective hip surgery. British Journalof Surgery 1994;81:1742–46.
9. NHS Centre for Reviews and Dissemi-nation, University of York. Influenzavaccination and older people. EffectivenessMatters 1996;2(1).
10. Department of Health Reference Pack.Clinical Effectiveness. London: DH, 1996.
Eurohealth Vol 12 No 431
EVIDENCE-INFORMED DECISION MAKING
New publications from the Observatory
Decentralization in health care
Edited by Richard Saltman, VaidaBankauskaite, Karsten Vrangbaek
Open University Press, December 2006 352 pages£25.99 Softback, £70.00 Hardback
This new book maps the current state of policy, service provision andfunding for mental health care across Europe, taking into account thediffering historical contexts influencing the development of services andthe ways in which they are delivered. A holistic approach is adopted,looking not only at mental health care services, but also at the influenceof environmental factors such as housing, poverty, employment, socialjustice, and displacement on mental health.
More information at http://www.euro.who.int/observatory/Publications/20070209_1
Mental health policy andpractice across Europe
Edited by Martin Knapp, David McDaid,Elias Mossialos, Graham Thornicroft
Open University Press, December 2006 488 pages £25.99 Softback, £70.00 Hardback
This new book explores the capacity and impact of decentralisationwithin European health care systems. It examines both the theoreticalunderpinnings as well as recent practical experiences, and assesses theappropriateness of management processes within health systems forimplementing a successful decentralisation strategy.
More information at http://www.euro.who.int/observatory/Publications/20070223_1
Eurohealth Vol 12 No 4 32
NEW PUBLICATIONS
Halting the brain drain. Why we need totackle global mercury contamination
Génon Jensen and Karolina Ruzickova
Health & Environment Alliance and HealthCare Without Harm, December 2006
40 pages
Freely available at: http://www.env-health.org/r/145
This report published by the ‘Stay Healthy,Stop Mercury’ campaign explains the rela-tionship between mercury and health;where mercury pollution comes from; themeasures that are already in place inEurope to control mercury; and what elseneeds to be done. The campaign is coordi-nated by two international health nongovernmental organisations, the Health &Environment Alliance and Health CareWithout Harm. The campaign aims to raiseawareness of a potential ‘child brain drain’taking place in Europe and around theworld as a result of environmental mercurypollution. It calls on the European Unionto show leadership in efforts to controlenvironmental mercury pollution bysecuring a global ban on mercury.
The report provides the results of a small-scale study in 21 countries that suggests
one in six women has a level of mercuryabove a widely-accepted recommendedsafety dose. This safety dose has beenrevised downward over the years and somestudies indicate that it should be muchlower. The campaign has also produced aseries of fact sheets that examine the impli-cations of mercury in health care and issuesincluding vaccines, dental amalgams, andfish consumption. Each fact sheet providesrecommendations to address the problem,and are available free for download.
Contents: Preface; Executive summary; 1. How does mercury affect our health?; 2. Mercury pollution – where does it comefrom?; 3. Mercury control – how far havewe come?; 4. Conclusion and recommen-dations; Annex 1: The testing protocol;Annex 2: Hair sample results, mean valuesper country; References.
Health Impact Assessment Guidance
Owen Metcalfe, Claire Higgins, CathalDoyle and Stephen McDowell
The Institute of Public Health in Ireland,April 2006
ISBN 0-9542316-2-7
44 pages
Freely available at:http://www.publichealth.ie/getFile.asp?FC_ID=424&docID=581
Developed by the Institute of PublicHealth in Ireland on behalf of the Minis-terial Group on Public Health (MGPH) inNorthern Ireland, this document describesHealth Impact Assessment (HIA) and thesteps involved in HIA. It gives advice basedon the experience of HIA practitioners andprovides tools to help carry out these stepsand adapt HIA to local circumstances. Itaims to provide a user friendly and prac-tical framework to guide not only policy-makers, but those developing specificproposals through the HIA process and toenable them to undertake a HIA.
The Investing for Health Strategy,launched in March 2002, sets out how thehealth and well-being of all the people ofNorthern Ireland can be improved, and inparticular, how the unacceptable inequal-ities in health can be reduced by takingaction to tackle the factors which impact onhealth.
The Strategy was developed by allgovernment departments through theMGPH. Investing for Health contained acommitment to develop a methodology toenable all departments to identify andevaluate the health impacts of new policydevelopments as they emerge in order toensure that any positive impacts on health
can be maximised and negative impactsminimised.
A small number of policy areas have beenput forward by departments on which topilot HIA and findings have been incorpo-rated into this guidance document. Thedevelopment of methodology is an iterativeprocess and this document will be reviewedin the light of feedback from users andongoing developments in HIA.
Contents: 1. The Purpose of this Docu-ment; 2. Overview of HIA; 3. Guidance onthe Methodology; 4. Statement of Influenceon Policy/Programme/Project; 5. Moni-toring and Evaluation; 6. Further Infor-mation and Advice on HIA; Appendices:Screening Tool, Checklist of items toconsider when establishing and managingthe Steering Group, Checklist of possibleHIA resource items, Tool for FramingRecommendations, Examples of Recom-mendations from Case Studies, ReportingFormat for Statement of Influence, HIACase Studies, Overview of Health Impactsof Transport Policies and Projects,Overview of Health Impacts ofEmployment, The Health Impacts ofHousing, Information Sources on HIA,Documents and other Sources of Infor-mation for this Publication.
Eurohealth aims to provide information on new publications that may be ofinterest to readers. Contact Sherry Merkur at [email protected] if you wishto submit a publication for potential inclusion in a future issue.
Eurohealth Vol 12 No 433
Please contact Sherry Merkur [email protected] to suggest web sites
for potential inclusion in future issues.
ERAWATCH
http://cordis.europa.eu/erawatch
Mental Health Foundation ofArmenia
http://www.mentalhealth.am
German Presidency of the EU
http://www.eu2007.de/en
Founded in 1996, the Armenian Mental Health Foundation works to improve mental health in thecountry. Since 1999, the Foundation has provided a wide range of community-based services,including supported employment, self help, and a day centre hotline. The website contains anoverview of activities, including a legislation and policy programme, advocacy training project,community-based service programmes, and a list of relevant publications. A limited number ofpublications, including some in English, can be accessed on-line.
Commission of the Bishops’Conference of the EuropeanCommunity
http://www.comece.org
COMECE, established in 1980, is made up of Bishops delegated by the Catholic Bishops’ Confer-ences of the European Union and has a permanent Secretariat in Brussels. It meets twice a year inplenary session. The Apostolic Nuncio to the European Communities also participates in theseplenary meetings. The group raises awareness of the development of EU policy and legislation withinthe Church and sets out views on many health policy related issues including human rights, bio-ethics (including the use of human tissues and cells) and social affairs. There is a detailed pressarchive, while working papers and position statements on a range of issues are available fordownload. Written by independent contributors, a monthly review of developments, Europe Infos,can also be accessed. The website is available in English, French and German.
Portalfarma
http://www.portalfarma.com
Portalfarma, developed by the Official Colleges of Pharmacists in Spain and the Spanish GeneralCouncil of Official Colleges of Pharmacists, provides a wide range of information targeted atboth pharmacists and the general public. This includes market statistics, price data and thenational health service share of total sales. There is also a detailed archive of press releasescommenting on developments in pharmaceutical policy and practice in Spain. Publications includeaccess to a regular newsletter, Farmacéuticos, as well as much information on new products andtheir indications. Information on relevant legislation and links to other useful sites are provided.There is a detailed English language version of the website, although links to information onstatistics and publications are more limited.
News and information on the German Presidency of the European Union.
Launched in January 2007 by the European Commission, this new online information platformoffers comprehensive and timely information on research systems in thirty seven countries coveringthe EU, as well as China, Croatia, Iceland, Israel, Japan, Liechtenstein, Norway, Switzerland, Turkey,and the United States. It contains information on recent policy documents, research programmes,funding agencies, research performance, and major indicators such as expenditure, publications andpatents. The service is kept up-to-date by a network of national contact organisations. Users canaccess and customise the way information is presented and downloaded.
The Canadian Best PracticesPortal for Health Promotionand Chronic DiseasePrevention
http://cbpp-pcpe.phac-aspc.gc.ca
This portal originates from the work of health promotion practitioners and experts in the field whoidentified the need to build capacity among those working in chronic disease prevention byproviding relevant and accessible best practices information to enhance decision making. Its ongoingmission and goals are to develop and disseminate best practice information for chronic diseaseprevention and control interventions; provide decision-makers with a comprehensive and stan-dardised resource about best practices; provide a centralised access point for best practicesapproaches; coordinate activities that increase their uptake and utilisation; and enhance the evaluationof effective interventions at community and population levels. There are currently 97 best practiceinterventions contained in the database. It is available in English and French.
WEBwatch
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EUROPEAN MONITOR
Schmidt outlines health prioritiesunder the German PresidencyGerman Minister of Health, UllaSchmidt set out the GermanPresidency’s priorities for healthin a speech to the EuropeanParliament’s Environment,Public Health and Food SafetyCommittee on 22 January 2007.The Minister emphasised theimportance of health as a way ofdemonstrating the role that theEU can play, stating that “asmoothly functioning cross-border health care system andsafe medicinal products makeEurope’s added value into some-thing palpable.”
There are three main elements tothe programme: innovation,prevention and access to healthcare services. All have beendeveloped in cooperation withthe subsequent Portuguese andSlovenian presidencies who willbe “taking up the baton andfurthering the work”
The Minister emphasised the rolethat scientific innovation inhealth can play, both in meetingpatient needs, and providing avaluable contribution towardsachieving the EU’s Lisbon goalson economic growth. She high-lighted events where these issueswill be explored further. “Wewill be demonstrating this in ourconference programme with twoconferences. The ‘ehealth week’from 16 to 20 April in Berlin, forexample, will be presenting thediverse telematics activitiesconducted by the MemberStates. The aim here is to identifypossible solutions for cross-border, interoperable processesand Europe-wide electronicservices.” A conference on phar-maceutical innovation will alsobe held in Bonn in June 2007.
The Minister recognised theimportance of investing inprevention, stating that“preventing disease takes prece-dence over the treatment ofdisease and is the necessaryresponse to the challenges ourhealth care systems will be facing
in the future. The rising costsbrought on by demographicchange can only be controlled byEurope’s health care systems ifwe manage – with the aid of asuccessful prevention policy – topermanently change people’sattitudes and behaviour.”
A high level conference on thepromotion of healthy lifestyles istaking place in Badenweiler. Thecontrol of communicablediseases was also highlighted. Aministerial conference in Bremenon 12–13 March will focus onthe question of how civil societycan be more effectively involvedin AIDS prevention.
Under the theme of access tohealth care services, envisagedregulations on cross-borderhealth care services in Europeconstituted, in the opinion of theminister, “the most important(legislative) project in the area ofEuropean health policy to beundertaken in the years tocome.” It will be discussed at theInformal Council of HealthMinisters in Aachen on 19 and20 April 2007.
Ms Schmidt spoke in detail on anumber of issues including therevision of the Medical DeviceDirectives. She noted that “theenvisaged improvements in thearea of clinical trials and theauthorisation procedures, willincrease patient safety. Here,too, we see an opportunity toachieve a political agreementwith the European Parliament inthe first reading. However, thiswill require a high degree ofwillingness to compromise onthe part of all who are involved.”She added that “the GermanPresidency will discuss thecompromise proposals elabo-rated in the Council workinggroup on topics that remaincontroversial such as ‘the re-processing of single-use medicaldevices’ and the ‘prohibition ofdangerous substances in medicaldevices’, in informal tri-partitetalks with the European Parlia-ment and the Commission.”
Turning to the CommunityFramework for Health Care
Services announced by theCommission for 2007, she saidthat “Germany has set its sightson contributing to having theMember States arrive at a clearstance in the coming months.”The Minister also made clear herown personal interest in theprevention and control ofHIV/AIDS. Speaking of theupcoming Bremen conferenceshe said that “I am very opti-mistic – after numerous prelim-inary talks – that, in Bremen, theHealth Ministers of theEuropean Union and the neigh-bouring countries will beendorsing their shared will totackle the spread of this scourgeat the highest political level andhelp to mitigate its destructiveconsequences.” She also recog-nised the challenge in ensuringthat there is access to medica-tions needed to treat HIV/AIDS,stating that “the existing systemsto prevent trade diversions mustbe further refined with a view tomaking the distribution channelssafe and enabling more medi-cines to be available at a reducedprice.” The Minister also, inreferring the Green Paper onMental Health, welcomed theintention of the European Com-mission to draft a CommunityStrategy on this topic.
The full text of the Minister’sspeech can be accessed athttp://www.eu2007.de/en/News/Speeches_Interviews/January/0126BMGPraesprogramm.html
Green Paper: Towards a Europefree from tobacco smoke According to the EuropeanCommission, tobacco is thesingle largest cause of avoidabledeath in the EU. The economicburden of tobacco is also high,such that the annual cost ofsmoking-related diseases in theEU-25 is between €98–€130billion (equivalent to 1–1.4% ofGDP in each country). TheCommission is committed toexploring both legal mechanismsand health-promotion initiativesto promote the goal of a“smoke-free Europe”, as statedin its Environment and HealthAction Plan (2004–2010).
New
s
Press releases andother suggestedinformation forfuture inclusion can be e-mailed tothe editor David [email protected]
Presented on 30 January 2007, the GreenPaper, Towards a Europe Free fromTobacco Smoke: Policy Options at EULevel, launched a public debate on thebest way to tackle passive smoking inthe EU. The Commission now wants toknow what role it is expected to playand what policy options are preferred bythe different stakeholders. The policyoptions range from the current statusquo to the introduction of “bindinglegislation”. More moderate optionsinclude voluntary measures and self-regulation, the use of coordination toconverge national smoke-free legisla-tions, and Commission or Councilrecommendations. The Green Paperconcludes that of these options, a“comprehensive smoke-free policywould bring the greatest health benefitto the population”.
The consultation on the Green Paper isopen until 1 May 2007, after which timethe Commission will analyse commentsreceived and report back on the consul-tation’s outcome. A CommissionCommunication is expected in 2008 anddependent on the outcomes of Councildiscussions, the Commission will bringforward relevant proposals.
More information at: http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/gp_smoke_en.pdf
Commission welcomes new agreementon pharmaceutical free-trade The European Commission haswelcomed the adoption by EU MemberStates of an international agreementwhich will make it easier to trade inpharmaceuticals. The third revision ofthe Pharma-GATT (Global Agreementon Tariffs and Trade) Agreement, theCommission believes, will eliminatecustoms duties among the main pharma-ceutical trading nations and territoriesand will improve the competitiveness ofEU pharmaceutical companies. Over thelast few years, the EuropeanCommission assumed a leading role inthe negotiations towards the conclusionof this Agreement and its revision.
The agreement, reached on 12 January2007, eliminates customs duties betweenthe EU, Switzerland and the USA onfinished pharmaceutical products and onthe chemical intermediates used in theirproduction. Japan is expected to applythis revision later this year. TheAgreement is also open to additionalmembers.
It replaces a previous agreement, from1994, which already enabled many phar-maceuticals to benefit from zero-tariffs,but did not cover any of the more recentproducts. With this review, 1,290 addi-tional products are added to the 7,329currently benefiting from duty-freetreatment.
EU Trade Commissioner, PeterMandelson, said “this agreement putsfree trade at the service of Europeanbusinesses and consumers. It is a showof confidence in the global competi-tiveness of the EU pharmaceuticalindustry, and a signal of ourcommitment to ensuring that themodern trading environment is in stepwith innovation”. The EuropeanChemical Industry Council (CEFIC)has also estimated the savings generatedby the Agreement for EU pharmaceu-tical companies to be approximately€230 million in 2007.
More information athttp://ec.europa.eu/trade/issues/global/medecine/pr120207_en.htm
EU regulation on paediatric medicines On 26 January 2007, the EU Regulationon Paediatric Medicines (No 1901/2006)came into force. The main aims of theRegulation are to increase research anddevelopment of medicines for use inpaediatrics, ensure that such medicinesare appropriately tested and authorisedand improve the information available topatients and prescribers, for example inrespect of clinical trial data. Another keyelement of the Regulation is the estab-lishment of a new Paediatric Committeeof the European Medicines Agency(EMEA). The main focus of theCommittee will be to assess and provideopinions on the content of paediatricinvestigation plans (PIPs). It will alsoreview applications for deferrals andwaivers.
From 26 July 2008, all new medicinesmust include in their application formarketing authorisation the results ofstudies performed under a PIP, the scopeof which should be agreed in advancewith the new Paediatric Committee ofEMEA. From 26 January 2009, thisregulation will also apply to new indica-tions, new pharmaceutical forms andnew routes of administration for existingmedicines. In some instances, it will bepossible to defer the studies or apply fora waiver in relation to studies, for part orall of the paediatric population.
There are also new incentives for phar-maceutical companies through patentextensions. After completion of a PIPand submission of the appropriate information to the relevant regulatoryauthority, a medicine’s patent may beextended for six months through theproduct’s Supplementary ProtectionCertificate. To receive the extension, themedicines must be authorised in all EUMember States. Also, for off-patentproducts, the regulation has created anew category – the Paediatric UseMarketing Authorisation (PUMA). Thiscategory is intended only for medicinesfor paediatric use and encourages thedevelopment of off-patent medicinalproducts for use in children. Thesuccessful applicant will benefit from tenyears of data and market exclusivity.
More information at: http://eur-lex.europa.eu/LexUriServ/site/en/oj/2006/l_378/l_37820061227en00010019.pdf
Mental health: Commission releasesreport about Green Paper consultationand publishes Eurobarometer surveyIn December, the European Commissionpublished a report on the results of itsconsultation on the Commission’s GreenPaper on Mental Health, launched inOctober 2005. It also presented theresults of an Eurobarometer survey onmental wellbeing. The survey indicatedthat 13% of respondents have soughtpsychological help over the last twelvemonths. 7% of EU citizens have beentreated for psychological or emotionalproblems with medications, while thosein psychotherapy and hospital respec-tively account for 3% and 1%. Mostrespondents to the consultation calledfor an EU mental health strategy, tofoster mental health prevention andpromotion and combat stigma.
Mental health problems affect everyfourth European citizen at least onceduring life and are one of the majorpublic health challenges in the EU. Theeconomic and social consequences aresignificant: very conservatively estimatedto be equivalent to 3–4% of the EU’sGross Domestic Product. As many asfour-fifths of those with enduringmental health problems are economicallyinactive compared with one third ofthose with physical disabilities.
Speaking on the publication of thereport, Markos Kyprianou, EuropeanCommissioner for Health andConsumer Protection said that “the
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importance of mental health needs to bebetter recognised. Good mental health ofthe population is a precondition for theEU’s success in the knowledge economy.The situation of those with mental healthproblems is an indicator of the level ofinclusiveness of EU societies.”
In the Green Paper, Improving themental health of the population. Towardsa strategy on mental health for the EU,the Commission proposed the devel-opment of a comprehensive strategy onmental health at the EU level. The reportnow published summarises the 234responses received. The responseswelcomed the Green Paper and called forincreased attention and priority formental health. Most respondentssupported the development of a mentalhealth strategy.
They advised that the emphasis be put onmental health promotion and prevention,as well as on enhancing the situation ofthose with mental health problemsthrough reducing stigma and discrimi-nation. To do that, the implications ofother sectors’ policies on mental healthshould be better considered in policymaking and implementation, and appro-priate tools further elaborated. It was alsonoted that there were substantial needsfor improvement in mental health care.Increased exchange and collaborationbetween Member States was recom-mended. Many research needs were iden-tified, as well as the need for improvedlinks between research and policy-making.
The report on the consultation is availableat http://ec.europa.eu/health/ph_determi-nants/life_style/mental_health_en.htm
The Eurobarometer on mental wellbeingis available athttp://ec.europa.eu/health/ph_publi-cation/eurobarometers_en.htm
Launch of European Charter to CounterObesityHalf of all adults and one in five childrenin the WHO European Region are over-weight. A third of these are already obeseand numbers are increasing rapidly.Obesity reduces the length and quality ofpeople’s lives. The epidemic causes onemillion deaths a year in Europe and seri-ously hampers economic development.
In response to this problem, on 20February, the European Charter onCounteracting Obesity, the first of itskind in this area, was launched in Copen-
hagen, in the presence of Her RoyalHighness, Crown Princess Mary ofDenmark, Patroness of the WHORegional Office for Europe. The Charterwas officially adopted by Member Statesof the WHO European Region inNovember 2006 at the European Minis-terial Conference on CounteractingObesity in Istanbul.
It provides political guidance and astrategic framework for strengtheningaction against obesity stating that “visibleprogress, especially relating to childrenand adolescents, should be achievable inmost countries in the next four to fiveyears and it should be possible to reversethe trend by 2015 at the latest”. Reachingthis goal requires specific, targeted actionacross many sectors.
The Charter identifies key areas of actionincluding: reducing marketing pressure,particularly towards children; promotingbreastfeeding; reducing free (particularlyadded) sugars, fat and salt in manufac-tured products; adequate nutritionlabelling of foods; and promoting cyclingand walking through better urban designand transport policies.
Speaking at the launch, Crown PrincessMary said that she believed the Charterto be “an important milestone inaddressing the challenge of obesity” andhoped that “the action it produces willserve as a turning point to adapt the envi-ronment we live in and ultimately enableeveryone in the WHO European Regionto make healthy choices”. WHO issupporting these efforts further by facili-tating the development of a Europeanaction plan, covering nutrition andphysical activity, and internationallycomparable monitoring mechanisms. Theaction plan is expected to be released inlate 2007.
The Charter is available at http://www.euro.who.int/Document/E89567.pdf
WHO: Encouraging progress on avianinfluenza vaccinesExperts meeting at the World HealthOrganization (WHO) in Geneva on 16February to discuss advances inpandemic influenza vaccine developmentreported encouraging progress. This wasthe third such meeting in just two yearsand more than 100 influenza vaccineexperts, from academia, national andregional public health institutions, thepharmaceutical industry and regulatorybodies throughout the world, attended
the meeting convened by the WHOInitiative for Vaccine Research and theWHO Global Influenza Programme.Information on more than twentyprojects was presented and discussed.
Sixteen manufacturers from ten countriesare developing prototype pandemicinfluenza vaccines against H5N1 avianinfluenza virus. Five of them are alsoinvolved in the development of vaccinesagainst other avian viruses (H9N2,H5N2, and H5N3). At present, morethen forty clinical trials have beencompleted or are ongoing. Most of themhave focused on healthy adults. Somecompanies, after completing safetyanalyses in adults, have initiated clinicaltrials in older people and in children. Allvaccines were safe and well tolerated inall age groups tested.
For the first time, results presented at themeeting have convincingly demonstratedthat vaccination with newly developedavian influenza vaccines can bring about apotentially protective immune responseagainst strains of H5N1 virus found in avariety of geographical locations. Some ofthe vaccines work with low doses ofantigen, which means that significantlymore vaccine doses can be available incase of a pandemic.
In spite of the encouraging progressnoted, the WHO stresses that the worldstill lacks the manufacturing capacity tomeet potential global pandemic influenzavaccine demand as current capacity isestimated at less than 400 million dosesper year of trivalent seasonal influenzavaccine.
In response to this challenge, the WHOlaunched the Global pandemic influenzaAction Plan (GAP) in 2006 to increasevaccine supply. This is a US$10 billioneffort over ten years. One of its aims is toenable developing countries to establishtheir own influenza vaccine productionfacilities through the transfer of tech-nology, providing them with the mostsustainable and reliable response to thethreat of pandemic influenza. The WHOis currently working with several vaccineproducers, mainly in developing coun-tries affected by H5N1, to facilitateestablishment of in-country influenzavaccine production.
More information on avian flu can befound at http://www.who.int/csr/disease/avian_influenza/en/index.html
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COUNTRY NEWS
Kyrgyzstan: Integrated householdsurvey to include health moduleFrom Baktygul Akkaziev*
A health module will form part of theKyrgyz Integrated Household Survey inMarch 2007. The survey will contributeto ongoing monitoring efforts on healthsystem performance and includes indi-cators on financial protection, equity inaccess, responsiveness and awareness ofrights to the State Guaranteed BenefitPackage (SGBP). All of these cancontribute to National Health ReformProgramme measures between 2006-2010 (Manas-Taalimi). The survey willbe conducted by the National StatisticalCommittee (NSC) with the technicaland financial support of the WorldHealth Organization and the UKDepartment for International Devel-opment. The population sample will bethe same as that for the general survey,which provides national and oblast(regional) level representative data. 5,016households are participating (approxi-mately 21,000 individuals).
The survey instrument is composed offive sections covering: (i) general demo-graphic information; (ii) utilisation andexpenditure on outpatient services in thelast thirty days (including the consump-tion of prescribed and non-prescribedmedicines); (iii) utilisation and expen-diture on hospital services in the lasttwelve months; (iv) self-reported healthstatus of each adult household member,as well as some objective measurementof cardiovascular disease risk-factors; (v)knowledge of the head of householdregarding entitlements to the SGBP.
The survey instrument follows interna-tional best practice and has been widelydiscussed with local experts from theMinistry of Health, Mandatory HealthInsurance Fund, and NSC to ensure itmeets the monitoring needs of Manas-Taalimi. The new questions on assessingknowledge of the SGBP have beenextensively field-tested. This led tomarginal modifications to the question-naire from 2001/04 in order to allow
comparative analysis over time.
There are several innovations in thishealth survey. Firstly, measuring bloodpressure will help establish the preva-lence of hypertension and link this to thequality of health service delivery.Cardiovascular disease generally is anunder-researched priority area in Manas-Taalimi and this survey will provideimportant new information. The surveywill use the global positioning system toaccurately pinpoint the locality ofhouseholds in relation to serviceproviders. It will also be the first timethat households’ awareness of theirrights within the SGBP have beenmeasured. Draft findings are expected by October 2007.
Russia: Muscovites live seven yearslonger than other RussiansThe Russian daily, Rossiiskaya Gazeta,reported on 19 February that lifeexpectancy for Muscovites increased bynine years over the last twelve years.This compared with an average ofeighteen months for Russia as a whole.
The survey conducted by the RussianScience Academy found that those livingin the centre of Moscow had the greatestlife expectancy: on average men living to70 and women 78. In the Zelenograd-suburb, however, the comparable ratesare just 65 and 75.5 respectively.
Apart from the centre, the northern,south-western and north-westernregions of Moscow proved ratherfavourable in terms of life expectancy,while the eastern, south-eastern andsouthern regions of the city turned outto be not so advantageous. Hereeducation levels are lower and it is speculated that the more educated aremore aware of health risks and thusfollow healthier diets.
There are however some anomalies. Thedeath rate for able-bodied Muscovites(from 20 to 39) went up. The principalreasons for this were cardiovasculardisease, as well as injuries andpoisonings. Moreover, non-residentsaccounted for more than 10% of alldeaths. Their social status is typicallylower than that of Muscovites.
Overall, the researchers attribute longerlives of Muscovites to economic growthand stable medical care. Yet while deathsfrom cancer are decreasing across Russiaand Moscow as a whole, the peak cancerrates are to be found among city centre
residents. Some Russian commentatorshave argued that the marked increase inlife expectancy may be somewhat erro-neous and due in part to poor statisticalcollection which in fact previouslyunderestimated life expectancy over thelast decade.
Kremlin unveils measures to counteravoidable mortalityOn 25 January, Russia`s First DeputyPrime Minister, Dmitry Medvedev,unveiled a host of measures to tackleRussia’s shrinking population. Theseinclude moves to cut the road trafficdeaths that account for almost 5% of thedecline. The population of the world’sbiggest country is falling by around750,000 people a year and PresidentVladimir Putin has ordered a nationalprogramme to reverse the trend.Medvedev said a key part of theprogramme would be to cut accidentaldeaths on Russia’s roads that numberaround 36,000 annually.
“In order to reduce deaths frompreventable causes, including traffic accidents, we are proposing a series ofmeasures, first and foremost providingfast, high-tech and qualified medical aidto victims,” he said. One of the firstmeasures is to provide an additional sixhundred ambulances equipped withresuscitation equipment to travel to thescene of accidents. Independent memberof the Duma (Parliament) and chair ofthe Russian Motorist Movement, ViktorPokhmelkin, commenting to journalistson the measures also said that there wasa need for more rapid access to medicalcare, stating simply that “a lot of peopledie on the roads because they do not gethelp in time.”
Medvedev said his national programmewould also try to reduce mortality byimproving treatments for cardiovasculardisease and acute poisoning (often aresult of drinking tainted alcohol).Russia’s demographic crisis is alarmingthe Kremlin. Birth rates in Russia arenow rising slowly but mortality levelsremain high. The average Russian manlives for just 58 years, 17 years less thanthe average German man.
Netherlands: Electronic medicationrecords introducedHealth care providers in the Netherlandsbegan working with an electronicmedication record system (EMR) fromJanuary 2007. Authorised individuals are
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* Baktygul Akkazieva is a Consultant,WHO-DFID Health Policy AnalysisProject, Center for Health SystemDevelopment, Bishkek, Kyrgyzstan.Email: [email protected]
now able to use this EMR system to gainaccess to a patient’s medication history.According to the Ministry of Health,Welfare and Sport, this system shouldmean that medication errors can beavoided, as authorised health care staffwill be supplied with the informationthey need through an on-line envi-ronment. Only if patients object, wouldsuch information not be available toservice providers. Health care providersshould therefore be able to avoidprescribing drugs that might otherwiselead to dangerous interactions withmedications that the patient mightalready be taking on the advice of anotherdoctor.
The EMR is one component of anationwide system known as the Elec-tronic Patient Record (EPR), intended tofacilitate the exchange of patient infor-mation. The EPR will be a virtual medicalrecord. Data from different health careinformation systems will be broughttogether for doctors who have authorisedaccess. They will then be able to form amore complete overall picture of thepatient’s medical history, including drugsprescribed.
This national EPR system will be built upin step by step fashion connecting variousregional systems to the new nationwideinfrastructure. In addition to the EMRnow in place, the EPR will also includeindividual patient identification through aCitizen Services Number; care provideridentification and verification with theUnique Healthcare Provider Identifi-cation Register; and secure and reliableexchange of information through a‘national switch point.’
Further information athttp://www.minvws.nl/en/nieuws-berichten/meva/2006/january-launch-for-electronic-medication-records.asp
Sweden: PM rejects call for cut in alcoholtaxesOn 19 February Swedish Prime Minister,Fredrik Reinfeldt, rejected a call putforward by members of his own party toreduce taxes on wine and beer. A numberof Moderate Party members of thegovernment’s taxation committee hadcalled for taxes to be reduced as a meansof tackling the illegal import of beer andspirits for sale on the Swedish market.Public health minister Maria Larsson, aChristian Democrat, had alreadydistanced herself from the proposal.
According to Swedish English languageon-line daily The Local, the PrimeMinister said “ we have not yet reachedan agreement with our alliance partnersand we should not do anything in thisarea if we are unsure of the budgetaryeffect. It is very important at the momentthat we underline that we want to reducetax on employment, which means thatthere will not be as much room for allother types of tax cuts.”
The Prime Minister said he was aware ofhis party colleagues’ view that theproposal would have no budgetary effectif balanced by higher taxes on spirits butadded that he wanted “to be sure that wehave evidence that this really is budgetneutral.” Prior to the election, Reinfeldt’sModerate Party had argued in favour ofreducing alcohol taxes, with the PrimeMinister himself critical of the previousgovernment for not cutting alcohol taxes.The latest developments come in thewake of a recent ruling by the EuropeanCourt of Justice which led to more thanthirty websites selling cheap foreignalcohol being closed down. EU regula-tions state that any reduction in taxes onbeer must be followed by similar reduc-tions for wine.
Ireland: Shake up in private healthinsuranceOn 14 December, BUPA Irelandannounced that it ‘had no option but tocommence its withdrawal from the healthinsurance market.’ The decision followedthe recent judgement of the High Courton the introduction of the risk equali-sation payments scheme. The schemecame into effect from 1 January 2006.BUPA estimated that under the schemethey would “be required to pay €161million in Risk Equalisation paymentsover the next three years to the dominantmarket insurer, the VHI. This would befar in excess of its estimated surplus of€64 million in this period.” Thus theyclaimed that the scheme would maketheir business unviable. Commenting onthe announcement, BUPA IrelandManaging Director Martin O’Rourkesaid “Irish consumers are the real losersas the market will be restored to a virtualmonopoly. Irish consumers have bene-fited from the choice, innovations andquality of service we have brought to themarket over the past ten years and it iswith great sadness that we must begin thewind-down of our business.”
Subsequently however, at the end of
January 2007 it was announced that theQuinn Group would purchase BUPAIreland Ltd. Unlike BUPA, as a newinsurer the Group would have beenexempt from risk equalisation paymentsfor three years. Emergency legislationwas however passed in the IrishParliament on 21 February to ensure thatany insurer could not seek to avoid riskequalisation provisions altogether bychanging their underwriter every threeyears.
Quinn Group Chairman, Sean Quinn,said that their entry into the market wassignificant for the group. “We believe ouragreement with BUPA presents anopportunity for real competition in theIrish health insurance market. In all ofour businesses, we operate in an open andcompetitive environment and we trustthat the report of the review group estab-lished by the Minister for Health, MaryHarney, [on the private health insurancemarket], and other initiatives, will lead toa more open and competitive landscape inthis market.”
The Minister for Health and Children,Mary Harney, has welcomed the news.She said that the government believesthere is still significant potential forreform of the market, stating that she‘will continue to pursue the government’spolicies of supporting a community ratedmarket and fair competition. It isimportant that health insurance remainsaffordable to older people and those withillnesses, and also that consumers benefitto the greatest degree possible fromcompetition and innovation in themarket.” She added that the QuinnGroup is a significant player in thegeneral insurance market and wasconfident that they could play a similarrole in sustaining competition in thehealth insurance market.
Report on competition in the Irish privatehealth insurance market The Health Insurance Authoritypublished a report on competition in theprivate health insurance market on 16February. This report was commissionedby the Minister for Health and Childrento look at “further measures to encouragecompetition in the private healthinsurance market and the strategy orstrategies which might be adopted inorder to create greater balance in theshare of the market held by competinginsurers.”
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Many of the conclusions and recommen-dations in the Health Insurance Author-ity’s report’s are similar to those in acorresponding report issued earlier inthe week by the Competition Authority.
The Irish private health insurancemarket is community rated. Thecommunity rating system is supportedby regulations concerning lifetime cover,open enrolment, minimum benefit andrisk equalisation. While the regulationsalso impact on competition, the HIAjudged that its impact is fair and proportionate and the regulations facilitate competition between insurers.Nevertheless, it noted that the Irishmarket is highly concentrated (with onlythree significant players) and there are anumber of measures recommended inthe report that should be taken in orderto benefit consumers by encouraginggreater competition in the market.
A primary objective of the report’srecommendations is to bring about asituation as soon as possible that allhealth insurers operate under the sameregulatory framework. To this end, anumber of recommendations are madewith the aim of VHI Healthcare, thedominant provider of health insurance,becoming an authorised insurer, regu-lated by the Financial Regulator andrequired to achieve solvency levels spec-ified in insurance legislation.
The HIA also noted that the absence ofrisk equalisation in a community ratedmarket gives a regulatory advantage toinsurers with lower risk profiles. TheRisk Equalisation Scheme it stated “isdesigned to reduce but not eliminate thisadvantage and insurers with lower riskprofiles will continue to have a signif-icant advantage, even with risk equali-sation payments.” The HIA came to theconclusion that such payments areessential and that any attempt to endsuch payments “would involve signif-icant risks for the current communityrated health insurance framework andwould not be in the interests of healthinsurance customers generally.”
The HIA report on competition in thehealth insurance market can be down-loaded at http://www.hia.ie/docs/reports/Competition-Report-2007.pdf
Scotland to get annual check upThere is to be an annual public review ofthe state of Scotland’s health. FirstMinister, Jack McConnell, made the
announcement on 4 December as thefirst annual Health Improvement Reportwas published by Health Minister, AndyKerr.
The report was commissioned last yearand approved by Scotland’s Cabinet forpublication at a World Health Organi-zation conference that took place inEdinburgh in December. It will be thefirst of a new form of annual reports tothe First Minister covering all actions onhealth improvement.
At the WHO conference, the FirstMinister explained that the report willnow form part of a new systematicannual process to examine Scotland’shealth needs and to identify priorities forthe year ahead. The new approach isaimed at enabling better co-ordinationand prioritisation of initiatives alreadytaking place to improve Scotland’s healthrecord.
Mr McConnell pointed to the impactpoor health has on people’s quality oflife, economic growth and the cost to theNHS as “reasons why improving ourhealth matters and it matters to all of us,not just those in the NHS”. The FirstMinister made it clear that, for thisreason, the new public review willengage expertise from outside the healthservice and harness a more roundedapproach to addressing health needs.
The report also measures progress beingmade across government to improveScotland’s health with the aim ofbringing it up to a par with the best inEurope. It highlights initiatives such asthe ban on smoking in public places,improved school meals and the alcoholtest purchasing pilot as examples of howall parts of government are workingtogether, in addition to stressing the roleof the NHS in more preventative andproactive care.
The First Minister said “my vision for ahealthier, happier more productiveScotland is one shared by the vastmajority of Scots. For that reason I feelconfident that we can open up our workon health improvement to a wide rangeof partnership organisations, experts andinfluential stakeholders. The annualhealth report we have published todaywill be sent for comment andengagement to the widest range of stake-holders – here in Scotland and beyond –to encourage them to play a full part in ahealthier Scotland. Their input will beeven more important in future years.
And to monitor progress and create ashared national agenda, there will be anAnnual Public Review based on thereport and what needs to be done. Thisnew, very public, annual check up willbe a way to rigorously examine what hasbeen done, so that our health improvesand our economy grows. Our poorhealth impacts not just on individuallives but on the NHS, our economicgrowth and our international reputation.These are just a few of the reasons whyimproving our health matters and itmatters to all of us, not just those in theNHS. But to turn around the reality andthe perception of the personal health ofScots, we need to step up our efforts,create a shared national purpose andcheck against progress each year. Whilewe recognise that Government cannotforce people into lifestyle choices, we dobelieve that there is enormous scope forindividuals in Scotland to make more oftheir lives.”
The first annual health report, Deliv-ering a Healthy Scotland can be down-loaded at http://www.scotland.gov.uk/Publications/2006/11/29141927/0
Scotland: Report on eyecare services On 14 December the results of a reviewof eyecare services, written under thechairmanship of Gareth Davies, MedicalDirector NHS Forth Valley, werepublished. The review had been commissioned in March 2004 by theScottish Executive government with thecharge of reviewing arrangements for theprovision of eyecare services in thecommunity in Scotland, and to providerecommendations on good practice foreffective models of care. Another aim ofthe review was to encourage the devel-opment of integrated eyecare services toensure patients receive a good qualityand efficient service in a convenientsetting without undue delay.
Among the key recommendations of thereview were that an integrated, patient-centred approach should be taken to thedesign of eyecare services, both forchildren and for adults. It also suggestedthat the planning of services should bebased on a broad definition of visualimpairment, so as to include those whohave additional disabilities or impair-ments. The particular needs of membersof minority ethnic groups should betaken into account. Minimum servicestandards should also be established toensure that patients receive a consistent
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quality of service across Scotland.
As a result of the review, the ScottishExecutive government are committed toan additional £2 million investment to aidcloser working between eyecareproviders. Speaking at the launch of thereport, Deputy Health Minister, LewisMacdonald said that future eyecareservices will focus on better support,enhanced preventative and quality ofcare: “we have already made significantprogress in the introduction of freeeyecare examinations in April this year.This review will bring even greaterbenefits to the people who need eyecare.”
Mr Macdonald added that “our wide-ranging recommendations set andmaintain national standards that can beadapted and implemented locally,establish better integration betweencommunities, hospitals, social work andgeneral practice and make better use ofoptometrists, orthopotists and opthalmicnurses.”
John Legg, speaking on behalf of theRoyal National Institute for the BlindScotland, said “we welcome the ScottishExecutive’s proposals to provide inte-grated patient-centred services to supportpeople on the sight loss journey. Properlyfunded and with robustly enforced stan-dards, these proposals have the potentialto provide Scotland with world-class eyecare services.”
The review can be accessed athttp://www.scotland.gov.uk/Publica-tions/2006/12/13102441/0
UK: New rules on television advertisingof food to childrenOn 22 February the UK’s independentregulator and competition authority forthe communications industries, Ofcom(Office of Communications), completedits review of the rules on the televisionadvertising of food and drink products tochildren, and published its final statementon the introduction of restrictions in this area.
Ofcom’s co-regulatory partners, theBroadcast Committee on AdvertisingPractice (BCAP) and the AdvertisingStandards Authority, are now responsiblefor implementing the new scheduling andcontent rules and securing compliancerespectively. The new rules will form partof the BCAP Television AdvertisingStandards Code.
Ofcom’s final statement follows the
conclusion of its additional consultation(published 17 November 2006). Thisproposed to extend restrictions on thetelevision advertising of food and drinkproducts high in fat, salt and sugar(HFSS) to include programmes andchannels aimed at children aged undersixteen.
After a detailed analysis of the evidence,including a full impact assessment,Ofcom concluded that it would beappropriate and necessary to adoptrestrictions intended to reduce signifi-cantly the exposure of children undersixteen to HFSS advertising.
The new restrictions will be phased in, sothat from 1 April 2007, HFSS advertise-ments will not be permitted in or aroundprogrammes made for children (includingpre-school children) or that are likely tobe of particular appeal to children agedfour to nine. From 1 January 2008, thisrestriction will be extended to childrenaged four to fifteen.
Children’s channels will be allowed agraduated phase-in period, with fullimplementation required by the end ofDecember 2008. Existing advertisingcampaigns, or those in the final stages ofcreative execution, can still be broadcastuntil the end of June 2007. However,from 1 July 2007 all advertisingcampaigns must comply with the newcontent rules.
In addition to the scheduling restrictions,content rules will also apply to all foodand drink advertising to children irre-spective of when it is scheduled. Theserules include banning the use ofcelebrities and characters licensed fromthird parties, promotional offers andhealth claims in HFSS product advertise-ments aimed at primary school childrenor younger. All restrictions on productadvertising will apply equally to product sponsorship. A review of theeffectiveness and scope of new restric-tions will take place in autumn 2008, oneyear after the full implementation of thenew content rules.
The full Ofcom statement can be accessedat http://www.ofcom.org.uk/consult/condocs/foodads_new/statement
UK: Historic changes for the pharmacyprofession The Chief Pharmaceutical Officers fromEngland, Scotland and Wales cametogether on 21 February to reveal plansfor historic changes to the regulation of
the pharmacy profession. The measures,which form part of the GovernmentWhite Paper on professional regulation,will see the formation of two separatebodies to oversee pharmacy. One organi-sation would act as a regulator and asecond would be responsible for leadingthe profession. It is envisaged that thetwo new bodies will take the form of aGeneral Pharmaceutical Council (GPC)to regulate the profession and a RoyalCollege to provide leadership.
Chief Pharmaceutical Officer forEngland, Dr Keith Ridge, said “I trulybelieve this is a good deal for pharmacy.Pharmacy is changing and so professionalleadership is vital. We envisage a GPCthat takes regulation forward and a RoyalCollege which is sustainable, underpinsthe science and practice of pharmacy, andcommands the respect the professiondeserves.
This is about ambition, consolidation,and leadership. It will put pharmacy intothe position it has earned and deserves. Ifwe do not seize this opportunity, we will,in my view, have failed pharmacy and ourprofession at a vital time; consigning it toa wilderness isolated from otherhealthcare professions.”
Chief Pharmaceutical Advisor for Wales,Carwen Wynne Howells, said that“pharmacy is a rapidly changingprofession and, as greater responsibilitiesare placed on it, the public needs to beassured of excellence in its governancearrangements. Whilst the creation of aGPC will move the regulation of theprofession forward, the establishment ofa Royal College will promote excellencein clinical practice, innovation and leadership within the profession. Ahistoric moment, certainly, but one whichpresents the profession with huge opportunities.”
Chief Pharmaceutical Officer forScotland, Professor Bill Scott, said “theevolution of pharmacists from a productand technical based focus to one ofclinical practitioner continues to gatherpace. The most recent independentprescribing powers are a prime exampleof how the Government is ensuring phar-macists and pharmacy practice will be fitfor the 21st century. It is thereforeessential that the underpinning regulatoryfunctions and professional leadership arealso fit for the 21st century.”
The Chief Pharmaceutical Officer forNorthern Ireland, Dr Norman Morrow,
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who was unable to attend, said that“good governance at both regulatoryand professional development levels is atthe heart of these proposals, and Ibelieve they offer the profession consid-erable opportunity for advancement,given the importance of the pharmaceu-tical contribution to the provision ofhealth care. The [Northern Ireland]Department of Health, Social Servicesand Public Safety and the Pharmaceu-tical Society of Northern Ireland arepositively engaged in consideration ofthe future arrangements which willpertain in Northern Ireland.”
This announcement comes as the safeand effective prescribing and dispensingof medicines becomes more complex andgreater clinical responsibilities are placedupon the pharmacy profession. It is inaccord with the Governmentcommitment to ensure that healthcareprofessionals will be independentlyregulated.
Unusually, the Royal PharmaceuticalSociety of Great Britain (RPSGB ) isboth the regulator and the professionalbody responsible for leading thepharmacy profession. In addition, it hasan important role in inspectingpharmacy premises and legislation willsoon be in place to enable it to take onthe role of regulating pharmacy techni-cians. The new move will require theRPSGB to separate its regulatory systemfrom its system of professional andclinical leadership, allowing each distinctfunction to focus solely on its core role.
Northern Ireland has its own profes-sional body, the Pharmaceutical Societyof Northern Ireland, and existingarrangements are broadly parallel tothose in Great Britain. The White Paperprovides the opportunity for a moreintegrated approach across the UK andthis is for Northern Ireland to consider.
The Department of Health in Englandwill present proposals for legislating onprofessional regulation at the earliestopportunity, on behalf of all healthadministrations. To help take this workforward a short-term working party willwork collaboratively with the broaderpharmacy profession, the Pharmaceu-tical Society of Northern Ireland andother key stakeholders, on agreedproposals for implementation. Theworking party will be led by LordCarter of Coles and includes the ChiefPharmaceutical Officers for England,
Scotland, Wales and Northern Ireland.Its work will also help inform futuredecisions about the regulation and lead-ership of pharmacy in Northern Ireland.It will report to ministers with recom-mendations by the end of March 2007. Itis anticipated that the necessary legis-lation to establish the new GPC shouldbe in place by mid 2008.
The government White Paper, Trust,Assurance and Safety, The Regulation ofHealth Professionals in the 21st Centurycan be accessed at viahttp://www.dh.gov.uk
Spain: health and beauty go hand inhand On 23 January, an agreement wasreached between Spain’s biggest fashionretailers and design houses and theMinistry of Health and ConsumerAffairs to work together on standard-ising clothing sizes in order to promote ahealthy and realistic body image forwomen. The Minister said that “it wasnot appropriate in a modern society tohave stereotypes of beauty. It is theagreement of all that beauty and healthgo hand in hand.”
One of the fundamental objectives of theaccord is the need to provide moreaccurate and understandable informationon clothing sizes. In reality, there is noagreed standard on clothing sizes, eitherin Spain or in the European Union as awhole. Sizes differ between manufac-turers, causing confusion and problemsfor consumers; this situation affects themajority of women. In addition tomanufacturers agreeing to conform to acurrent European voluntary standard,Health Minister, Elena Salgado-Mendez,announced that the National ConsumerInstitute will, over a period of eighteenmonths, measure 8,500 women betweentwelve and seventy years of age, with theaim of “defining standard patterns andredefining and normalising sizes.”
A second fundamental objective is topromote healthy body images. The idealpicture of beauty sometimes advocatedby the fashion industry can put pressureon women to be too thin, which in somecases can lead to health problems such asanorexia nervosa. Major retailers such asInditex, which owns the fashion retailerZara, as well as El Corte Ingles, Mangoand Cortefiel are all behind theagreement. Shop dummies will now beat least a European size 38, while size 46will no longer be considered outsize.
This is the latest measure taken to curbweight-related disorders and follows theprohibition of models below a certainweight from Madrid catwalks. Similarmeasures have been taken in otherEuropean countries. The plans forreform will not stop with women.According to the Minister “if everythinggoes well as we expect then of course wewill continue with (a resizing) for men –but it seems that men’s sizes are moreadvanced.” Once the study is completed,retail sizes will be unified over aneighteen month period.
The text of the accord in Spanish only isavailable at http://www.msc.es/gabi-netePrensa/notaPrensa/pdf/TextoAcuerdo.pdf while information on the survey ofbody sizes is available athttp://www.msc.es/gabinetePrensa/notaPrensa/pdf/DossierEstudioAntropo-metrico.pdf
German Länder to introduce limitedsmoking banOn 23 February, Germany’s sixteenregional states (Länder) agreed to alimited smoking ban in restaurants andcafes. Meeting in Hannover, regionalhealth ministers agreed on rules thatwould protect restaurant customers andemployees from second-hand smoke,but still allow designated closed-offsmoking areas. The ban would coverrestaurants and cafes, nightclubs,theatres, cinemas, museums and playcentres for children as well as publicbuildings. Two regions, Lower Saxonyand North Rhine-Westphalia, insisted onretaining the right to create legislationthat would allow businesses to specifi-cally cater to smokers. The agreementmust now be approved at a meeting ofthe regional heads of government on 22March.
Consumer Affairs Minister HorstSeehofer said the measure was “longoverdue.” The federal government hadbeen forced in December to abandonproposals for a nationwide ban onsmoking in public places which wouldhave included restaurants and schoolsalthough not bars. The interior andjustice ministries feared that such a banwould contravene the constitutionwhich gives broad legislative powers tothe country’s regional states.
European Parliament lights up
This move in Germany comes at a timewhen European parliamentarians have
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been criticised for voting to set up sealedsmokers’ rooms in their Strasbourg andBrussels buildings after a voluntary banfailed. A spokesman said that “a completeban started on 1 January. In practice, thiswas not working too well, people werenot obeying it.” Green MEP, GerardOnesta, a member of the parliament’sadministrative office, was outvotedtwelve to one on the issue. He said thatMEPs would be sending a “horriblepolitical signal” at a time when smokingbans are spreading throughout the EU, asevidenced by France’s recent ban onsmoking in public places. He also notedthat the step could be costly as the roomswould require special air filters.
The vote comes on the heels of the callfrom EU’s Health Commissioner,Markos Kyprianou, for a comprehensiveban on smoking in public places acrossthe EU. “It certainly is an odd message.Everywhere else in the world, smokingbans are respected,” said a secondparliament official.
Germany: agreement reached on healthreform planOn 13 January, German Health Minister,Ulla Schmidt, said that a compromise hadbeen reached on plans to reform thecountry’s €140 billion ($181.3 billion)health care system, ending months ofhaggling in the Grand Coalitiongovernment. “All those who are sick arewinners with this reform,” MinisterSchmidt told reporters, describing themulti-party compromise as a “break-through” in the months-long impasseinside the grand coalition.
Health insurance will become obligatoryfor all German citizens if the reformscome into effect as planned by April2007. The Minister said that “as a resultof rising health costs even the moreaffluent Germans have no longer beenable to pay treatment costs withoutinsurance, and an obligatory healthinsurance scheme is also the bestprotection against abuse, because indi-vidual health costs can no longer bepassed on to society as a whole.”
Obligatory health insurance was theMinister’s suggestion to break thedeadlock in the talks over the future ofprivate insurance companies. In contrastto public health insurance funds in whichthe majority of Germans are insured, thewealthiest 10% of the population can getprivate insurance which has traditionallybeen viewed as offering better services. It
is estimated that between 200,000 and300,000 people in Germany do not havehealth insurance.
There had been much dispute on whetherprivate insurance companies must openthemselves to uninsured people withoutbeing allowed to check on an applicant’shealth status. The Social Democrats(SPD) were strongly in favour of theplan, saying it was a contribution tonational solidarity. The ChristianDemocrats rejected it, arguing that itwould ruin private insurance companies.As part of the compromise the SPDdropped this condition.
The controversial plan for an overhaul ofthe healthcare regime has divided Chan-cellor Angela Merkel’s power sharingcoalition for months, hitting popularsupport for her government. Severalconservative state leaders, includingBavarian premier, Edmund Stoiber, andBaden-Wuerttemberg premier, GuentherOettinger, had led opposition to thereform and initially refused to drop this,even after a government study demon-strated that the burden on rich states liketheirs would be limited.
Portugal : abortion to be legalisedPrime Minister, Jose Socrates, has saidabortion will be legalised in Portugaldespite the turnout for a referendumbeing too low to be legally binding.Turnout in the traditionally Catholiccountry was about 40%, far less than the50% required, but of those who did vote,59.3% backed a proposed change to thecurrent law. The proposal allows allwomen abortion until the tenth week ofpregnancy.
Currently, abortions are only allowed incases of rape, a health threat to themother or serious foetal abnormality.Under the current system, women whohave an abortion can go to prison for upto three years. Those aiding womenundergoing terminations can also beprosecuted.
One high profile case in recent times wasthat where the main defendant, midwifeMaria de Ceu Ribeira, was sentenced tomore than eight years in jail. In totalforty-nine people went on trial alongsideseventeen women who had aborted at aclinic in the town of Maia in the north ofthe country. Doctors, pharmacists, andeven taxi drivers who had transportedthem, faced the judges and several wereconvicted. Many thousands of
Portuguese women therefore have goneto Spain for terminations or resort toillegal abortions.
The “yes” campaign had focused on theestimated 23,000 secret abortions carriedout every year. Jose Socrates, the primeminister, called them “Portugal’s mostshameful wound” and argued that legalising abortion would end such back-street operations and allow women toobtain proper treatment. In a referendumheld in 1998, voters upheld the existingabortion law by 51% to 49%, but theresult was declared void as nearly sevenout of ten voters stayed away. TheSocialists made holding another refer-endum part of their election platform in2005.
The leader of the conservative PartidoPopular, Jose Ribeiro e Castro, whocampaigned against the change, said theprime minister was acting too hastily.“Socrates will be responsible for this sadchapter in Portugal’s history, for insistingon a political move that has splitPortuguese society,” he said adding that“low voter turnout has confirmed that(abortion) was not a critical issue.”
The Catholic Church were at the fore-front of opposition to any change in thelaw, with church radio stations tellinglisteners that they still had “time to savelives” and reminding them that theunborn were “children of God”. CardinalJose Policarpo, the patriarch of Lisbon,declared abortion to be “an attack oncivilisation” and in his televisedChristmas Eve address to the nation saidthat “whatever the motives that justifythis dramatic act in the eyes of a woman,it is always the denial of a place in theworld for a human life that wasconceived.” In a final move, Portuguesebishops gathered at Fatima, one of theholiest shrines in Catholicism, where thefaithful believe the Virgin Mary appearedto three children in 1917. They set up aninformation desk at the shrine during thefinal week of the campaign handing outleaflets asking people to vote against thenew law.
The Prime Minister did not indicatewhen a bill to legalise abortion would besent to parliament. He can however relyon the support of the main oppositionparty, the centre-right Social Democrats,which should ensure there will be noobstacles to legalise abortion for theSocialists, who already have a parlia-mentary majority. When the ban is lifted,
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Portugal will join most European coun-tries in allowing abortions, except asmall group with strict abortion laws:Malta, Ireland and Poland.
Italy: Police raids expose major hospitalhygiene and safety concerns Health Minister, Livia Turco, ordered anationwide investigation into the state ofItaly’s hospitals following raids byspecial health units from the Carabinieriparamilitary police on 321 of Italy’s 672public medical centres during earlyJanuary. The police reported some gravelapses in hygiene and safety includingexpired pharmaceuticals, unlicensednurses, stray cats and scuttling rats.
The raids followed an undercover inves-tigation by a journalist for L’Espressomagazine who worked for a month as acleaner at Rome’s Policlinico Umberto I.His report contained photographs ofpiles of rubbish in the hospital’scorridors and unguarded labs containingradioactive and bacteriological material.A spokesman for the Policlinico, whichtreats more than 80,000 patients a year,said that they were aware of theseproblems but did not have the funds toaddress the situation.
However, Ignazio Marino, a surgeon andpresident of the Health Committee ofthe Italian Senate, said that “the situationat the Umberto I General Hospital asdescribed by the Espresso investigation isintolerable, however unfortunately notsurprising. There are only two possibleroutes to take regarding the Umberto Ihospital, it can either be razed to theground and rebuilt according to moderncriteria or it can be given to the CulturalHeritage ministry and used for otherpurposes”.
Francesca Moccia, the National Coordi-nator of the Patients’ Rights Court-Cittadinanzattiva, added that “thedreadful condition of the Umberto IGeneral Hospital of Rome is not anisolated case. The problem comes fromthe scarce attention paid to controllinghospitals by all levels of staff. This is aproblem common in many Italianhospitals.”
The police investigation found that some17% of hospitals, mostly in southernand central Italy, had problems seriousenough to recommend possible judicialinvestigations against 111 people. Theyfound that in Calabria, some nurses wereunlicensed, while some hospital workers
in Sicily had friends or family clockthem in and out of work while they wereearning extra money elsewhere! Italiannewspapers also reported that policefound a colony of stray cats in thebasement of Milan’s San Carlo hospital,while rats were found in a Napleshospital, where bulldozers had to becalled in to remove piles of garbage andmedical refuse left in undergroundcorridors.
General Saverio Cotticelli, head of theunit that made the inspections,confirmed these reports but insisted theproblems were limited and didn’t affectpatient care. “The problem of strayanimals is one that returns periodically,you exterminate and after a month theyare back,” he said. “We found disorderand lack of maintenance ... there aresome modest changes to be made, oftenit’s simply an issue of mentality.”
Minister Turco insisted that Italianscould still trust their health system,noting the problems affected a minorityof the country’s hospitals. “Citizens cantrust the Italian health system, there arecases of negligence that must be dealtwith firmly, there are problems ofneglect that must be solved, but there isa lot of good health work being done,”she said at the presentation of theinspection’s results.
Despite the Minister’s assurances, it hasnot gone unnoticed that several highprofile figures, including former PrimeMinister Silvio Berlusconi who recentlyhad a pacemaker fitted, have receivedtreatment abroad. Opposition leaderUmberto Bossi went to Switzerland torecover from a stroke and members ofthe Agnelli family, owners of the Fiat cargroup, have gone to the United Statesregularly for medical treatment. Thesedecisions to receive treatment abroadhave been met with much criticism inthe Italian press.
The Ministry will now launch an investi-gation to know if Italian hospitals arerespecting the rules and protocolsrelative to safety and hygiene. Theannouncement was made by MinisterTurco during an inquiry of the Parlia-mentary Social Affairs Committee of theChamber of Deputies. The investigationwill be conducted independently fromthe Carabinieri inspections, which willcontinue in the private accreditedhospitals and health facilities in Italy.
According to the first European
Barometer on European Health Systemsand Citizen Evaluation, approximately70% of Italians have a negative opinionof the National Health System. 76%think assistance given to the elderly isunder par. The result is that 68% of theItalians are ready to go abroad fortreatment because they think there arebetter services in other countries andthat foreign countries are more techno-logically advanced (75%). The Ministryare keen to point out that despite therecent revelations, between 4.5 and 7%of patients in Italy contract an infectionwhile staying in hospital, a rate in linewith that of other European countries.
Latvia: Ban on junk food sales inschoolsIn November 2006 Latvia became thefirst EU country to ban the sale of softdrinks, confectionery, crisps andchewing gum from schools and nurs-eries. The move banned productscontaining artificial additives such ascolouring and flavouring agents, preserv-atives, amino-acids and caffeine. The banis part of the government’s attempt toimprove children’s diets and also coversfoods containing excessive levels of saltand sugar.
School shops and cafeterias are no longerbe able to sell sugary drinks sodas,chocolates, sweets and crisps. However,pupils can still bring their own confec-tionery to school. Healthy alternativesincluding dried fruit, unsalted nuts,unsweetened fruit juice, yoghurt, whole-grain snacks, mineral water and milk arenow being provided.
The move highlights the increasingpressure on soft drinks and snack foodproducers in the EU to restrict the avail-ability of their products amongstchildren. The move by Latvia is just oneof a number of steps taken by Europeancountries. In September 2006, Russiaalso introduced a similar ban in schoolswhile vending machines are also beingremoved from French schools. InJanuary 2007 the Union of EuropeanBeverages Associations announced thatthey would voluntarily ban advertisingto children across the European Unionand also pledged to provide unbrandedvending machines in secondary schoolsand that there would be “no engagementin any direct commercial activity” inprimary schools.
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A sporting chance for health The European Union has no direct com-petence for sport, however, Europeanpolicies in a number of areas have a con-siderable and growing impact. The Euro-pean Commission has therefore launcheda public consultation on a planned WhitePaper. This will focus on the role ofsport in European society, its economicimpact and the way in which it is organ-ised. The consultation, which runs until3 April 2007, includes reflection onhealth and social inclusion impacts.
More information at http://ec.europa.eu/yourvoice/consultations/index_en.htm
2007 public health call announced The 2007 call for proposals in the fieldof public health has been announced bythe Health and Consumer ProtectionDirectorate General. The deadline forapplications is 21 May.
Further information is available athttp://ec.europa.eu/phea/calls/call_for_proposals_en.html
Update to Health For All Database The January 2007 updates of both theWorld Health Organization’s EuropeanHealth For All database (HFA-DB) andthe European Mortality Database(MDB) are now available. HFA-DBprovides fast and easy access, in graphi-cal form, to a wide range of basic healthstatistics on the 53 countries of theWHO European Region. The MDBprovides the same user-friendly access tomortality statistics by 67 causes and forseveral age groups.
The database can be downloaded athttp://www.euro.who.int/hfadb
Report: Future funding of health carein EnglandIn order to help inform the debate aboutfunding health in England over the nextfive to ten years, the independent healthpolicy think tank, the King’s Fund, organised a meeting of senior NHSmanagers, Department of Health offi-cials, Prime Ministerial policy advisersand academic health economists. It setout to consider not just the immediatequestion of what level of public fundingis feasible and desirable in the immediatefuture and beyond, but also the processby which such decisions should bereached and the framework that ought
to guide and inform policy-makers. Thereport includes presentations on key aspects of current system reforms in theNHS and a summary of the discussions.It also includes a chapter on interna-tional trends in funding.
More information at http://www.kings-fund.org.uk/resources/publications/funding_health.html
Health care reform in Russia: problems and prospectsThis working paper, written by WilliamTompson at the Organisation for Economic Cooperation and Develop-ment, examines the prospects for reformof Russia’s health care system. It beginsby exploring a number of fundamentalimbalances that characterise the currenthalf-reformed system of health care provision before going on to assess thegovernment’s plans for going ahead withhealth care reform over the mediumterm. The challenges it faces includestrengthening primary care provisionand reducing the current over-relianceon tertiary care; restructuring the incen-tives facing health care providers; andcompleting the reform of the system ofmandatory medical insurance.
The report is available athttp://www.olis.oecd.org/olis/2006doc.nsf/linkto/eco-wkp(2006)66
Masterfoods to stop advertising tothe under 12sIn February 2007, Masterfoods, themaker of Mars and Snickers chocolatebars, announced that it would stop marketing confectionery to childrenyounger than twelve by the end of theyear. The self-imposed ban will apply toall advertising, including online and newmedia. Masterfoods already has a policyof not advertising to children aged undersix. It is the first time a major food company has set such a high global agethreshold for confectionery products.Writing to Robert Madelin, the Euro-pean Commission Director-General forHealth and Consumer Protection, thecompany stated that they had “decidedto make an official policy change to acut-off age of twelve years for all coreproducts.” Some have speculated thatthe move has been made in anticipationof regulatory measures. In the UK thebroadcast regulator Ofcom recently
announced plans to introduce a ban onjunk food advertising to those under six-teen (see article in main news section).This is the latest in a series of voluntarymoves by the food and drink industry.The Union of European Beverages Associations last year agreed to stop advertising to children under twelve inEurope. Coca-Cola does not market itscarbonated drinks to children undertwelve globally.
DG names senior team and revisedstructureOn 22 February, Dr Margaret Chan, Director-General of the World HealthOrganization (WHO), named her seniorteam to lead the health programmes, or‘clusters’ at WHO headquarters inGeneva. Dr Chan also announced a revised structure including three newclusters, in order to realign WHO'sstructure with the six core areas she hasidentified to take WHO's work forward: health development, health security, health systems capacity, evidence and information, partnership,and performance.
More information on the new structuresat http://www.who.int/mediacentre/news/notes/2007/np08/en/index.html
Home safety campaign launchedThe European Child Safety Alliancelaunched its home safety campaign at theend of November in Brussels. For thecampaign the Alliance has made somehome injury fact sheets and parent tipsheets and has also produced a ChildSafety Product Guide. The Alliance defines home injuries as those occurringin or around the home, including thegarden, garage and driveway, and excluding the pavement, street or community playground.
Presentations and fact sheets are avail-able at http://www.eurosafe.eu.com/csi/eurosafe2006.nsf/wwwVwContent/l4homesafetycampaign.htm
eurohealth Vol 12 No 4 44
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