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EurohealthHealth worker migration in Europe: assessing the policy options

Volume 13 Number 1, 2007RESEARCH • DEBATE • POLICY • NEWS

Migrant health in the EU

England: payment by results

Albania: pharmaceutical reimbursement

Spain: long-term care reform • Mental health policy in Europe: time to refocus Croatia : introduction of DRGs • Nicotine replacement therapy revisited

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Train of thought: migration and health

As James Buchan writes in this issue of Eurohealth,the migration of health workers has now become a significant feature of the global health policy debate. It has particularly taken on prominence in Europe asthe EU expands yet further. It is all too easy to see theinternational recruitment of health workers as a ‘quickfix’ short-term solution to the health professional skillshortages that can be observed in some European coun-tries. Why invest scarce resources and many years intraining up the domestic workforce, when it is mucheasier simply to launch overseas recruitment drivesand free ride on the training efforts of others? Well this would be fine, if not for the consequences forthose ‘donor’ countries; often low-income countries themselves with severe shortages of health care professionals.

Global problems require global solutions, yet it is remarkable that so little is still known about the impact of migration on the effectiveness of health systems in Europe; nor is there any system in placethat can accurately measure the stocks and flows ofmigrant health care workers. This raises all manner ofethical and practical challenges for policy makers. Professor Buchan sets out here some of the potentialpolicy options that the international community maywish to consider in their deliberations, including thegreater use of international codes of practice, as well asbilateral agreements.

Of course, it is not just health care professionals thatcontinue to migrate across Europe. When does thehealth status of immigrants become comparable to thatof the local population? What steps can be taken to protect both the health of migrants and that of established residents. Again, as Philipa Mladovskynotes, European countries rarely collect health data byethnicity, making it difficult for policy makers to address some of these issues. Carefully targeted policies would seem merited, given that in many instances first generation migrants may enjoy a betterstate of health than that experienced by subsequentgenerations.

David McDaid EditorSherry Merkur Deputy Editor

MENT

EurohealthCOM

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Contents EurohealthVolume 13 Number 1

Seán Boyle is Senior Research Fellow, LSE Healthand the Personal Social Services Research Unit,London School of Economics and PoliticalScience.

James Buchan is Professor, School of HealthSciences, Queen Margaret University, Edin-burgh, Scotland.

Joan Costa-Font is Research Fellow in Healthand Pharmaceutical Economics, LSE Health,London School of Economics and PoliticalScience and Associate Professor of Economics,Centre for Economic Analysis and SocialPolicies, University of Barcelona.

Aleksandar Dzakula is Research Fellow,Department of Social Medicine and Organi-sation of Health Care, Andrija Stampar Schoolof Public Health, Medical School, University ofZagreb, Croatia.

Anna García González, is Research Assistant,Centre for Economic Analysis and SocialPolicies, University of Barcelona.

Florentina Gjeci is a PhD student in PublicHealth, Pierre & Marie Curie University, Paris,France. From 1995 to 2003, she was Head ofthe Price Unit of the Reimbursement Departmentof the Health Insurance Institute, Tirana, Albania.

Walter Holland is Emeritus Professor of PublicHealth Medicine and Visiting Professor, LSEHealth, London School of Economics

David McDaid is Research Fellow, LSE Healthand Social Care and the European Observatoryon Health Systems and Policies, London Schoolof Economics and Political Science.

Philipa Mladovsky is Research Assistant, LSEHealth, London School of Economics andPolitical Science.

Tihomir Strizrep is Head of Department forContracting of Inpatient and Outpatient HealthCare Services at the Croatian Institute for HealthInsurance.

Luka Voncina is Research Fellow, Department ofSocial Medicine and Organisation of HealthCare, Andrija Stampar School of Public Health,Medical School, University of Zagreb, Croatia.

Migration and health6 Health worker migration in Europe: assessing the policy options

James Buchan

9 Migrant health in the EUPhilipa Mladovsky

Health Policy Developments12 Payment by Results in England

Seán Boyle

17 Mental health policy: Time to refocus on promotion andpreventionDavid McDaid

20 Long-term care reform in SpainJoan Costa-Font and Anna García González

European Snapshots1 Albania: The Health Insurance Institute and pharmaceutical

reimbursementFlorentina Gjeci

4 The introduction of DRGs in Croatia Luka Voncina, Tihomir Strizrep and Aleksandar Dzakula

Evidence-informed Decision Making

23 “Bandolier” Nicotine replacement therapy (NRT) revisited

25 “Risk in Perspective” Air pollution risks in China

Monitor

29 Publications

30 Book ReviewSilent victories. The history and practice of publichealth in twentieth-century AmericaReview by Walter Holland

31 Web Watch

32 News from around Europe

Eurohealth Vol 13 No 11

EUROPEAN SNAPSHOTS

Health care in AlbaniaAlbania has a population of 3.58 million.This is one of the youngest populations inEurope, with an average age of 28.9 years.1

In 2005, total health expenditure was 6.6%of Gross Domestic Product,2 putting thecountry in line with the average for lowermiddle income countries. Albania’s healthcare system prior to this transition wascharacterised by strong centralgovernment control over all aspects of thesystem. This was based on the Semashkostyle, which in one manner reflected therelationship between countries in centraland eastern Europe. A series of reformswere initiated in the mid-1990s, whichincluded the decentralisation of primarycare management, privatisation of thepharmaceutical sector and the estab-lishment of the Health Insurance Institute(HII).

The government is the major provider ofhealth care services. They are organised onthree levels: (i) primary health care isprovided at health centres and polyclinics;(ii) secondary health care is provided atdistricts hospitals (51 hospitals in 36districts); and (iii) tertiary health care isprovided at the University HospitalCentre (CHU) located in the capitalTirana, where more than one-fifth of thepopulation lives.

The HII covers primary health careservices, including general practitioner and

specialist visits, as well as the reim-bursement of a list of outpatient pharma-ceuticals (‘positive list’). In contrast,hospital care remains under direct stateadministration. Established in 1995, it is anindependent body funded by payroll taxcontributions as well as contributions fromthe self-employed and farmers, andgovernmental budget contributions for thedependent (non-active) population.

Pharmaceutical distribution and reim-bursement Patients treated at polyclinics and healthcentres who require a pharmaceuticalproduct receive a prescription and collect itfrom a private pharmacy. Private phar-macies procure products from privatewholesalers. If the patient is insured(covered by the HII), the pharmacy will bepartially or fully reimbursed for the priceof the medicine. The patient pays theremainder out-of-pocket.

Under the HII there is 100% reim-bursement of prescription drugs forchildren 0–12 months, people with severedisabilities, military veterans, old agepensioners, as well as patients with cancer,tuberculosis, multiple sclerosis, anaemiacaused by chronic kidney failure, majorthalasaemia, and kidney transplantation.

There is partial reimbursement rangingbetween 50% and 95% of prescriptioncosts, dependent on therapeutic class foremployees, the voluntarily insured, thosewith mild and moderate disabilities, socialwelfare recipients, children aged one yearand over, students, expectant and newmothers and soldiers. The levels of reim-bursement were last approved by theCouncil of Minister in February 2007. Thepercentage of reimbursement is calculatedusing a reference price which representsthe lowest retail price of a generic drug

(lowest CIF price* + wholesale margin +retail margin). Moreover, military veteranscan be prescribed any branded product(i.e. a registered drug, regardless ofwhether on the reimbursement list).).

The current distribution margins inAlbania are high compared to those ofother countries - 18% for wholesale and33% for retail. The current fixed marginscreate an incentive to distribute higherpriced drugs. At the same time, a digressivemargin system has been introduced for themost expensive drugs (about 20% of drugson the reimbursement list), aimed atreducing this incentive to sell expensivedrugs. For example, the drug Erythropoi-etinum ampoule, has lower margins of 8%for wholesale and 15% for retail, (thehigher the price – the lower the margins).There remains however scope for informalpayments to be potentially linked toprescribing practices as highlighted by theHII.3 There may also be perverse incen-tives for physicians and pharmacists tocollude to process ‘ghost’ prescriptions,and then share the additional reimburse-ments received from the HII. A confi-dential telephone hotline has also been setup to allow the public to report instanceswhere a patient has felt been pressurised toprocess their prescriptions in specific phar-macies.3

The positive list and pharmaceuticalexpenditureThere are currently 341 drugs on the reim-bursement list (that came into force on 1April 2007), and some can only beprescribed under specific conditions orfollowing approval from a specialist. Inthis case, the primary health care (PHC)physician completes a form in which he

Albania: The Health InsuranceInstitute and pharmaceuticalreimbursement

Florentina Gjeci

Florentina Gjeci is a PhD student inPublic Health, Pierre & Marie CurieUniversity, Paris, France. From 1995 to 2003, she was Head of thePrice Unit of the ReimbursementDepartment of the Health InsuranceInstitute, Tirana, Albania. Email: [email protected] * Cost, insurance and freight price.

Eurohealth Vol 13 No 1 2

EUROPEAN SNAPSHOTS

recommends the specific drug to aspecialist, for example, Ibuprofen 400 mg.The specialist may, however, prescribeanother drug, different to that prescribedby the PHC physician, for example,Voltaren 50 mg.

In principle, all drugs prescribed byspecialist doctors have to be endorsed by aPHC physician. Often, patients can getconfused when they receive a differentbrand than that prescribed by the specialistand which they desired to have. To avoid

this confusion, some patients choose tovisit the specialist first and afterwards goto the PHC physician to endorse theprescription. The pharmacists are allowedto substitute less expensive, branded andgeneric drugs. The positive list is updatedevery year by a committee set up by theOrder of the Minister and is made availableto PHC physicians by the HII.

Over the past few years, the HII has beenfacing the problem of growing pharma-ceutical expenditure.

Expenditure on pharmaceutical reim-bursement drastically increased during2003 and 2004 (see Table 1). In 2004, HIIexpenditure on drugs was €28.9 million(3.66 billion Leke).* This equated to 60%of total HII expenditure or 10.6% of totalhealth expenditure (including all publicand private spending on health).

The increase in expenditure is due to acombination of factors, including theexpansion of the positive list and the newco-payment exemption. For example 72new drugs were added to the list in 2004,many of which were very expensive. At thesame time, the reimbursement committeedecided that drugs for pensioners shouldbe fully reimbursed. In 2004, the HIItherefore ran up a deficit of €4.8 million,that increased to €8 million in 2005.

Another challenge in Albania is that physi-cians tend to prescribe expensive brandname drugs, which leads to high expen-diture. As indicated in Table 2 out of thetop ten reimbursed drugs by value, six aresingle source and these are also veryexpensive. Approximately 50% ofexpensive drugs in the reimbursement listare single source drugs.5

Challenges and measures forimprovementAs drug distribution in Albania has beenproblematic and partially undermined bycorruption, the HII has introduced anumber of measures intended to improve

* The average annual exchange rate for 2004was €1 = 126.5 Leke.

Table 1. Total Expenditure of Health Insurance Institute of Albania, 1995–2004 (€ millions)

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Reimbursement of drugs 2.4 6.8 9.5 14.1 15.3 13.5 13.3 13.4 17.8 28.9

% of total HII exp 73.4 68.2 74 74.9 74.9 70 56.7 47 51.5 60.2

Doctors 0.6 2.5 2.7 3.4 3.8 4.2 4.8 6.9 7.8 8.7

Administration 0.2 0.5 0.6 1.1 1.2 1.4 1.8 2.4 2.5 2.8

Investments 0.1 0.2 0.0 0.2 0.2 0.2 0.2 0.6 1.0 0.8

Pilot project expenses 0.0 0.0 0.0 0.0 0.0 0.0 3.4 5.2 5.4 6.8

Total 3.3 10 12.8 18.8 20.5 19.3 23.5 28.5 34.5 48.0

Source: Health Insurance Institute of Albania, 2005.4

Table 2: Top ten reimbursed drugs by value 2005

INN Name Indication Quantity Value (Leke)

Enalapril 20 mg ACE Inhibitors, Hypertension 21,351,668 233,511,574

Risperidon 2 mg Neuroleptic, psychosis, Angiotenstin II antagonist

967,302 224,430,982

Valsartan 80 mg Hypertension 1,747,126 195,308,163

Interferon beta Multiple Sclerosis 14,730 137,119,170

Amlodipine 10 mg Calcium antagonist, hypertension 3,991,451 127,660,162

Fluvastatine 40 mg Cholesterol lowering 1,519,703 122,557,294

Finasteride 5 mg Benign prostatic, hyperplasia Alpha-blocker

701,542 107,054,934

Tamsulosin 0,4 mg Hyperplasia 576,959 106,183,326

Olanzapine 10 mg Neuroleptic, psychosis 101,448 95,819,722

H-insulin bi-phasic Diabetes 87,766 90,516,449

Note: Single source drugs in bold. Source: Health Insurance Institute, 2005.6

the situation and contain costs. First,certain drugs can now only be prescribedunder specified conditions. In mid-2006,there was a revision of the positive list andcontracts that HII have with familydoctors and pharmacists. A drug budget isdetermined for each PHC doctor in orderto control spending. The budget is indi-vidualised and differs according tohistorical spending and the number of war

veterans and people with disabilities seenby the physician. Also, additional controlsare in place at polyclinics and in phar-macies to prevent the generation of falseprescriptions that in fact are not dispensed.Furthermore, important steps have beentaken to improve transparency along thepharmaceutical distribution chain. TheHII is also looking into establishingtreatment guidelines for primary care that

could then be used to monitor prescribing.

These measures are in themselves insuffi-cient to curb the rapidly increasing expen-diture, thus the HII is continuing tointroduce new elements, including twelvehealth economic indicators, in an attemptto improve both the quality of primaryhealth care and the efficient remunerationof physicians. These are thus dividedbetween two performance and ten qualityindicators (see Box 1).

ConclusionsThe Health Insurance Institute iscommitted to consolidating efforts tostrengthen the management of the healthinsurance system. The measures intro-duced, including these health economicindicators, are only the beginning of a longand complex process. Remaining chal-lenges include strengthening control in themarket; increasing transparency in thevarious commissions that make decisions;and revision of the level of pharmaceuticaldistribution margins. The success of theseefforts will depend greatly on the futureorganisational model adopted as well as onthe improvements in the rules andmanagement capacities of the healthsystem.

REFERENCES:

1. Central Intelligence Agency. World FactBook. Arlington: CIA, 2007. Available athttps://www.cia.gov/cia/publications/factbook/print/al.html

2. World Health Organization. NationalHealth Accounts Series – Albania.Geneva: World Health Organization,2005. Available athttp://www.who.int/entity/nha/country/ALB.pdf

3. Health Insurance Institute, Focus2007;2(March).

4. Health Insurance Institute. AnnualReports 2004. Tirana: HII, 2005.

5. World Bank. Albania – Health SectorNote. Washington: World Bank, Report32612, 2006. Available atwww.worldbank.org

6. Health Insurance Institute. Data fromthe Department of Information andStatistical Analysis. Tirana: HII, May2005.

7. Health Insurance Institute. Personalcommunication. Tirana: HII, PhysicianDepartment, 2007.


EUROPEAN SNAPSHOTS

Box 1: Health economic indicators

Performance indicators

1. Thirteen medical visits per doctor per day (rural) and sixteen visits per doctor perday (urban), with consideration for special cases, for example, physicians workingin mountainous areas.

2. 60% of people registered in each health centre should be covered by insurance.Currently only 40–45% of the population benefit from coverage under themandatory health insurance system, indicating that the majority of population stillpay for medicines out-of-pocket.6

Quality service indicators

3. Planning of patient visits (all visits will be planned for chronically ill patients)aimed at avoiding the long waiting time and towards better organisation ofphysician time.

4. Maintaining the percentage level of immunisations in accordance with nationalstandards

5. Improving the situation of chronically ill patients (aiming to monitor and keepunder control the diagnosis of chronic diseases and reimbursement expendituresfor these patients).

6. Obtaining direct feedback from the population (for example, patient question-naires) at least twice per year. (This point has been largely neglected)

7. First time patient visits have to cover 60% of an area’s population (this aims fordoctor to knows the epidemiologic situation at areas he/she works).

8. Child mortality rates to be under the average of the health centre (for each doctorthese data will be compared with data of the health centre where he/she works,data of regional level/data of national level).

9. The average prescription value per diagnosis to be in the regional level (Theregional average prescription value per diagnosis is considered as a benchmark).

10. Decrease the average prescription value per inhabitant by 5% (This value to bedecreased up to 5% when compared with that of previous year).

11. Decrease in references given by PHC physician to the specialist doctors by 5%.(This requires more responsibility and professional skills of PHC physicians, whosometimes recommend patients to a specialist without having clearly motivatedreasons).

12. Participation of the medical staff in continuing professional development.

Source: Health Insurance Institute, 2007.7

https://www.cia.gov/cia/publications/factbook/print/al.html

http://www.who.int/entity/nha/country/ALB.pdf


EUROPEAN SNAPSHOTS

In Croatia, hospitals have been funded bymonthly payments from the state healthcare budget, controlled by the state healthinsurance fund (Croatian Institute forHealth Insurance, HZZO). Funds have tobe accounted for through the issue of billsfor medical services. These bills are acombination of fee-for-service (FFS)payments and charges levied under a Diag-nosis Related Groups (DRG) systemreferred to as the PPTP (Placanje po terapi-jskom postupku).

Furthermore, hospitals have hard budgets.If a hospital exceeds its annual budget, itwill not receive additional funding for anybills levied for further services provided.Conversely if hospitals do not provideenough services to account for all of theirbudgets in a given year, then, in accordancewith their contracts with the HZZO, in thesubsequent fiscal year their budgets shouldbe reduced by an amount equal to theseunspent funds.

Under the FFS reimbursement system,hospitals are reimbursed on the basis ofinputs used. The payment system consistsof three separate components: (1) hospitalhotel services, paid via a flat rate per diem;(2) medical services provided; and (3) phar-maceuticals and other supplies that arepaid for separately, depending on the costof each item. Under the current FFSschedule, hospitals have an incentive to

maintain a high level of bed occupancy andextend length of stay, since this high occu-pancy rate results in stable fundingthrough per diem payments, while themajority of costs tend in fact to be concen-trated in the first few days of hospitalstays. Low occupancy rates also increasethe risk that the HZZO will lower theglobal budget ceiling.1 The effects onservice provision can be seen in Table 1, asaverage lengths of stay and bed occupancyrates in Croatian hospitals for acute careare significantly higher than in some neigh-bouring countries such as Slovenia,Hungary and Austria.

In 2002, the government started tointroduce the PPTP, the parallel DRG-based element of the payment system forcertain diagnoses that makes use of broadcase groupings. By 2006, the number ofservices reimbursed via the PPTP systemhad grown to 118 selected diagnoses, withthe remainder still being paid for by thepoint-based FFS schedule. Interventionsfor these PPTP case groupings were eithercostly or numerous and the prospectivepayment system was intended to providehospitals with incentives to increase thetechnical efficiency of service provision.Both the use of broad-based case

groupings in the PPTP system, as opposedto more detailed DRGs, as well as theprices set for particular PPTPs, have madethem quite unpopular with providers. Thissystem has on occasion been accused ofunderestimating the intensity of resourceuse for more complicated medical cases.

Nonetheless, encouraged by reports ofefficiency gains arising from the imple-mentation of the PPTP schedule, includingreductions in length of stay,3 thegovernment has now decided to graduallymove towards a comprehensiveprospective case-adjusted payment systembased on DRGs. This will represent animportant step in rationalising incentivesin the health care system.

As in some other European countries, suchas Ireland, Romania, Germany andSlovenia, Croatia has decided not decide todevelop its own DRG system, but ratherto import and modify the AustralianRefined-DRG (AR-DRG) system (specif-ically, version 5.1), known locally as Dijag-nosticko terapijske skupine (DTS). It hasalready been piloted in four Croatianhospitals since February 2006. As of April2007, it has been introduced by the HZZOinto all Croatian hospitals, initially

The introduction of DRGs inCroatia

Luka Voncina, Tihomir Strizrep and Aleksandar Dzakula

Luka Voncina and Aleksandar Dzakulaare Research Fellows in the Departmentof Social Medicine and Organisation ofHealth Care, Andrija Stampar School ofPublic Health, Medical School, Universityof Zagreb, Croatia.

Tihomir Strizrep is Head of Departmentfor Contracting of Inpatient and Out-patient Health Care Services at theCroatian Institute for Health Insurance.Email: [email protected]

Table 1: Average length of stay and bed occupancy rates for acute inpatient care 2003

Country Average length of stay(days) per hospitalisation

Bed occupancy rates

Croatia (2004) 8.20 89.90%

Hungary 6.65 77.15%

Austria 6.35 76.20%

Slovenia 6.10 68.12%

Source: HZJZ 2005.2


EUROPEAN SNAPSHOTS

running in tandem with existing billingsystems. Until January 2008, all hospitalswill continue to account for their budgetsaccording to the old two-tiered FFS andPPTP schedule, but are now also obligedto keep track of cases according to the newDTS schedule. During this period, theHZZO plans to actively work withhospitals to ensure the appropriateness andquality of the coding used .

One of the greatest challenges to the intro-duction of this Australian system inCroatia still to be addressed is thedifference in DRG costing between thetwo countries. The original ARG-DGsystem unsurprisingly made use of

Australian data on resources use, clinicalpractice and the monitoring of hospitalbilling. A second challenge related to thepossibility of a form of ‘gaming’ known as‘code creep’ in DRG systems, i.e. codingpatients as having more serious/compli-cated conditions that they actually have.This issue will have to be closely examinedonce the DRG system is fully imple-mented, but as yet the system is still in tooearly a stage of development and the issuehas not received sufficient attention. InAustralia, in contrast, six different mecha-nisms are now employed to reduce thisrisk of upcoding.4

REFERENCES

1. Voncina L, Jemiai N, Merkur S, et al.Croatia: Health System Review. HealthSystems in Transition 2006; 8(7).

2. HZJZ. Report on Hospital Activities in2004. Zagreb: Croatian National Institutefor Public Health, July 2005. [in Croatian]

3. World Bank, Europe and Central AsiaRegion, Human DevelopmentDepartment. Croatia Health FinanceStudy. Washington, DC: World Bank,2004.

4. Steinbusch PJ, Oostenbrink JB, ZuurbierJJ, Schaepkens FJ. The risk of upcoding incasemix systems: A comparative study.Health Policy 2007;81(2–3):289–99.

New Health Systems in Transition (HiT) profiles from the Observatory

Croatia HiT

By: Luka Voncina, Nadia Jemiai, Sherry Merkur,Christina Golna, Akiko Maeda, Shiyan Chao and Aleksandar Dzakula

Edited by: Sherry Merkur, Nadia Jemiai and Elias Mossialos

Available athttp://www.euro.who.int/document/e90328.pdf

Bulgaria HiT

By: Lidia Georgieva, Petko Salchev, RostislavaDimitrova, Antoniya Dimova and Olga Avdeeva

Edited by: Olga Avdeeva and Melinda Elias

Available athttp://www.euro.who.int/Document/E90023.pdf

10-page summaryhttp://www.euro.who.int/Document/E90023brief.pdf

This new HiT profile highlights some of the main reformscarried out to make the Bulgarian health system more efficientand responsive to patients’ needs. In the new system, the role ofprimary care has been strengthened, especially that of thegeneral practitioner operating as a gatekeeper. Also, inpatientcare has been restructured and rationalised, reducing thenumber of hospital beds and the average length of stay.

Armenia HiT

By: Tatul Hakobyan, Mihran Nazaretyan, TatyanaMakarova, Movses Aristakesyan, HovhannesMargaryants and Ellen Nolte

Edited by: Ellen Nolte and Erica Richardson

Available athttp://www.euro.who.int/Document/E89732.pdf

Since independence, the health care system in Armenia hasundergone numerous changes that have effectively trans-formed a centrally run state system into a fragmented healthcare system that is largely financed from out-of-pocketpayments. Armenia is increasingly reforming the health systemfrom one that emphasises the treatment of disease andresponds to epidemics to one which emphasises prevention,family care and community participation.

Croatia’s health system is based on the principles of inclusivity,continuity and accessibility. Since 1991, it has been subject to arange of organisational reforms, which have mostly relied ondecreasing public and increasing private expenditure in thesystem. The Croatian health system has a well-trained work-force, a well-established system of public health programmesand health delivery system, and good health outcomes inrelation to countries at comparable income levels.


MIGRATION AND HEALTH

Polish physicians working in Germany.German physicians flying to England towork at weekends. Angolan nursesworking in Portugal. Estonian pharmacistsworking in Finland. Doctors from theKyrgyz Republic migrating to Kaza-khstan. The issue of the migration ofhealth workers has become a more signif-icant feature of international health policydebate in the last few years, in Europe andelsewhere,1–4 and has taken on additionalprominence in Europe as more countrieshave joined the European Union (EU).5

The international recruitment of healthworkers has become a “solution” to thehealth professional skill shortages in somecountries. It offers a “quick fix” which canbe attractive to policy makers. It can takethree to five years to train a nurse, andfifteen to twenty to train an experiencedsenior physician. Recruiting in other coun-tries can deliver these staff much quicker -and with the training costs having beenmet by someone else. This activerecruitment of nurses, doctors and otherworkers is in addition to any “natural”migration flows of individuals movingacross borders for a range of personalreasons.

Just as international recruitment can be asolution to the staff shortages in somecountries, it can also create the additionalproblem of skills shortages in others.Countries that lose scarce skilled staff maysuffer a negative impact on the effec-tiveness of their health care systems. Thisissue has been debated at the World HealthAssembly,6 has received attention at EUlevel and in the Council of Europe, and hasbeen identified as a critical humanresources for health issue within theEuropean region of the World HealthOrganization.4

Some European countries have beenactively recruiting health workers fromother countries. Others, particularly in theeast, are concerned about the out-migration of health workers as a result ofaccession to the EU.

General migration trends in EuropeIn relation to the countries of the EU, andEU enlargement, a recent overview for theEuropean Foundation for theImprovement of Living and WorkingConditions5 reported the following keyestimates:

– There were thirteen million non-national citizens living in the fifteen EUmember states in 2000, but half werenationals of other EU countries;

– the income gap between central andeastern acceding countries and existingmember states is estimated at 60%,

which is much higher than in theprevious enlargement of the EU;

– migrants from the accession states arelikely to be relatively young and educa-tionally well qualified, with womenmaking up to 40–45% of the total,creating a potential ‘youth drain’ in thesource countries.

Assessing trends in the migration ofhealth workersHow important is the migration of healthworkers to health system effectiveness inEurope? The simple answer is that we donot know, because of limitations inavailable data. There are two main indi-cators of the relative importance ofmigration and international recruitment toa country: by examining the ‘inflow’ ofworkers into the country from othersource countries (and/or the ‘outflow’ toother countries), or by assessing the actual‘stock’ of international health workers inthe country at one point in time.

Many countries in Europe and elsewherecurrently cannot monitor with anyaccuracy the stocks and flows of migranthealth workers. This limits their capacityto assess the impact of policies and meansthat they cannot be clear about the impactof migration. This constrains any attemptto develop a clear Europe-wide picture ofthe overall flows of health workers. Manycountries, both ‘source’ and ‘destination’,need therefore to improve their ability to

Health worker migration in Europe:assessing the policy options

James Buchan

Summary: The issue of the migration of health workers has become amore significant feature of international health policy debate in the lastfew years, in Europe and elsewhere. It has taken on additional promi-nence in Europe as more countries have joined the European Union. Thispaper examines trends in general migration in Europe, and highlights thekey policy options for ‘source’ and ‘destination’ countries when moni-toring and assessing the implications of health worker migration.

Key words: migration, workforce planning, international recruitment

James Buchan is Professor, School ofHealth Sciences, Queen MargaretUniversity, Edinburgh, Scotland. Email : [email protected]

assess the dynamics of migration, in orderto decide if migration is a problem or asolution, and to identify the correct policysolutions.

‘Source’ countriesGovernments and policy makers in coun-tries that are experiencing a net outflow ofhealth workers, such as some in the east ofEurope and central Asia, need to be able toassess why this is happening and evaluatewhat impact it is having on the provisionof health care in the country. It isimportant that the available informationenables policy-makers to assess the relativeloss of staff due to outflows to other coun-tries in comparison with other internalflows, such as health workers leaving thepublic sector to work in the private sector,or leaving the health professions to take upother forms of employment. Migrationmay be the most obvious source of “loss”of health workers, but it may not be themost important.

In addition, for some of these countries,out-migration may be encouraged, eitherto reduce oversupply of specific types ofworker, to encourage some workers toacquire additional skills or qualificationsbefore then returning, or to stimulate thereturn of hard currency through remit-tances from these migrant workers. Otherpolicy responses to reducing outflow relateto a more direct attempt to curtail the pushfactors, for instance by dealing withmatters concerning poor pay and careerprospects, poor working conditions andhigh workloads, as well as responding toconcerns about security, and improvingeducational opportunities.

‘Destination’ countriesThe first concern of stakeholders in desti-nation countries should be the monitoringand assessment of inflow trends (in termsof numbers and sources), as this is vital if acountry is to be able to integrate this infor-mation into its workforce and serviceplanning process, as well as assess therelative contribution of internationalrecruitment compared with other keyinterventions (such as home-basedrecruitment, improved retention, and thereturn of home-based non-practisinghealth professionals).

A second element of the ‘management’ ofmigration for destination countries is thatof efficiency and effectiveness. If there isan inflow of health workers from sourcecountries, how can this inflow bemoderated and facilitated so that it makes

an effective contribution to the healthsystem? Policy responses have included‘fast tracking’ of work permit applications;developing coordinated, multi-employerapproaches to recruitment to achieveeconomies of scale in the recruitmentprocess and developing multi-agencyapproaches to coordinated placement ofhealth workers when they have arrived inthe source country. These may include theprovision of initial periods of supervisedpractice or adaptation as well as languagetraining, cultural orientation and socialsupport to ensure that the newly arrivedworkers can assimilate effectively into thenew country, culture and organisation.Another related challenge may be that oftrying to ‘channel’ or direct internationalrecruits to the geographic or specialityareas that most require additional staff.

The migration and internationalrecruitment of health workers creates chal-lenges for both individual health workersand policy makers in ‘source’ and ‘desti-nation’ countries, and at European level.Some of the key issues are summarised inTable 1 which also highlights some of thepotential opportunities created whenhealth workers are, or can be, interna-tionally mobile.

Policy optionsEssentially there are two viable policystances for states and regions faced withthe issue of in-migration and/or out-migration of health workers. Either non-intervention, or some level of interventioneither to moderate flows via some type offramework or code, or to attempt tomanage the migration process so that it is

nearer ‘win–win’, or at least is not exclu-sively ‘win–lose’, with the countries thatcan least afford to lose being the biggestlosers.

One option is for individual countries toestablish bilateral agreements to recruithealth workers; one example was thatbetween England and Spain to encourageSpanish nurses to work in England.Another option is to introduce a code ofpractice, either unilaterally or multilat-erally, which sets down principles foreffective and ‘ethical’ internationalrecruitment. The Department of Health inEngland has a Code of Practice on Inter-national Recruitment.7 The Code requiresNational Health Service employers not toactively recruit from developing countries,unless there is government- to-government agreement. It also listsapproved recruitment agencies.

Another option would be for a regionalbloc such as the EU as a whole tointroduce some type of guidelines, code orframework. There is already an example ofa multilateral code, which was introducedby the Commonwealth.8 Some interna-tional health professional associations havealso promoted codes and principles forinternational recruitment, as in the case ofthe European Federation of Nurses.9

Whatever the source of such a frameworkor code, its effectiveness will be based onthree factors: content, coverage, andcompliance. What is its content? What arethe principles and practical details set outto guide international recruitment? Whatis its coverage? Does it cover all relevantemployers and countries? Is complianceassured? Are there systems in place to



Table 1: International recruitment of health workers: opportunities and challenges

Opportunities Challenges

Destination countries Solve skills/ staff shortages. A “Quick Fix”.

How to be efficient and ethical in recruitment.

Source countries Remittances

Upskilled returners (if theyreturn)

Outflow causes shortages with negativeimpact on delivery of care. Costs of “lost”education. Increased costs of recruitment of replacements. “Manage” migration?

Internationally mobilehealth workers

Improved pay, career opportunities, education.

Achieving equal treatment in destinationcountry

Static health workers [If worker oversupply]

Improved job and careeropportunities

Increased workload as staff leave. Lower morale.

monitor cross border recruitment activity,and what are the penalties for non-compliance?

Table 2 sets out some options for policy atorganisational, state and internationallevels; some are relevant for ‘source’ coun-tries, some for ‘destination’ countries, butfew have been fully implemented or eval-uated. The next round of policy researchshould focus on two aspects of migration.Firstly, there is a clear need to improve theavailable data so that the monitoring oftrends in flows of health workers can bemore effective. Secondly, it should assessthe viability and effectiveness of thevarious possible policy interventions, to

identify which, if any, are relevant and mayhave the potential for mutual and bene-ficial impact in Europe.

REFERENCES

1. Tjadens F. Health care shortages: whereglobalisation, nurses and migration meet.Eurohealth 2002;8(3):33–35. Available at:http://www.lse.ac.uk/collections/LSEHealthAndSocialCare/pdf/eurohealth/vol8no3.pdf

2. Stilwell B, Diallo K, Zurn P, Dal Poz MR, Adams O, Buchan J. Developingevidence based ethical policies on themigration of health workers: conceptual

and practical challenges. Human Resourcesfor Health 2003;1(1):8. Available athttp://www.human-resources-health.com/content/1/1/8

3. Buchan J. Migration of health workers inEurope: policy problem or policy solution?In: Dubois C, McKee M, Nolte E (eds).Human Resources for Health in Europe.Buckingham: Open University Press, 2006,41-62. Available athttp://www.euro.who.int/Document/E87923.pdf

4.Buchan J, Perfilieva G. Health WorkerMigration in the European Region:Country Case Studies and Policy Implica-tions. Copenhagen: WHO Regional Officefor Europe, 2006. Available athttp://www.euro.who.int/document/e88366.pdf

5. Krieger H. Migration Trends in anEnlarged Europe. Dublin: European Foun-dation for the Improvement of Living andWorking Conditions, 2004. Available athttp://eurofound.europa.eu/pubdocs/2003/109/en/1/ef03109en.pdf

6. World Health Organization. Agendaitem 12.11., Fifty Seventh World HealthAssembly: Health Systems IncludingPrimary Care. International Migration andHealth Personnel: A Challenge for HealthSystems in Developing Countries. Geneva:World Health Organization, May 22, 2004.

7. Department of Health. Code of Practicefor the International Recruitment ofHealthcare Professionals. London:Department of Health, 2004. Available athttp://www.dh.gov.uk/en/Publicationsand-statistics/Publications/PublicationsPoli-cyAndGuidance/DH_4097730

8. Commonwealth Secretariat. Common-wealth Code of Practice for the Interna-tional Recruitment of Health Workers.London: Commonwealth Secretariat, 2003.Available via http://www.thecommon-wealth.org/Internal/34042/human_resources_for_health/

9. European Federation of Nurses. GoodPractice Guidance for International NurseRecruitment. European Federation ofNurses, Brussels, 2004. Available athttp://www.efnweb.org/version1/en/docu-ments/EFNGoodPracticeGuidancefor-Recruitment.doc



Table 2: Examples of potential policy interventions in international recruitment

Level Characteristics/ examples

Organisational

‘Twinning’ Hospital in ‘source’ and ‘destination’ country develop links, based on staffexchanges, staff support and flow of resources to source country.

Staff exchange Structured temporary move of staff to another organisation, based on careerand personal development opportunities/ organisational development.

Educationalsupport

Educators and/or educational resources and/or funding in temporary movefrom ‘destination’ to ‘source’ organisation.

National

Government-to-governmentbilateral agreement

‘Destination’ country develops agreement with ‘source’ country to underwritecosts of training additional staff, and/or to recruit staff for a fixed period,linked to training and development prior to staff returning to ‘source’ country,or to recruit ‘surplus’ staff in ‘source’ country

Ethical recruitmentcode

‘Destination’ country introduces code that places restrictions on employers, interms of which source countries can be targeted, and/or length of stay.Coverage, content and compliance issues all need to be clear and explicit.

Compensation Much discussed, but not much evidence in practice. Destination country payscompensation, in cash or in form of other resources, to source country.Possibly some type of sliding scale of compensation related to length of stayand/or cost of training, or cost of employment in destination country possibly“brokered” via international agency?

Managedmigration(can also beregional)

Country (or region) with outflow of staff initiates programme to stemunplanned out-migration, partially by attempting to reduce impact of pushfactors, and partially by supporting other organisational or national interven-tions that encourage planned migration.

Train for export [Can be a subset of managed migration] Government or private sectormakes explicit decision to develop training infrastructure to train healthprofessionals for export market- to generate remittances, or up-front fees.

International

International code As above, but covering a range of countries. Its relevance will depend oncontent, coverage, and compliance, the Commonwealth Code is an example.

Source: [4]

http://www.human-resources-health.com/content/1/1/8

http://www.euro.who.int/Document/E87923.pdf

http://www.euro.who.int/document/e88366.pdf

http://eurofound.europa.eu/pubdocs/2003/109/en/1/ef03109en.pdf

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4097730

http://www.thecommonwealth.org/Internal/34042/human_resources_for_health/

http://www.efnweb.org/version1/en/documents/EFNGoodPracticeGuidanceforRecruitment.doc

http://www.lse.ac.uk/collections/LSEHealth/pdf/eurohealth/vol8no3.pdf



The thirty-five to forty million foreign-born people in Europe continue to facedifficulties in becoming a full part of theeconomic, cultural, social, and politicallives of their adopted societies.1 This situ-ation is undesirable both from theperspective of European integration andhuman rights. The right to health obligesgovernments to ensure that “health facil-ities, goods and services are accessible toall, especially the most vulnerable ormarginalised sections of the population, inlaw and in fact, without discrimination onany of the prohibited grounds”.2

Migrant health trendsUnlike Australia, Canada and the UnitedStates, European countries rarely collecthealth data by ethnicity (the UK, Swedenand the Netherlands being exceptions).One difficulty in studying migrant healthis defining the subject. At least five sub-categories of ‘migrants’ have been be iden-tified: students; economic migrants;asylum seekers; irregular or undocu-mented migrants; and displaced persons.3

However, it is still unclear how long beforea group of people thought of as ‘migrants’begin to simply constitute a socially orculturally distinct or ethnic group of resi-dents;4 there are different understandingsof what it means to be a ‘migrant’ across

Europe.

Another difficulty is a lack of data. Thedata that are available give rise to acomplex and dynamic picture. A review ofthe literature suggests that infectiousdiseases (including sexually transmittedinfections), accidents, injuries, muscu-loskeletal disorders, violence and drugabuse all appear to disproportionatelyaffect certain migrant groups compared towhat are referred to technically as the‘autochthonous’ or long-standing residentEuropean populations. These patterns arelikely to be linked to increased exposure torisk factors, either in the country of originand/or in European countries wheremigrants are forced to live and work inpoor conditions.

Migrants are not necessarily disadvantagedin all areas of health though. Relatively lowrates of low birth-weight infants have longbeen observed in migrant groups in the USand Europe. Many studies have shownthat chronic diseases are less prevalent insome, though by no means all, migrantgroups compared to indigenous European(and North American) populations. This isknown as the ‘healthy migrant effect’. Ithas been suggested that (self-) selectivemigration may play a role; such findingsmay also be explained by a difference intiming between the health benefits and thehealth risks of migration.5

However, this relative advantage does nottranslate across all countries and across allmigrant groups. Also, research suggests

that the advantage may diminish over time(length of stay) or in subsequent genera-tions. In short, a review of the literaturesuggests that it is not useful to make gener-alisations about the health of migrants,since mortality and morbidity patternsvary across space, time, age, gender,disease, different countries of origin andtype of migration. Disaggregatingmortality and morbidity data by cause, andby country of origin, is crucial.

Five explanations for the differences inhealth between ethnic groups have beenidentified:6,7 genetic differences; culturaldifferences; socioeconomic position; short-term migration history; and ethnic identity.In terms of more proximal determinants,varying patterns in risk factor prevalence(smoking, inactivity, alcohol consumptionand so on) account in part for the differ-ences in health between migrants and theindigenous populations. Additionally, itseems that access to and utilisation ofhealth services also plays a role. Findingsthat some immigrants are comparativelyhealthy and under utilise health servicesrefute the simplistic assumption that immi-grants represent a disproportionate burdenon European health care systems.

Health care access and utilisationMost countries grant full equality oftreatment to third country nationals afterawarding them long-term or permanentresidence status. So is access to health carestill an issue? Data on this topic are rela-tively sparse, but several studies suggest

Migrant health in the EU

Philipa Mladovsky

Summary: Across European Union countries, attempts to incorporate the needs of migrantsinto health systems have remained uncoordinated. The limited available data suggest thatinfectious diseases, accidents, injuries, musculoskeletal disorders and violence disproportion-ately affect certain migrant groups compared to long settled populations in the EuropeanUnion. However, low birth-weight and some chronic diseases are relatively less prevalentin some migrant groups, known as the ‘healthy migrant effect’. This advantage maydiminish in subsequent generations. Legal barriers, communication, lack of information andmistrust are some obstacles to providing good quality care for migrants. Several researchtopics and policy considerations merit greater attention to address these inequalities.

Keywords: migrants, immigrants, inequalities.

Philipa Mladovsky is Research Assistant,LSE Health, London School of Economicsand Political Science. Email: [email protected]

migrants do experience unequal access tohealth care. One issue is that requirementsfor permanent status vary across Europeand obtaining this status may take severalyears.8 Secondly, undocumented migrantsin many countries are not granted equalityof treatment. Besides the legal barriers,migrants also face other specific difficultiesin accessing health care. In clinicalencounters, language and literacy are themost obvious cultural obstacles toproviding good quality care. In addition,miscommunication and dissatisfactionstemming from cultural differences andexpectations can also contribute to suboptimal care. Categories and concepts usedby migrants to explain health problemsmay differ significantly from Westernunderstandings, as the field of medicalanthropology has long demonstrated. Thissuggests there is a major role for userinvolvement in the design of effectiveservices for migrants.

A lack of knowledge about the health caresystem may also be a serious obstacle toaccess, sometimes even despite tailoredpublications and orientation services.Mistrust of service providers may be animportant issue for some, particularlyundocumented migrants fearing detection.In countries with complex registrationsystems for social health insurance, admin-istration and bureaucracy is a majorbarrier. Barriers to health care may resultin worse health outcomes, as is suggestedby the relatively high rate of avoidablemortality found among migrants in somestudies, resulting in health inequalities.They also may result in increasedconsumption of more expensive emer-gency treatments.

Certainly, migrants are likely to facedifferent barriers/inequalities in differentEuropean countries. There are also diffi-culties with measuring utilisation. Also,immigration may not always be theprimary explanatory factor for differencesin health care utilisation, with incomebeing an important confounding variable.Nevertheless, in countries with immigrantpopulations, it does seem that language-adapted and culture-sensitive programmesare needed to decrease inequality in accessfor ethnic minority groups.

Measurement and indicatorsMeasurement of migrant health and healthcare utilisation is challenging for a varietyof technical and political reasons.7 Medicalresearch favours homogeneous samples,resulting in ignorance about the effec-

tiveness of treatments on ethnic minorities,while recording ethnicity in clinicalrecords can be perceived as discriminatory.Ethnic minorities often have low responserates in epidemiological surveys, in partbecause monitoring undocumented immi-grants is difficult and information cannoteasily be validated. Moreover, immigrantmortality in the population may be under-estimated in register-based studies becausesizeable numbers of immigrants whosubsequently leave their new homeland(the host country) fail to register this factwith the national registration authorities.

Several techniques have been developed tocounter a lack of data on migrant health,for example linking datasets and devel-oping algorithms to identify persons ofethnic origin by surname in registries. Ifsurveys do include migration variables,they mostly depend on a broad ‘socialscience’ definition of immigrant status,employing country of birth, parentalcountry of birth and length of stay in thehost country as indicators to identify thispopulation. Conceptually, there are twomain problems with this. Firstly, theparadigm incorporates important sub-categories of persons, such as refugees,who may experience specific non-randompatterns of health and health care thatdiffer to those of non-refugee immigrants.Secondly, the paradigm does not capturelegal status which may affect access to andutilisation of health services, which in turnmay also affect patterns of disease in a non-random manner.9 To make these indicatorsrelevant to health research, an under-standing of the way in which immigrationlaw relates to eligibility in accessing publicservices is important. This may becomecomplex when legal criteria on the eligi-bility of immigration subcategories changeover time.9

Reflecting both these technical difficulties,but also political concerns, there are veryfew, if any, national or European surveyscurrently available to measure the health offirst and second generation migrantsrelative to the health of the native popu-lation. There are also generally low levelsof reporting on migrant health. Exceptionsinclude the Netherlands and to someextent Sweden and the UK. Countriessuch as Belgium, Spain and Germany haveonly very recently started to introducequestions on migration into healthsurveys. New Member States, reflectingtheir relatively low levels of immigration,rarely include indicators of immigration inhealth surveys, but this may change in the

future as the numbers of immigrants tothese countries are also increasing.

Migrants and health policyAcross EU countries, attempts to incor-porate the needs of migrants, in particularfrom non-EU countries (so-called third-country nationals), into welfare systemshave remained scattered and uncoordi-nated. In terms of Europe’s policyresponse, it seems there is an increasingeffort at the supra-nationalisation ofmigration policy. This has affected theupgrading of many national anti-discrimi-nation policies, but at the same time thereis a concern that the focus of EC policy onthe flexibility of the labour market maytake precedence over concerns with socialcitizenship and the protections afforded bythe welfare state.10

To some extent, however, diversity inpolicy is to be expected, since the waymigrant health is approached to someextent depends on the type of immigrationaffecting the country.7 A country’sapproach to migrant health issues will alsodepend on its welfare regime, withdifferent nations responding to similarpolitical challenges in idiosyncratic ways.10

Furthermore, where migrant health policyis elaborated, implementation may notnecessarily reflect this on the ground.

A consultation with country experts inhealth policy revealed that in France, socialanalyses by ethnic origin are not routinelycarried out both for cultural and adminis-trative reasons and migrant health policyhas mainly focused on preventing thespread of infectious diseases. In Germanyand Ireland, at the national level, the issueof migrant health and access to health carehas also not yet been developed as aspecific policy issue, though there is anincreasing interest in tackling healthinequalities. Politically, migration itselfwas a widely neglected policy area inGermany until very recently. In Italy, onthe other hand, policy regarding the healthof migrants is relatively developed, thoughhow successful the government has been atimplementation is not clear. At the centrallevel, immigrant related health policytargets have been set since the 1990s.

As early as 1997, the Netherlands Organi-sation for Scientific Research (NWO) setup a working party on culture and health,and a programme to stimulate research andcare innovations in this area was launched.Indeed, the Netherlands stands out inEurope for its sustained and systematicattention to the problems of migrant



health, although a closer look at thecurrent situation suggests there is a dangerof these initiatives stagnating. In Spain,migrant health and health care issues haverecently started to feature in national andregional plans for the integration of immi-grants. The general Swedish nationalhealth policy aims to create social condi-tions that will ensure good health, on equalterms, for the entire population with aspecial emphasis on vulnerable groupssuch as immigrants. The government hasthus developed a multi-sectoral approachto coordinating services in a way thatpromotes health among newly arrivedindividuals.

In the UK, health policy relating tomigrants is largely integrated into a policyframework addressing health inequalitiesin general (dating from the 1980s) and thehealth inequalities of ‘black and minorityethnic’ (BME) groups specifically. TheDepartment of Health (in England) hascommissioned a number of initiatives togenerate or collate good practice in “raceequality”. However, as in most Europeancountries, the lack of baseline data onethnicity makes it difficult to evaluate theimpact of such projects, which in turnmakes it hard to identify good practice.

In light of this variability, there appears tobe a significant role for the EU to play infacilitating the development and transfer ofevidence and information on immigranthealth policy. The upcoming Portuguesepresidency, which is focussing on immi-gration, may be a timely opportunity forfurther policy development on this issue.

Potential policy considerationsBoth this and previous reviews7 throw up anumber of concurrent potential policyconsiderations. The methodologicalproblems associated with migrant healthresearch indicate a need to increase fundingand collaboration at the European levelbetween national research centres todevelop research techniques. This couldinclude some focus on methodologicalbarriers to the inclusion of data on migrantsin national and European health surveys.

Nutritional and psychosocial problemsamong migrant children and youth signal aneed for greater attention paid to multi-sectoral policies, particularly across healthand education. While problems relating to

sexuality, reproduction and family life,might imply that there should be moreattention devoted to the improvedplanning and provision of targetedpreventive and curative sexual healthservices; ante and post natal care; and socialservices for vulnerable women. At theother end of the life course, the ageing ofmigrant populations requires the devel-opment of culturally appropriate longterm care.

The access of illegal/undocumentedmigrants to health services remains a majorproblem, as much political as it is technical.Greater transparency in countries’approaches to responding to health andhealth care utilisation inequalities experi-enced by this population, within theframework of human rights, is merited.

As this review indicates, migrant groupscan play an important role in the designand provision of services. This alsoresonates, and could be integrated, withmany countries’ more general attempts toimprove empowerment through betteraccess to information, strengthened patientrights and choice and enhanced complaintsprocedures. Linkages between sender andreceiver countries could also be exploredto provide insights into health norms,culturally relevant methods of research andtreatment, and the expectations and healthbeliefs of migrants.

Preserving the health ‘advantage’ of somenewly arrived migrants could potentiallybe a very important preventative strategy,particularly in terms of chronic diseases;focusing on healthy diets and otherlifestyle related factors through targetedprogrammes is a possible way forward.Where individuals are at risk, such as in theworkplace, multi-sectoral policies need tobe developed to address this importantarea of migrant health. However, this ispotentially a political issue since poorworking conditions are often related to theexploitation of undocumented migrants. Insettings where there is a need to preventand control tuberculosis and HIV/AIDSamong migrants, it may also becomeapparent with further research that inter-ventions fully mainstreamed within thehealth care system are more effective bothclinically and in terms of cost than verticalprogrammes (run at ports and borders forexample).

REFERENCES

1. Papademetriou DG. Europe and itsImmigrants in the 21st Century: A NewDeal or a Continuing Dialogue of theDeaf? Washington: Migration PolicyInstitute, 2006.

2. General Comment 14. On the right tothe highest attainable standard of healthadopted by the Committee on Economic,Social and Cultural Rights in May 2000,E/C.12/2000/4, CESCR, 4 July 2000.

3. Health Protection Agency. MigrantHealth. Infectious Diseases in non-UKBorn Populations in England, Wales andNorthern Ireland. A Baseline Report.London: Health Protection Agency, 2006.

4. Landman J, Cruickshank J K. A reviewof ethnicity, health and nutrition-relateddiseases in relation to migration in theUnited Kingdom. Public Health andNutrition 2001:4:647–57.

5. Mackenbach JP, Bos V, Garssen MJ,Kunst AE. Sterfte onder niet-westerseallochtonen in Nederland [Mortalityamong non-western migrants in TheNetherlands]. Nederlands Tijdschrift voorGeneeskunde 2005;149:917–23.

6. Stronks K, Uniken Venema P, DahhanN, Gunning-Schepers L. Allochtoon, dusongezond? Mogelijke verklaringen voor desamenhang tussen etniciteit en gezondheidgeïntegreerd in een conceptueel model[Foreign, thus unhealthy? Possible expla-nations for the relation between ethnicityand health, integrated in a conceptualmodel]. Tijdschrift voor gezondheidsweten-schappen 1999;77:33–40.

7. Ingleby D, Chimienti M,Hatziprokopiou P, Ormond M, De FreitasC. The role of health integration. In:Fonseca L, Malheiros J (eds). Social Inte-gration and Mobility: Education, Housingand Health. IMISCOE Cluster B5 State ofthe art report. Lisbon: Centro de EstudosGeográficos, 2005.

8. Holzmann R, Koettl J, Chernetsky T.Portability Regimes of Pension and HealthCare Benefits for International Migrants:An Analysis of Issues and Good Practices.Geneva: Global Commission on Interna-tional Migration, 2005. Available athttp://www.gcim.org/attachements/TP2.pdf

9. Loue S, Bunce A. The assessment ofimmigration status in health research. VitalHealth Statistics 1999;2:1–115.

10. Schierup C-U, Hansen P, Castles S.Migration, Citizenship, and the EuropeanWelfare State: A European Dilemma.Oxford: Oxford University Press, 2006.



This article is based on a policy brief prepared for the European Commission, DGEmployment and Social Affairs, under the European Observatory on the Social Situation,under the project Health Status and Living Conditions (VC/2004/0465)

http://www.gcim.org/attachements/TP2.pdf


HEALTH POLICY DEVELOPMENTS

Payment by Results (PbR) was introducedinto the English NHS in 2003/04. Theintroduction of a system of regulatednational tariff prices was a major change inthe financial regime for public health carein England. In an earlier article in EuroOb-server1 the implementation of PbR up to2005/06 was discussed and some of its keyfeatures outlined. In this article progresssince then is examined, and some of thekey features of the scheme as it currentlyexists are discussed. It concludes withsome remarks on issues concerning PbRthat have emerged.

How Payment by Results operatesIn introducing the concept of Payment byResults in 2002, the Secretary of State forHealth was clear that the policy wasintended to address the need to introducestronger incentives to ensure improvedperformance.2 Primary care trusts (PCTs)– the commissioning agencies in theEnglish NHS – would be free to purchasecare from the most appropriate providerwhether in the public, private or voluntarysectors. The driving force behind thesechanges, at least explicitly, was to giveproviders incentives that would rewardbetter performance. This in turn requiredincentives for those making choices aboutwhere patients would be treated (the PCTsthat commission services) to send patientsto hospitals that performed better. At thesame time the Government was looking to

hand over more choice directly to thepatient. Eventually patients would go totheir hospital of choice and ‘money wouldfollow the patient’.

Instead of block contracts for activity(which are insensitive to the volume andnature of activity), providers are paid forthe activity they undertake. This is doneusing national average NHS provider coststo establish a standard tariff for the sametreatment regardless of provider. It isintended that over time the NHS willmove to a system where all activity iscommissioned against a standard tariff,using either Health Resource Group(HRG) benchmarks (an English version ofDiagnosis Related Group – DRG) or otherappropriate measures that differentiateactivity according to casemix.

Local commissioning will focus onvolume, appropriateness and quality notprice, as this will be fixed using regionaltariffs to reflect unavoidable differences incosts in different parts of the country. Thusthe market created by PbR differs fromthat of the previous ConservativeGovernment reforms of the early 1990swhen providers were able to quote localprices based on their own local costs.Under PbR the intention is that compe-tition on price is excluded.

ImplementationThe introduction of PbR has been slowerthan originally intended. Although by2005/06 the national tariff was supposed toapply to around 80% of activity in acuteand specialist hospitals, and almost allactivity was to be commissioned usingcost-and-volume contracts, this did not

prove possible. Instead, it was agreed thatfor most providers the mandatory nationaltariff would only apply to elective care.Non-elective cases, outpatients andaccident and emergency (A&E) casesremained outside the scope of the schemefor most providers, although these wereincluded for Foundation Trusts, a form oforganisation introduced in April 2004where existing, selected NHS trusts weregiven more financial freedoms and adifferent accountability regime.1

In 2006/07 the tariff was extended acrossall NHS providers to cover admittedpatient care, outpatient and A&E atten-dances. However errors in the 2006/07tariff published by the Department ofHealth on 31 January 2006 resulted in agreater overall average increase in the tariffthan had been intended. The Department’sintention was an overall increase of 1.5%but some PCTs reported increases of 4%or more in the cost of activity.3 As a resultthe tariff was withdrawn and reissued on17 March 2006. This gave the NHS verylittle time to plan for 2006/07 on the basisof the new tariff.

The structure of PbR remained essentiallythe same in 2007/08.4 The Department ofHealth has always recognised it wouldtake time for providers to adjust to a set ofnational tariffs which would result,initially at least, in many of them receivingless income than their actual costs. Simi-larly, PCTs might find themselves payinga higher price than they had previously.Transitional arrangements – known aspurchaser parity adjustments (PPA) in thecase of PCTs – were introduced so thatgains and losses would not be immediate

Payment by Results in England

Seán Boyle

Summary: Payment by Results (PbR) was introduced into the EnglishNHS in 2003/04. The introduction of a system of regulated national tariffprices was a major change in the financial regime for public health care inEngland. In this article progress since 2005/06 is examined and some ofthe key features of the scheme as it currently exists are discussed.

Keywords: payment by results, health resource groups, efficiency, quality,England

Seán Boyle is Senior Research Fellow, LSEHealth and the Personal Social ServicesResearch Unit, London School ofEconomics and Political Science. Email: [email protected]

but would be achieved over a four-yearperiod. In line with the aim to phase outthese transitional arrangements by2008/09, the level of purchaser parityadjustment (PPA) was reduced in 2007/08to 25%. Moreover, it is intended that fromDecember 2006 all practice-based commis-sioning would be based on PbR.

PbR, as it stands, has tended to reinforcethe delivery of care in acute hospitalsettings. To enable the unbundling of thecare pathways which equate to acutehospital spells, so that care can be deliveredin a multitude of different settings, theDepartment of Health has issued a set ofindicative unbundled tariffs relating toboth care pathways and the use of diag-nostics, and guidance in support of theunbundling of services. Howeverunbundling is not a mandatory part of thesystem so far.

Key features of the new systemIn 2007/08 the mandatory PbR tariff ispayable for a large proportion of theactivity carried out by NHS trusts, NHSfoundation trusts, PCTs as providers and

Independent Sector Extended CareNetwork (ISECN) providers. Some keyfeatures of the system: coverage, calcu-lating prices, the role of the independentsector and quality are now discussed here,while other points are highlighted in theaccompanying table.

Coverage

The Government intends that almost allhealth care activity purchased by NHScommissioners will be covered by the PbRsystem. As already indicated, in 2007/08the national tariff will cover almost allpatients admitted for care – elective andnon-elective, outpatient attendances, andA&E attendances. However a wide rangeof activity remains excluded (see otherservices). Hence in 2006/07 over £22billion of services were delivered underPbR, representing around 35% of PCTrevenue allocations, or over 60% of acutehospital income (source: personal commu-nication, Department of Health).

The focus has been on getting it right forthe existing tariff structure and hence overthe last two years there have been a series

of adjustments to the way in which tariffsare calculated.

Admitted patient care. Tariffs have been setfor patients who are admitted electivelyand non-electively. These are based onHRG spells, and there are now 548separate HRG tariffs in use. For 2007/08,for elective care, these range in price from£200 to £20,165 with a mean price of£1,920 and a median of £1,255. For non-elective care the range is from £350 to£19,565 with a mean of £2,730 and amedian of £2,180.

Outpatient care. Outpatient tariffs are setat specialty level for first and follow-upattendances. There are 39 specialty tariffsand these are based on the specialty ofconsultant responsible for the outpatientclinic. For 2007/08 these range in pricefrom £155 to £288 for first attendance, andfrom £76 to £161 for follow-up attendance.The tariff has been structured to load thepayment towards the first attendance so asto provide a financial incentive to minimisefollow-ups. The tariff for children underthe age of seventeen years is usually greaterthan that for an adult.

There are also tariffs for a small number ofprocedures that may be carried out in anoutpatient clinic. Where these occur theyreplace the outpatient tariff. Currentlythere are just nine of these: colposcopy;hysteroscopy; flexible sigmoidoscopy;rigid sigmoidoscopy; epidural injections(for pain services); fine needle biopsy ofbreast; needle biopsy of prostate; and laserdestruction of lesions of the skin. For2007/08 these range in price from £180 to£408.

A&E attendances. A&E tariffs are set atthree levels: high-cost, standard-cost andminor A&E /minor injury unit (MIU).Prior to 2006/07, the lowest level appliedonly to MIUs, but in that year a combinedminor A&E and MIU tariff was intro-duced that reflected the average cost ofminor attendances at A&E departmentsand attendances at MIUs. Attendances arecosted at the same rate whether a patient isadmitted or not. In 2007/08 the A&E tariffranges in price from £55 to £101. Althoughthe Department of Health has stated itsintention to also include attendances atWalk-in Centres, these are currentlyexcluded from the PbR scheme.

Other services. As indicated earlier thereremain a considerable number of servicesthat are outside the scope of the PbRscheme in 2007/08. In these cases the pricepaid is subject to local negotiation. These



Table: Key features of PbR system in England

Issue Comments

Purpose To improve efficiency, quality, choice

Start date Apr 2003

Coverage – activity Covers admitted patient, outpatient and A&E activity

Critical care Currently treated outside the PbR system but work is ongoing to include

Mental health Currently treated outside the PbR system but work is ongoing to include

Coverage – providers Includes public, private and voluntary providers but differences in how PbR is applied

Tariff system Uses national average NHS provider costs to produce cost per HRG spell,outpatient attendance, etc.

Regional adjustments Yes, using the Market Forces Factor

Academic centres Some funds dealt within PbR but education and R&D funds excluded

Quality of care There is no evidence so far

Increased productivity There is no evidence so far

Cream-skimming, up-coding

There is some evidence of overcoding and optimising coding but noevidence of fraudulent activity.

include:

– Community services

– Mental health services

– Ambulance services (other than patienttransport services)

– Well babies

– Private patients in NHS hospitals

– Chemotherapy

– Learning disabilities

– Critical care

– Continuing/intermediate care

– Respite care

– Regular attenders

– Radiotherapy

– Direct access radiology and pathology

– Renal dialysis

– Rehabilitation in discrete rehabilitationward/unit

– Primary Care Services

– Walk-in Centres

Also a number of specific HRGs andoutpatient specialties are outside thecurrent scope of the PbR scheme, eitherbecause they have low volumes, volatilecosts and/or are of a highly specialisednature, for example, heart, liver, lung trans-plant, and cystic fibrosis HRGs; neuro-surgery and cardiac surgery outpatients.

The Department of Health intends toinclude critical care in the PbR scheme.However, the Department is not yet in aposition to produce representative pricesowing to the lack of appropriate datacollection. Data are currently beingcollected but a considerable amount ofwork remains to be done. Critical careincludes high dependency units, intensivecare units and burns intensive care units;coronary care units are now included asoverheads in tariffs for cardiac activity.

Similarly it is still not clear how mentalhealth services will be treated. There are noobvious examples from other countriesthat easily translate to the NHS. Socurrently mental health services arecommissioned as before. The Departmentof Health has undertaken a project toattempt to define mental health currenciesthat can be used to describe and costmental health activity across inpatients,outpatients and community services foradults of working age and older people.This has required a special data collection.The Department hopes that a mental

health tariff can be published in late 2008,with its use beginning in 2009/10.

Calculating prices

The pricing system for PbR has becomemore complicated as each year moreactivity is added to the scheme. In thissection the way in which prices are derivedfor the three principle types of care–admitted patients; outpatients and A&Eattendances – is considered, as are anyspecial considerations or exceptions thatmay affect the price paid.

There is a separate national tariff foradmitted patients who are elective or non-elective. This tariff is derived from aweighted average cost of inpatient spells.These include all clinical costs, e.g. costs ofdiagnostics and monitoring interventions,and all non-clinical costs, for example,capital charges, food, cleaning and mainte-nance.

Admitted patients national tariffs for2007/08 is based on a simple uplift of the2006/07 tariff of 2.5%. This reflectschanges in pay, prices and governmentpolicies that have been calculated to impacton costs, e.g. Agenda for Change, NationalInstitute of Health and Clinical Excellence(NICE) appraisals and guidelines. The2006/07 tariffs were based on referencecosts for 2004/05 (which represented theaverage cost of an admitted patient spell)with uplifts to reflect the expected increasein the cost of NHS provision over the twointervening years, specific HRG adjust-ments to take account of NICE tech-nology appraisals, and long-stay outlierpayments (patients staying longer inhospital than a pre-determined cut-offpoint). Similarly outpatient tariffs, the nineoutpatient procedure tariffs, and the threeA&E tariffs for 2007/08 are a simple upliftof 2.5% of 2006/07 tariffs.

There are adjustments made to the tarifffor emergency admissions. In 2005/06Foundation Trusts had been paid the fulltariff price for all activity undertaken. Thisplaced all the financial risk of increasedlevels of emergency admissions on PCTs.When the tariff was extended to allproviders in 2006/07, the Department ofHealth decided the risk should be sharedand so introduced a reduced rate tariff of50% for all emergency spells above a setthreshold: 3.2% above the level in 2004/05.This was the Department’s best estimate ofthe emergency activity level in 2005/06. Ifactivity fell below the threshold, then 50%of the tariff would be withheld from theprovider. This differential tariff for emer-

gency admissions above a set threshold hasbeen retained in 2007/08, although thethreshold will be based on the level ofactivity in 2005/06. Some emergency tariffsare also reduced where the actual length ofstay in hospital is less than two days, andthis is less than the average length of stayfor that HRG.

There are top-up payments for somespecific procedure and diagnosis codes insome specialist and children’s activities, forexample, in spinal surgery andorthopaedics. These codes are based on thesecond edition of the Specialised ServicesNational Definition Set. There are also anumber of exclusions from the calculationof tariffs: for example heart, liver, lung, andkidney transplant HRGs; and some high-cost drugs and devices, for exampleprimary pulmonary hypertension drugsand implantable defibrillators.

There are adjustments made to the A&Etariff to take account of variations fromplanned activity. Providers are funded attariff for their planned activity level. Ifactual activity is less than planned, theirincome is reduced by just 20% of the tariff;on the other hand if actual activity isgreater than planned this will be paid forat the full tariff price.

Regional adjustments to the national tariff.HRGs are intended to take account of alllegitimate differences in costs betweentrusts. To take account of geographically-determined unavoidable differences inlocal cost due to different costs ofresources, tariffs for each provider areadjusted by the application of the marketforces factor (MFF). The MFF has beenused for many years to weight allocationsof funds to commissioners. Over time itscalculation has come to depend more onthe specific circumstances of individualPCTs.

It comprises a weighted index of threeseparate cost indices: a staff index based onvariations in wages in the private sector,and calculated at the PCT level; a buildingsindex based on a moving average of tenderprices for all public and private buildingcontracts, and calculated on a LondonBorough and county basis; and a landindex based on the land value per hectare(10,000 square metres) for each individualprovider or PCT location. Where aprovider operates over many sites indifferent areas, this is taken into accountby producing an index for this providerbased on activity weights, where theserelate to bed numbers in each location.



The MFF is rebased so that the providerwith the lowest MFF has an MFF value of1. All other providers receive a propor-tional increase in tariff relating to the valueof their MFF. In 2007/08 the value of theMFF weighting ranged from 1.00 to 1.45,so the price received by one provider couldbe 45% more than another for what isessentially the same spell of care, butdelivered in a different location. WhenPbR was first implemented MFF passeddirectly from PCT to provider but thepotential for price competition that thisintroduced has now been eliminated. Eachprovider receives the same tariff price fromits commissioning PCT, and the MFFuplift is paid to providers by theDepartment of Health from funds top-sliced from PCT budgets for this purpose.

Treatment of capital. Changes to forecastcapital charges at a national level arereflected in the inflation uplift applied tothe national tariff. Account is taken of localchanges to capital and land costs throughthe MFF. However, the Department ofHealth has recognised that a tariff based onnational average costs may not alwaysreflect fully the local costs of a newly builtfacility. This is particularly true wherethere have been policy changes, forexample, changes in the accounting rulesthat impact on the assumptions underlyingsome of the early PFI schemes. TheDepartment of Health also acknowledgesthat new hospitals can be more costly,citing quality improvements such as ahigher proportion of single rooms, moresophisticated equipment, as well as one-offprocurement and double-running costs.The Department believes that “if fundingis not provided outside of the tariff thereis a risk that PbR would significantly disin-centivise capital investment.”5

Hence, until 2006/07 the NHS Bankdistributed a centrally-held budget tosupport a number of major NHS capitalinvestments. The Bank contributed to thecosts of procurement for major PFIprojects and also made some contributionin the first few years of operation of allmajor projects. These funds were provideddirectly to providers, though routedthrough the PCT where their primary sitewas located. From 2006/07 this centralbudget has been managed by the StrategicHealth Authorities (SHAs).

Research and Development (R&D) andteaching adjustments. There are subsidiescurrently provided by the allocation ofeducation/R&D monies to some trusts.Moreover, some work is undertaken as

research trials. These may lead to regionalvariations in the cost of service delivery.The Department of Health has consideredboth the amount and distribution ofexisting education and R&D levies with aview to eliminating any significant cross-subsidies between the patient care and levyfunding streams. However, it has decidednot to attempt to rebase these levies; atleast until the end of the transition periodfor PbR.

Independent sector

Detailed policies on how the national PbRtariff will apply to new independent sectorproviders are not fully developed. TheDepartment of Health intends to ensurenew providers’ costs converge with thetariff by the end of the PbR transitionperiod. In August 2006 the Departmentstated that, “further work is needed beforePbR can be extended to other sectors,including the voluntary sector and theindependent sector… to assess thedifferent economic factors affecting eachof the different sectors to inform the devel-opment of the national tariff in a way thatis consistent with achieving a level playingfield.”6

"The government has argued

PbR will provide incentives for

levelling-up quality because

prices will be fixed"

However, in 2006 a number of privateproviders came under the scope of PbRwith the introduction of the ExtendedChoice Network (ECN) offering choicesto patients from NHS Foundation Trusts,Wave 1 Independent Sector TreatmentCentres (ISTCs) and Wave 2 ISTCs thathad bid specifically to be ECN providers.There have also been contracts with Wave1 ISTCs and Wave 2 ISTCs, where PCTspay for activity commissioned from theindependent sector up to the level of tariffprices, with a central budget used to coverany differences.

Quality

The national tariff includes the cost conse-quences of general quality improvements,for example, NICE recommendations orNational Service Framework require-ments, that have occurred after reference

cost data were collected. But in general,quality standards are set by mechanismsoutside the financial system and under-pinned by appropriate clinical governancearrangements and regulation of qualitystandards. However it is expected thatcontracts or service level agreements willeventually include appropriate qualityprovisions agreed between trusts andcommissioners.

Concluding remarksThe Government may see the PbR schemeas the solution for all the problems of theNHS. However it will be some time beforePbR is properly bedded into the NHS.Meanwhile questions remain around theextent of coverage; costs, prices and effi-ciency, as well as the operation of themarket.

Extent of coverage

PbR still applies to only a limited numberof activities, and these are mainly in theacute hospital sector. This can cause distor-tions in provider behaviour. While theGovernment is committed to the‘unbundling’ of care, so that eventually thecare pathway for any particular patient’scondition can be delivered by a wide rangeof providers, either individually or incombination, in practice this has proveddifficult to deliver. This is seen as key toencouraging the introduction of new waysof delivering health care. However, theDepartment of Health’s guidance7 oncontracting for acute hospital servicesserves as an illustration of how difficultthis will be even in the acute hospitalsector. Although the aim is to extend PbRso that national tariffs are set independ-ently of the setting in which care isprovided – hospital or community – diffi-culties experienced in setting acute sectorprices suggest that this may prove an insur-mountable task. Nevertheless, the intro-duction of some ‘indicative’ unbundling ofactivities is a move in the right direction.

Costs, prices and efficiency

The Government has argued PbR willprovide incentives for levelling-up qualitybecause prices will be fixed. Under a fixednational tariff providers will have tocompete on quality. However anomaliesremain in the system. Geographical varia-tions in costs are recognised by the PbRscheme, and hence there are variations inprices paid. The NHS may be paying up to45% more to deliver the same treatment toone set of patients, in inner London say,compared with the price for an equivalent



set of patients in rural Cornwall. Astraightforward hip replacement may bepriced at a level £2,500 higher if done ininner London. Competition on the basis ofprice is ruled out however, even though intheory an inner London PCT could saveconsiderable sums of money if its patientscould be persuaded, through incentives forexample, to travel for their electivetreatment.

There is also a wide variation in the costsof individual HRGs across differentproviders. The Government has arguedthat PbR provides an incentive to reducethese costs and also to improve quality.Cost differences may be due to ineffi-ciencies but they may equally well be dueto differences in quality. The effect of PbRcould be to reduce quality in thoseproviders that are better than average butwhich cost more. Providers end upcompeting on cost. There is evidence fromother countries that where prices are fixed,quality is reduced in order to keep costsdown.

The Audit Commission found littleevidence of improvements in efficiency orincreases in activity resulting from theintroduction of PbR.8 But there is evidencefrom other countries that the introductionof similar funding systems was accom-panied by ‘HRG-drift’ where patients are‘up-coded’ to more expensive procedures,or by better counting resulting in apparentincreases in activity, or higher rates ofintervention and higher levels ofadmission, all of which may push up totalcosts.9 It has also been argued that someproviders may cream-skim patients(choosing the easier ones within aparticular casemix category). The consis-tency and quality of the activity andcoding data on which national tariffs arebased are therefore of fundamental impor-tance.

There have been several disputes betweenPCTs and providers about the accuracy ofcoding and the source of activity inflation.The Government recognised that theremay be issues around accuracy of codingand the potential for gaming in the system,and in January 2006 asked the AuditCommission to develop a data assuranceframework for PbR. The purpose was toinstill confidence in the data underpinningthe whole PbR system. The AuditCommission report of November 200610

found evidence of clinical coding errorsleading to inaccurate payments under PbR.It also found evidence of overcoding, i.e.recording more diagnosis and procedure

codes than is necessary, as well as trustsactively optimising their coding tomaximise income, although as theCommission carefully stated this was all“within existing coding rules”.

Operation of the market

It is not clear that, in the market for healthcare services introduced by PbR, bothproviders and commissioners are on anequal footing. Contracts depend verymuch on the information supplied byproviders. PCTs may be short of theexpertise to monitor these contractsclosely. It could prove quite costly toremedy this situation, and the mechanismsfor doing so may be quite complex (see theDepartment of Health’s guidance7 oncontracting for acute hospital services).

"The Audit Commission found

little evidence of improvements

in efficiency or increases in

activity resulting from PbR"

In its report in 2005 the AuditCommission found the costs of imple-menting PbR were greater than antici-pated.8 Another report in 2006 confirmedthat costs increased by between £90,000and £190,000 in organisations as a result ofthe introduction of PbR.11 This was due tohigher costs of negotiation, data collection,monitoring and enforcement. Thecomplexity of the tariff system will requiresignificant improvements in theproduction and use of detailed finance andactivity information. However, this couldbe a good thing if it contributes to a betterunderstanding of the health care businessfrom the perspective of both providers andcommissioners. It has been reported thatindividuals felt the higher administrativecosts of PbR were justified by benefitssuch as greater clarity of payment rules andsharper incentives.11

REFERENCES

1. Boyle S. Payment by Results in England.Euro Observer 2005;7(4):1–4. Available athttp://www.lse.ac.uk/collections/LSEHealthAndSocialCare/pdf/euroObserver/Obsvol7no4.pdf

2. Department of Health. Delivering theNHS Plan – Next Steps on Investment,

Next Steps on Reform. London:Department of Health, 2002. Available athttp://www.dh.gov.uk/assetRoot/04/05/95/26/04059526.pdf

3. Lawlor J. Report on the Tariff SettingProcess for 2006/07. London: Departmentof Health, 2006. Available athttp://www.dh.gov.uk/assetRoot/04/13/73/42/04137342.pdf

4. Department of Health. Payment byResults Guidance 2007/08. London:Department of Health, 2006. Available athttp://www.dh.gov.uk/assetRoot/04/14/16/20/04141620.pdf

5. Department of Health. NHS BankRevenue Support for Capital Developmentfrom 2005/06. London: Department ofHealth, 2006. Available athttps://www.dh.gov.uk/assetRoot/04/11/03/26/04110326.pdf

6. Department of Health. Payment byResults Implementation Support Guide2006/07 (Technical Guidance). London:Department of Health, 2006. Available athttp://www.dh.gov.uk/assetRoot/04/13/84/14/04138414.pdf

7. Department of Health. Guidance on theNHS Contract for Acute Hospital Servicesfor 2007/08. London: Department ofHealth, 2006. Available athttp://www.dh.gov.uk/assetRoot/04/14/24/07/04142407.pdf

8. Audit Commission. Early Lessons fromPayment by Results. London: AuditCommission, 2005. Available athttp://www.audit-commission.gov.uk/Products/NATIONAL-REPORT/B502F0FC-E007-4925-AD24-529C4889AD02/EarlyLessons-FromPaymentByResultsPrintFriendly11OCT05REP.pdf

9. Harrison A, Appleby J. Health Costs:The Rough Guide. Public Finance2003;10:28–30. Available athttp://www.cipfa.org.uk/publicfinance/search_details.cfm?News_id=17507&keysearch-appleby

10. Audit Commission. Payment byResults Assurance Framework Pilot Resultsand Recommendations. London: AuditCommission, 2006. Available athttp://www.audit-commission.gov.uk/Products/NATIONAL-REPORT/BE765294-44C1-4a5d-BE76-1328BCD45747/PbR%20AF_final%20proof.pdf

11. Marini G, Street A. The AdministrativeCosts of Payment by Results. York: Centrefor Health Economics, University of York,2006. CHE Research Paper 17. Available athttp://www.york.ac.uk/inst/che/pdf/rp17.pdf



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http://www.dh.gov.uk/en/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/DH_063684

http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=22989&Rendition=Web


http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_064142

http://www.audit-commission.gov.uk/Products/NATIONAL-REPORT/B502F0FC-E007-4925-AD24-529C4889AD02/EarlyLessonsFromPaymentByResultsPrintFriendly11OCT05REP.pdf

http://www.cipfa.org.uk/publicfinance/search_details.cfm?News_id=17507&keysearch-appleby

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http://www.lse.ac.uk/collections/LSEHealth/pdf/euroObserver/Obsvol7no4.pdf



As many as one quarter of all Europeancitizens may be affected by poor mentalhealth in any one year. The human, socialand economic costs are substantial,conservatively estimated to be between3% and 4% of Gross Domestic Product inEU countries.1

These socioeconomic impacts reach farand wide. While health care system costsare clearly significant, the vast majority ofcosts are incurred outside the health sectorbecause of lost employment opportunities.In total across Europe, the costs ofdepression were estimated to be €118billion in 2004, of which €76 billion weredue to productivity losses from poorhealth and premature mortality.2 Althoughin absolute terms their number are muchsmaller, people living with psychoticdisorders such as schizophrenia still havesubstantial non-health system costs. ManyEuropean studies, such as those in Englandand Hungary, report that health and socialcare costs account for just one third of allcosts, with the other two thirds due to lostemployment.1

Individuals with poor mental health are

also more likely to have co-morbidphysical health problems. Stigma, igno-rance and subsequent discrimination maylimit educational, employment and housingopportunities. There is also a greater risk ofcontact with the criminal justice system.Family relationships can suffer, there maybe concerns about behaviour such as rest-lessness, hypochondria, sleep disturbances,or aggressiveness. In many cases, familymembers may find that they have to devoteconsiderable time every day to providingsupport and informal care to a loved one.This may reduce their own opportunitiesto maintain employment and social activ-ities. It may also place strain on theirmarital relationships. The children ofpeople with mental health problems canalso experience parental neglect and theirschooling may be disrupted, againcurtailing long-term opportunities.

These impacts raise major concerns forboth national and European-level policymakers that have been reflected in boththe World Health Organization (WHO)European Region Declaration and ActionPlan on Mental Health endorsed by allMember States in 2005,3,4 and theEuropean Commission’s Green Paperresponse.5

The Mental Health Economics EuropeanNetworkIt is against this background that theMental Health Economics European

Network (MHEEN), established in 2002with the support of the EuropeanCommission, has been collating infor-mation, initially across seventeen, but nowthirty-one European countries. Jointlycoordinated by the London School ofEconomics and the Brussels-based NGO,Mental Health Europe/Santé MentaleEurope, the aim has been to develop anetwork of representatives, at least onefrom each country, with expertise and/orexperience of health economics and withpersonal work or commitment to theeconomics of mental health (seewww.mheen.org).

Activities in the first phase of work weregrouped around a number of themes:financing; expenditure and costs;provision, services and workforce;employment; and the capacity foreconomic evaluation. A series of papers onthese topics were published in an issue ofthe Journal of Mental Health in 2007.6 Thesecond phase of work includes detailedanalysis of some of the issues involved inmaking the economic case, not only forinterventions to treat and alleviate mentalhealth problems, but also for thepromotion of mental well being and theprevention of mental health problems.

This article reflects on some of this work,arguing that there is a growing evidencebase indicating that a more public healthorientated approach to mental health is

Mental health policy: Time to refocus on promotion and prevention?

David McDaid

Summary: The socioeconomic impacts of poor mental health are substantial and havean impact far beyond the health system. Their increasing recognition has helped drivemental health up the European health policy agenda. The Mental Health EconomicsEuropean Network has, since 2002, been collating data on a range of issues, includingfunding, employment and the use of economic evidence. What is clear is that fundingfor mental health remains modest in many European countries. Moreover,investment is still largely focused on treatment and rehabilitation. There is growingevidence that more emphasis on a public health orientated approach to mental healthnot only would be effective, but also potentially cost effective, and consistent with theEU’s Lisbon Process goals of economic growth and social cohesion.

Keywords: mental health policy, public health, cost effectiveness, Europe

David McDaid is Research Fellow, LSEHealth and Social Care and the EuropeanObservatory on Health Systems andPolicies, London School of Economics andPolitical Science. Email: [email protected]

both effective, potentially cost effective,and consistent with the EU’s Lisbon goalson economic growth and social cohesion.

Fair funding for mental health? Although mental health related healthservices are funded largely in an identicalfashion to other health services, i.e.through taxation and/or social insurance,there is considerable variation in the levelsof funding allocated to mental healthacross Europe. Although prevalence ratesfor psychiatric disorders vary very little,different health systems identify differentlevels of need, devote different levels offunding and choose different ways todeliver services. These variations in need,funding and response arise for manyreasons, including differences in demog-raphy, socioeconomic and politicalstructure and culture.

Another key factor is that the boundariesbetween what are considered to be healthand social care services, which may befunded separately, can vary substantiallybetween countries. Thus, cross nationalcomparisons of investment in mentalhealth are difficult.7 These caveats notwithstanding, what is undoubtedly clear isthat in many European countries mentalhealth care remains grossly under-funded.The share of Gross Domestic Productspent on mental health in Latvia and theCzech Republic is approximately fivetimes lower than that spent in Germany(See Table).

Even if there is sufficient politicalcommitment to investment in effectiveinterventions, implementation remainsproblematic. Multiple costs, not just todifferent agencies within the public orprivate sector, but also to individual serviceusers and their families, raise a number ofchallenges. In particular, unless the full costimplications of mental health problems,and of changes to mental health systemsare recognised, multiple costs raise the riskthat any reform process will be seriouslyunder-funded. They also give rise to thepotentially very constraining problem ofsilo budgets: resources held in one budgetcannot be allocated to other uses, to thegeneral detriment of the pursuit of effec-tiveness.

There is also a risk that key opportunitiesto promote service user well-being will bemissed, for example by denying indi-viduals the opportunity to secure paidemployment.

Some of these problems may be addressed

through the creation of joint budgets formental health across sectors, as seen inEngland and Sweden. Resource implica-tions and benefits are shared by sectors,increasing flexibility to deliver services thatbest address need.8 The issue of resourceinflexibility may also be addressed by agreater degree of partnership working withnon-governmental organisations. Ifcommissioned to deliver services, theymay be able to respond more flexibly thanthe statutory sector and adapt to changinglocal circumstances.

Mental health and economic wealth Data collected by MHEEN also show atrend of increasing absenteeism and earlyretirement due to mental health problems(particularly depression) across Europe.9

In Germany, for example, the number oflong-term sick due to mental healthproblems increased by 74% between 1995and 2002, compared with a 10% increasein sickness absence due to musculoskeletalor respiratory problems.10

In comparison to the impact on those atwork, where it can be argued that theavoidance of mental health problemswould help boost workplace performanceand competitiveness, different issues arefaced by those with long standing mentalhealth problems. They are far less likely tobe employed than the general working agepopulation. The majority of Europeancountries employ no more than 20%–30%of this group.9 Individuals with mentalhealth problems may also have a 40%lower chance of obtaining employmentcompared to other disability groups.11

There are however substantial variationsacross Europe. Italy, for instance, reportsemployment rates of 46.5% for all thosewith mental health problems compared to18.4% in the UK.12 This suggests thatdifferent socioeconomic contexts,including the structure of disability benefitsystems, account for some of this variation.

Making the economic case for promotionand preventionAlthough all EU countries now have amental health policy in place, either at thenational or regional level, much policy isstill focused on the treatment, and to alesser extent, rehabilitation of people withsevere mental health problems. Compara-tively little policy attention is paid to thepromotion of good mental health andwell-being at a time, conversely, whenthere is an increasing emphasis on the casefor investment in health promotion more

generally.

One criticism levied at mental healthpromotion/prevention interventions isthat the supporting evidence base is, atbest, weak. Certainly it is more difficult toconduct randomised controlled trials, withcomplex community-based interventions.This is not to say that the evidence base isabsent; in fact there is a growing body ofincreasingly robust evidence to support thedelivery of some of these interventions.13

In particular, the evidence base is strongfor early interventions to support veryyoung children and their parents, such ashome visiting programmes for low income



Public expenditure on mental health in selectedEU countries (latest available year)

% of GDP

1 Germany 1.11

2 Sweden 1.01

3 UK 1.00

4 Malta 0.92

5 Luxembourg 0.82

6 France 0.81

7 Netherlands 0.78

8 Denmark 0.72

9 Iceland 0.66

10 Hungary 0.62

11 Belgium 0.58

12 Ireland 0.50

13 Portugal 0.48

14 Cyprus 0.44

15 Italy 0.42

16 Spain* 0.41

17 Lithuania 0.38

18 Slovakia 0.30

19 Romania 0.24

20 Czech 0.21

21 Latvia 0.21

* Spanish estimate based on data from three ofthe seventeen Autonomous Communities.

women expecting their first child. Lowcost parent training interventions can havea positive impact on child behaviour. Ifthese impacts were to be maintained in thelong run, then it might be possible to avoidsome of the high lifetime public purse costsassociated with behavioural problems.Studies have estimated these to be as muchas ten times more than for the generalpopulation.14 In another area, work under-taken by the WHO also suggests that theuse of taxation instruments to dissuadeindividuals from the over-consumption ofalcohol and subsequent alcohol relatedaddictive behaviours can be highly costeffective.15

There is also a growing base of evidence onthe effectiveness of various workplace-based programmes, both to promote goodmental well-being and deal with some ofthe early signs of stress and mental healthproblems. There may well be substantialscope for economic as well as healthbenefits through companies investing inworkplace mental health promotionstrategies. In the US, one Employee Assis-tance Programme run by the McDonnell-Douglas company managed to reduce bothwork loss days (25%) and turnover (8%)for people with mental health problems.16

Economic evaluation of such interventionsin a European context remains limited:there is an urgent need for the robust eval-uation of the cost effectiveness of modelsof workplace based mental healthpromotion.

Putting to one side the issue of access tosocial welfare benefits, there is also asubstantial body of evidence suggestingthat supported employment programmes,where individuals are placed in real jobsand then receive ongoing support, arehighly cost effective.17 Stable employmentis just one outcome of supportedemployment programmes. In comparisonto other employment related interventions,higher rates of employment can be asso-ciated with other benefits such as a reducedneed for health care services, increasedlevels of social inclusion and improvedquality of life.

One eleven year US evaluation followingthree thousand employment service clientsfor forty-eight months, reported thatoverall costs were lower because the use ofhealth services was much lower duringperiods of stable employment.18 A six-country European Commission supportedstudy, EQOLISE, has now investigatedthe cost effectiveness of supportedemployment for people with severe mental

illness using the same approach. This is thefirst large scale study in Europe andpublished findings are anticipated soon(See http://www.eqolise.sgul.ac.uk formore information).

Perhaps remarkably, given the use ofsuicide rates often as the sole target ofpublic mental health strategies, thereremains little evaluation of the effec-tiveness, let alone the cost effectiveness ofpopulation-wide suicide preventionstrategies. This is not to say that noEuropean evidence exists. One Danishstudy suggests that a multi-faceted inter-vention strategy to tackle suicide over atwenty year period was instrumental inreducing the suicide rate by some 60%.19

Another multi-faceted community basedapproach, first tested in Nuremberg, isnow being rolled out and evaluated in anumber of cities across the EU in aCommission funded study.20

Despite the limited evidence, the economiccase for investment in effective population-wide suicide strategies may be compelling.Recent analysis in Scotland, where thereare approximately 800 suicides per annum,suggests that a very small reduction in therate of suicide (less than 1%) would,because of the high lifetime costs ofcompleted suicides, make it highly likelythat such a strategy would comparefavourably with most health care interven-tions currently considered to be costeffective.21

A timely opportunityPoor mental health remains a major publichealth issue in Europe; it has manyprofound personal and socioeconomicconsequences for individuals and theirfamilies. The economic costs to society atlarge are also substantial. Perhaps morethan any other health issue, mental healthrequires an effective coordinated multi-sector approach to both the developmentof policies and the delivery of services. Acomprehensive and holistic approach, asrecommended by the WHO, shouldprovide a range of interventions andstrategies to promote positive mental well-being and take preventive actions to reducethe risk that mental health problems willoccur.

The case for investment in a more publichealth orientated approach is alsosupported by an emerging evidence baseon the effectiveness and potential costeffectiveness of this approach. Indeed, themainstreaming of mental health withinpublic health and health promotion

strategies will also be important; publichealth programmes to improve physicalhealth have mental health benefits and theconverse also applies.

The European Commission, now has atimely opportunity, through the devel-opment of its mental health strategy, topotentially play a highly significant role infacilitating the greater uptake of effectivepromotion and prevention interventionsacross the continent.

REFERENCES

1. Knapp M, McDaid D. Funding andResourcing Mental Health in Europe. In:Knapp M, McDaid D, Mossialos E, Thor-nicroft G (eds). Mental Health Policy andPractice Across Europe. Buckingham: OpenUniversity Press, 2007.

2. Sobocki P, Jonsson B, Angst J et al. Costof depression in Europe. Journal of MentalHealth Policy and Economics2006;9(2):87–98.

3. World Health Organization. MentalHealth Declaration for Europe. Facing theChallenges, Building Solutions. Copen-hagen: World Health Organization, 2005.

4. World Health Organization. MentalHealth Action Plan for Europe. Facing theChallenges, Building Solutions. Copen-hagen: World Health Organization, 2005.

5. Commission of the European Commu-nities. Improving the mental health of thepopulation: Towards a strategy on mentalhealth for the European Union. GreenPaper. Brussels: Health and ConsumerProtection Directorate, EuropeanCommission, 2005.

6. Knapp M, McDaid D. The MentalHealth Economics European Network.Journal of Mental Health2007;16(2):157–66.

7. McDaid D, Oliveira MD, Jurczak K,Knapp M, the MHEEN Group. Movingbeyond the mental health care system: anexploration of the interfaces betweenhealth and non-health sectors. Journal ofMental Health 2007;16(2):181–94.

8. Hultberg E L, Glendinning C, AllebeckP, Lonnroth K. Using pooled budgets tointegrate health and welfare services: acomparison of experiments in England andSweden. Health and Social Care in theCommunity 2005; 13 (6): 531–41.

9. Curran C, Knapp M, McDaid D,Tomasson K, MHEEN Group. Mentalhealth and employment: an overview ofpatterns and policies across westernEurope. Journal of Mental Health2007;16(2):195–210.





Long-term care (LTC) provides assistance,most typically to older people, with someof the most fundamental activities of dailyliving, including eating, washing, anddressing. Its financing is high on the policyagenda across Europe, given the ageing ofpopulations across Europe;1 the size of thedependant elderly population beingexpected to double over the next 50 yearsin countries such as Spain.2

Changing family structures,3 for examplesmaller families and the greater partici-pation of women, who currently make up83% of all carers in the labour force, pointtowards a potential reduction in the avail-ability of informal family caregivers and aconsequent higher demand for paid formalcare. European Commission supported

research concluded that with a few excep-tions, social security or insurance coveragefor LTC in the EU is insufficient.4 Giventhis context, it is not surprising that overthe last decade, much reform of LTCsystems in Europe has begun to take place.

Spain stands out as one country where theageing process is becoming morepronounced, access to informal care isdecreasing, but only 6% of householdsreceive some form of public support.1

Despite this, it was only after some eightyears of deliberation that a law for thepromotion of independent living and helpfor dependent individuals (Ley dePromoción de la Autonomía Personal yAtención a las Personas Dependientes) waspassed in 2006. This is expected to benefitapproximately 3% of the Spanish popu-lation in the short term, and it has beenpublicised as being the ‘fourth pillar’ of thewelfare state. It complements pensions, aswell as existing health and social careservices.

To date, public coverage of LTC has beeninsufficient; and dependent on the capacityof decentralised and under-funded socialservices. 70% of all funding has tradi-tionally been allocated to residential care5

with little made available for home care.6

Only the most severe cases have beenassisted within the health care system. Thishas led to ‘bed blocking’, that is an

Long-term care reform inSpain

Joan Costa-Font and Anna García González

Summary: Public funding of long-term care services in Spain has been limited;traditionally there has been a reliance on family members to provide informalunpaid care. The ageing of the population, coupled with changing family struc-tures, have raised the issue of long-term care up the policy agenda. A new law,guaranteeing the right to long-term care services, funded through taxation butsubject to means testing has now come into effect. While increasing publiccoverage for long-term care services, this new legislation raises challenges inrespect of coordination and deliver of services within and across the seventeenAutonomous Communities that are responsible for the provision of social careservices.

Keywords: long-term care, social care policy, Spain

Joan Costa-Font is Research Fellow inHealth and Pharmaceutical Economics,LSE Health, London School of Economicsand Political Science and AssociateProfessor of Economics, Centre forEconomic Analysis and Social Policies,University of Barcelona. Email: [email protected].

Anna García González, is ResearchAssistant, Centre for Economic Analysisand Social Policies, University ofBarcelona. Email: [email protected]

10. Houtman ILD. Work-related Stress.Dublin: European Foundation for theImprovement of Living and WorkingConditions, 2004:33.

11. Berthoud R. The Employment Rates ofDisabled People. London: Department ofWork and Pensions, 2006.

12. Kilian R, Becker T. Macro-economicindicators and labour force participation ofpeople with schizophrenia. Journal ofMental Health 2007;16(2):211–22.

13. Jane-Llopis E, Barry M, Hosman C,Patel V. Mental health promotion works: areview. Promotion and Education2005;Suppl 2:9–25.

14. Scott S, Knapp M, Henderson J,Maughan B. Financial cost of socialexclusion: follow up study of antisocialchildren into adulthood. British MedicalJournal 2001;323:191.

15. Chisholm D, Rehm J, van OmmerenM, Monteiro M. Reducing the globalburden of hazardous alcohol use: acomparative cost-effectiveness analysis.Journal of Studies on Alcohol2004;65(6):782–93.

16. Alexander ACG. McDonnell DouglasCorporation Employee Assistance ProgramFinancial Offset Study 1985–1989. West-port: Alexander Consulting Group, 1990.

17. Latimer EA, Lecomte T, Becker DR, etal. Generalisability of the individualplacement and support model of supportedemployment: results of a Canadianrandomised controlled trial. BritishJournal of Psychiatry 2006;189:65–73.

18. Perkins DV, Born DL, Raines JA et al.Program evaluation from an ecologicalperspective: supported employmentservices for persons with serious psychi-atric disabilities. Psychiatric RehabilitationJournal 2005;28(3):217–24.

19. Nordentoft M, Laursen TM, Agerbo E,Qin P, Hoyer EH, Mortensen PB. Changein suicide rates for patients with schizo-phrenia in Denmark, 1981–97: nested case-control study. British Medical Journal2004;329(7460):261.

20. Hegerl U, Althaus D, Schmidtke A,Niklewski G. The alliance againstdepression: 2-year evaluation of acommunity-based intervention to reducesuicidality. Psychological Medicine 2006;36(9):1225–33.

21. McDaid D, Halliday E, Mackenzie M,et al. Issues in the Economic Evaluation ofSuicide Prevention Strategies: Practical andMethodological Challenges. London:Personal Social Services Research Unit,London School of Economics and PoliticalScience. Discussion Paper 2407, 2007.

inability to discharge an individual fromhospital who does not have medical careneeds, because of a lack of appropriatesocial care services. Public funding foressential services such as home helps andLTC cover no more than 4% of the popu-lation (Table 1). More than 65% of care forolder people is still provided informally byfamily members.5

Framework of new systemWhile some countries, including Germany,finance LTC through social insurance,Spain has opted for a tax funded approach,consistent with its tax funded health caresystem. A initial budget of €12.638 billionhas been set aside for the ‘National Long-Term Care System’ that commenced oper-ations in 2007. The system will beimplemented in stages, with the aim of fulloperation by 2015.

Alongside the new funding, thegovernment has introduced a “universal,but subjective” right to LTC. The scheme

can also apply to younger people whohave LTC needs, for example, those withearly onset dementia. Individuals are guar-anteed access to a package of care services(subject to some cost sharing), regardlessof place of residence, if they are deemedeligible following an assessment of careneeds, income and financial assets.Although cost sharing schemes are stillbeing defined, several forms of insurancecoverage are also likely to develop,including both complementary and substi-tutive private insurance. There are also anincreasing number of financial productsbeing developed to facilitate the self-financing of LTC expenses, for exampleschemes to free up equity tied up in anindividual’s home.

Care packages will also vary, depending onwhich of three categories of dependencyan individual may fall within. In the first(mild dependency), an individual wouldrequire assistance with one activity of dailyliving at least once a day. For those fallinginto the moderate dependency category, anindividual would need help with at leastone activity of daily living two or threetimes daily, but could still function inde-pendently without the constant presenceof a caregiver. The highest level of assis-tance is made available to those deemed tobe severely dependent, that is requiringhelp with the activities of daily livingfrequently and also in need of constantcaregiver support. There will also be twogradations of support within eachcategory, depending on the intensity ofcare needs. Determination of dependencylevel will be made by a newly establishedTerritorial Council.

Assistance can take the form both offormal service provision, such as homehelps, access to day and long term resi-dential care, and/or cash payments to assistfamily carers. The system is expected toinitially cover 1.125 million people (Table2), 80% of whom will be over the age of65.6 Little change is predicted in thebalance between different levels of needbetween 2005 and 2020, although the totalnumber of individuals receiving support isprojected to increase by one third toalmost 1.5 million.

The first phase in introducing the newsystem began in 2007 with the provision ofcoverage to those qualifying individualsdeemed to have the most severe level ofdependency. In the subsequent three yearscoverage will be extended to those incategory two, with coverage of those incategory one complete by 2015. This will



Table 2: Estimated number of future dependents by level of dependency

2005 2010 2015 2020

Category Three (Severe Dependency)

194,508 223,457 252,345 277,884

Category Two(Moderate Dependency)

370,603 420,336 472,461 521,065

Category One (Mild Dependency)

560,080 602,636 648,442 697,277

Total 1,125,190 1,246,429 1,373,248 1,496,226

Source: Libro Blanco de la Dependencian (2005).

Table 3: Estimated central state allocation tothe new long-term care system

Year Funding (€ millions)

2007 400

2008 679

2009 979

2010 1,160

2011 1,545

2012 1.674

2013 1,876

2014 2,112

2015 2,212

TOTAL 12,638

Table 1: Publicly funded long-term care services

Places Coverage (% Population over 65)

Home help 256,992 3.50

Telecare 208,107 2.84

Residential care 283,134* 3.86

Day care 39,554 0.54

Source: Libro Blanco de la Dependencia, 2005.

* 57% private, 18% private with public sector contracts and 25% public.

increase total public expenditure on LTCfrom 0.33% of Gross Domestic Product in2007 to 1% by 2015 (Table 3) .

Devolution and coordinationOne of the chief characteristics of the‘modern’ Spanish state is its decentralisedpolitical, and to a lesser extent, structure.The seventeen Autonomous Communities(AC) in Spain have progressively obtainedresponsibility for all areas of social policy,including education, health and social care.This means that they can design their ownspecific policies to tackle perceived prior-ities. Indeed, there is evidence of wideheterogeneity in preferences and attitudestowards the funding of health and socialcare.8 The new law allows for flexibility infinancing arrangements, so as to accountfor local variation in priorities, whilstmaintaining a basic system for the wholecountry.

This has been achieved through a Terri-torial Council for the National Long-TermCare System (Consejo Territorial delSistema Nacional de Dependencia) wherethe central government and the ACs willdiscuss and establish ‘Integral ActionPlans’ and plan the organisation of thesystem. The legislation gives rise to sometensions between the national governmentguarantee (subject to means testing) onequal access to a basic package of servicesaccording to need on one hand, andregional responsibility for social care onthe other. Complementary packages ofcare may also be provided by some ACs.However small these differences incoverage may be, they might arguably giverise to incentives for individuals to movebetween ACs in order to improve theiraccess to services. Regulation may thus berequired to counter these incentives, forinstance ensuring that funding comes fromthe AC where the individual has paid tax.

One source of funding for long-term care,may be inheritance tax which is a ACresponsibility. This issue has been heavilypoliticised, with ACs run by conservativeadministrations reducing the role of thistax. Given the structure of Spanish decen-tralisation, unless this tax is linked to thefinancing of LTC so that individuals mayperceive some benefit from its retention, itis likely that one of the few instruments toguarantee federal financing of LTC willdisappear.

Another key policy issue is that of coordi-nation between health and social care,which is split between departments ofhealth and social welfare respectively.

Moreover, social care is managed bymunicipal local authorities, who takeresponsibility for the day-to-day deliveryof services. Unfortunately, with somenotable exceptions (Catalonia, the BasqueCountry and Cantabria), coordinationbetween health and social care has beenlimited and remains an important policygoal for the next decade. Institutionalreform might be one obvious response,perhaps through the creation of inde-pendent coordinating agencies for LTC.

Overall, the progressive decentralisation ofsocial policy responsibilities seems to havebrought significant efficiency improve-ments, including the creation of incentivesfor policy innovation and replication ofsuccessful pilot welfare reform schemesacross ACs with similar needs and charac-teristics.8

Finally, the new legislation also hassensitive political connotations, particu-larly for those mainstream political partiesthat campaign for greater devolution andultimately independence in different ACsacross Spain. This might potentially lead tosome competition between regional andcentrally mandated services, given theblurred distribution of policy responsibil-ities.

ReflectionsThe law which sets out the framework forLTC coverage in Spain, is a first steptowards an increased awareness thatfunding for social care will need to rise inorder to cope with the demands of anageing population. It makes clear the needfor a highly flexible system for LTC. Apre-funded tax-based system guarantees abasic coverage but may also create incen-tives for private sector institutions todevelop financial products and/or expandcapacity to deliver care. Yet, a key chal-lenge is how coordination and cooperationacross the ACs will operate, withoutaffecting efficiency and policy innovation.8

Another key issue will be whether healthand social care are coordinated through thecreation of specific agencies, as is proposedin some ACs, or alternatively are inte-grated within inter-departmentalprogrammes.

An important question, is the broaderimpact of the introduction of LTC systemson individual responsibility, regarding theway individuals save, invest and considerleaving assets to their relatives. Regardingsavings, individual expectations that thepublic sector will, subject to means testing,pay for LTC, may create an incentive to

exhaust wealth (for example by sellingproperty) in order to be eligible for publicsupport. In southern European countriessuch as Spain, individual wealth is concen-trated in housing; this has traditionallybeen seen as a way of financing LTC. Onesolution could be setting means testingmechanisms which account for wealth, notonly at the later stage of life, but across thelife span (inter-generational equity). Alter-natively, one might argue in favour of auniversal and uniform system resemblingthat for Spanish health care, but how thenmight this be financed? One possibilitycould be to draw on inheritance taxes,which in Spain are collected by the ACs;however, there is no uniform policy onsuch taxes. Some ACs, such as Madrid,have eliminated this tax, which will remainunpopular with much of the populationunless some clear cut entitlement to care isoffered in exchange.

REFERENCES

1. Comas-Herrera A, Wittenberg R, Costa-Font J, et al. Future long-term care expen-diture in Germany, Spain, Italy and theUnited Kingdom. Ageing and Society2006;26:285–302.

2. Costa-Font J, Mascarilla O, Elvira D.Means testing and the heterogeneity ofhousing assets: funding long-term care inSpain. Social Policy and Administration2006;40(5):543–59.

3. Costa-Font J, Patxt C. The design of thelong-term care system in Spain: policy andfinancial constraints. Social Policy andSociety 2005;4(1):11–20.

4. Pacolet J, Bouten R, Lanoye H, VersieckK. Social Protection for Dependency in OldAge. A Study of the Fifteen EU MemberStates and Norway. Aldershot: Ashgate,2000.

5. Ministry of Labour and Social Security.Libro Blanco de la Dependencia [WhiteBook on Long Term Care]. Madrid: Minis-terio de Trabajo y Asuntos Sociales, 2005.

6. Costa-Font J, Font-Vilalta M. Designlimitations of long-term care insuranceschemes: a comparative study of the situ-ation in Spain. International Social SecurityReview 2006;59(4):91–110

7. Costa-Font J, Patxt C. The intergenera-tional impact of long-term care financingalternatives in Spain. The Geneva Papers onRisk and Insurance 2004;29(4):599–620.

8. Costa-Font J, Rico A. Vertical compe-tition in the spanish national health system.Public Choice 2006; 128(3–4):477–98.



One of the interesting aspects of looking atevidence is the effect of time. Initial results for newinterventions or observations often look good, butthen look less good as more evidence comes in.That is why a degree of caution is sensible. Timecan also affect results in the sense that those resultsmay look better or worse as duration of treatmentor observation lengthens. Clinical trials have timelimits, while clinical practice may have differenttime horizons.

It behoves us, then, occasionally to revisit theevidence, especially when time is a feature. This has

been done with nicotine replacement therapy,1

reminding us that our judgements on efficacy andeffectiveness can change with time.

Systematic review This systematic review of nicotine replacementtherapy (NRT) for smoking cessation looked forrandomised trials with endpoints beyond 12months after the start of treatment. It had a terrificsearch strategy. The aim of trials was permanentcessation of smoking, and required that active andcontrol arms differed only by use of NRT, soallowing supportive advice or counselling atvarious intensities. Use of any NRT product forany duration was allowed. Information oncessation rates at 12 months and at the longest timeafterwards was abstracted.

ResultsThere were 12 trials with 4,792 patients reportingcessation results at 2–8 years, with a weighted meanof 4.3 years. Trials used nicotine patch, gum, orspray for 3 to 52 weeks, with most using NRT for12 weeks or longer (weighted mean 22 weeks). Allbut one of the trials assessed smoking cessation bybreath carbon monoxide or urine cotinine meas-urement. Trials predominantly excluded lightsmokers of fewer than 10–15 cigarettes daily.Support and advice on cessation was of varyingintensity.

Figure 1 shows smoking cessation results of theindividual trials at the longest time. Most of thetrials were small, with two contributing over 2,600patients, and having low quit rates with both NRTand placebo.

Table 1 shows quit rates and derived statistics forthe trials both at 12 months and at the longestduration. The proportion of patients who werenon-smokers fell between 12 months and thelongest duration, as previous quitters begansmoking again. A third of quitters had begun tosmoke again (Figure 2) after both NRT andplacebo. Figure 3 shows the results for 24 indi-vidual treatment arms of the 12 trials.

This adversely affected the efficacy of NRT as


Nicotine replacement therapy (NRT) revisited

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 2006. © Bandolier, 2006.

Figure 1: Smoking cessation rates at longest study duration with NRT andplacebo

measured by the number needed to treat(Table 1). NRT rather than placebo wouldhave to be used in 12 patients to induceone more patient to quit smoking at 12months. But NRT would have to be usedin 19 patients for one more to be a non-smoker after an average of 4.3 years.

CommentNRT has clear efficacy in helping somepatients stop smoking over the short term.The effectiveness of NRT is eroded by thepropensity of former smokers to beginsmoking again. This study showed that atleast a third of quitters began to smokeagain after NRT or placebo.

In the case of NRT the argument of costeffectiveness is governed by how manypeople stop smoking because of NRT. At12 months, after an average of 22 weeks ofNRT treatment, the answer is 1 patient in12. But at longer follow up, it is more like1 in 19.

The real importance of this study is not,however, about smoking cessation, butabout how duration of observation canaffect how we perceive a result. In thiscase, there is an argument that an inter-vention that looks just about useful afterone year, is tipping towards irrelevance byfour.

What this does is to open something of aPandora's box of cost effectiveness. If theeffect of NRT in smoking cessationcontinues to diminish as recidivist quittersbegin to smoke again, does the cost of theeffort outweigh the health gains? It mayjust be easier to ban smoking in publicplaces. In California, where bans began,smoking rates have halved.

REFERENCE

1. J Etter, JA Stapleton. Nicotinereplacement therapy for long-termsmoking cessation: a meta-analysis.Tobacco Control 2006;15:280–85.


EVIDENCE-INFORMED DECISION MAKING

Figure 2: Smoking cessation rates at 12 months and at longest study duration

Figure 3: Percentage of quitters at 12 months smoking again at longest durationmonths and at longest study duration

Table 1: Results of trials at 12 months and at longest duration

Duration of Percent stopped smoking Relative risk NNT

observation NRT Placebo (95% CI) (95% CI)

12 months 18.2 10.1 1.8 (1.6 to 2.1) 12 (10 to 16)

Longest 12.2 7.0 1.7 (1.5 to 2.1) 19 (15 to 28)

IntroductionAs in many rapidly developing countries,energy generation capacity andconsumption in China have increasedtremendously over the past 25 years andwill continue to increase substantially inthe foreseeable future. Due to the use ofcoal for the majority of power generation,many cities are experiencing severe levelsof air pollution and decision- makers arefaced with the difficult task of mitigatingpollution while supporting continuedeconomic growth.

This edition of Risk in Perspective reportssome results of the Harvard Center forRisk Analysis’ work on these issues,undertaken as part of the University’sChina Project. The China Project is aninterdisciplinary academic researchprogram focused on the Chinese atmos-pheric environment and its national andinternational implications, bringingtogether faculty, researchers, and studentsfrom across Harvard’s schools under theauspices of the University’s Center for theEnvironment and Division of Engineeringand Applied Sciences.*

As indicated in Figure 1, ascertaining thebenefits of air pollution control (i.e., ofreducing the human health risks associatedwith energy generation) involves fourmain steps: estimating the quantities ofpollutants emitted, determining the impactof these emissions on ambient concentra-tions and hence on population exposure,assessing the incremental damages tohuman health (for example, on mortalityand morbidity) due to exposure, anddetermining the value of these damagesusing monetary or other measures. Theanalysis discussed in this article focuses onthe second of these components, and esti-mates the impact of emissions on ambientconcentrations and population exposure ina form that can be directly translated intohuman health risks. We also brieflysummarise related work on the Chinesemonetary values for these risk reductions.

What is an intake fraction?The link between emissions and exposuresis often determined by running complexmodels that require significant time andresources. However, there are more than


Risk inPerspective

Ying Zhou, Jonathan Levy, John S Evans and James K Hammitt

This article is reproduced with permissionand was first published as Risk inPerspective Volume 15, Number 1 by theHarvard Center for Risk Analysis inJanuary 2007.

Harvard Center for Risk Analysis,Harvard School of Public Health,Landmark Center, 401 Park Drive,PO Box 15677, Boston,Massachusetts, 02215 USA.The full series is available atwww.hcra.harvard.edu

AIR POLLUTION RISKS IN CHINA

"Our work suggests thatintake fractions canfacilitate risk-basedpriority-setting whenresources are limited."

Figure 1: Steps in estimating the benefits of pollution controls

Estimateamount ofpollutantsemitted

Determinechanges inpopulationexposure

Estimatechanges in humanhealth risks

Determinethe value of riskchanges

* The research described below was funded by grants from the Energy Foundation, the V.Kann Rasmussen Foundation, the Bedminster Foundation, and the Dunwalke Trust, withadditional support from the Harvard Center for Risk Analysis.

2,000 coal-fired power plants in Chinawith capacity greater than 12 MW. Theanalytical cost of running detailed fate andtransport models for each of them wouldbe prohibitive, and the time needed toapply such models is likely to delaydecision-making. Instead, we run adetailed long-range transport model(CALPUFF) for a subset of China’s coal-fired power plants and use the outputs todevelop simple yet meaningful measures ofthe emissions-exposure relationship. Bybuilding models to determine how thisrelationship depends on the geographiclocation of the source, we can estimate therelationship for sites not included in oursample.

For this analysis, we utilise the concept ofan ‘intake fraction’, defined as theproportion of material or its precursorreleased from a source that is eventuallyinhaled or ingested by a population. Forpollutants with linear concentration-response functions, population health riskwill be directly proportional to the intakefraction. The intake fraction (iF) can becalculated as:

N

iF = ∑Pi x Ci x BRi=1

Q

Our modelling domain covers all theheavily populated areas in China, and isdivided into 14,400 grid cells indexed by i.Pi is the population in cell i, derived using1999 county-level population data. Ci isthe incremental concentration at location i(g/m3), estimated using CALPUFF. BR isthe population-average breathing rate(m3/s), for which we assume a nominalvalue of 20 m3/d. Q is the emission rate ofthe modelled pollutant or its precursor(g/s).

Pollutants modelledPrimary pollutants are formed directlyduring the combustion process, whilesecondary pollutants are formed in theambient air by the chemical reactions ofgaseous precursors during atmospherictransport. We calculate intake fractions forprimary pollutants (particulate matter(PM) and sulphur dioxide (SO2)), and forsecondary pollutants (ammonium sulphateinhaled per unit of sulphur dioxide emis-sions and ammonium nitrate inhaled perunit of nitrogen oxide emissions).

The particle size distributions of primaryPM can vary substantially for differentcombustion processes and controlequipment and influence the fate andtransport of particles in the atmosphereand therefore the intake fractions. For thepurpose of this study, we define PM1 to beparticles of 1µm in aerodynamic diameter,with parallel definitions for PM3, PM7 andPM13. We calculate the intake fraction oftotal primary particles as the weightedaverage of the intake fractions of particlesof different sizes.

Power plant selection and source charac-teristicsFor our analysis, we select power plantsthat allow us to evaluate geographic factorsthat influence intake fractions. Werandomly choose one site from each of theChinese administrative units covered byour modelling domain. Figure 2 shows thelocations of the 29 selected sites.

Allowing plant characteristics to varysignificantly between sites would make itdifficult to identify the independent effectsof population and meteorology on intakefractions. Moreover, newly constructed orproposed power plants in China follow thesame engineering design guidelines andtheir source characteristics (for example,stack height, exit temperature, exitvelocity) are usually within a narrowrange. Consequently, we evaluate theintake fractions associated with locating atypical modern power plant in China ateach of the 29 sites.

ResultsTable 1 lists the estimated annual averageintake fractions for the 29 sites as well asthe standard deviation and minimum andmaximum values. PM1 has the highestmean intake fraction, 1 x 10-5. This meansthat for every metric ton of PM1 emitted,10 grams are eventually inhaled by peoplein the domain. PM3 has the second highestmean intake fraction, followed by SO2,secondary ammonium sulphate, PM7,secondary ammonium nitrate, and PM13.Among the primary particles, largerparticles have smaller intake fractions.Averaging the intake fraction estimates forPM yields an overall intake fraction forprimary particles of 6 x 10-6.

We also estimated how far from the powerplant one would need to be to capture atleast half of the intake fraction (andtherefore half of the population risk). Theaverage distance ranges from less than 200km (for PM13) to nearly 500 km (forsecondary nitrate particles). For primaryparticles, the distance from the sourcecapturing a certain percentage of the totalintake fraction decreases with increasingaerodynamic diameter.

We construct regression models to studywhether variability in intake fractions canbe explained using easily obtainableparameters that represent the effects ofimportant variables, including meteoro-logical conditions, source characteristics,and population distribution. We includegeneral meteorology variables (such as



Figure 2: Location of modelled power plants



climate zone and precipitation) and char-acterise population based on fixeddistances from each plant (within 100 km,between 100 and 500 km, between 500 and1,000 km, and beyond 1,000 km).

We find that population is a strongpredictor of intake fractions, as expected.Generally speaking, the near-source popu-lation is more important for large primaryparticles while population at medium andlong distances is more important forprimary fine particles and secondaryparticles. We also find that intake fractionsare generally lower for power plants inareas with more precipitation.

Sensitivity analyses indicate that stackheight has a greater effect on primary thansecondary particles, because secondaryparticles have long residence times, cantravel further distances in the atmosphere,and are not as strongly influenced by thelocal population density as primaryparticles. The size distribution of primaryparticles has a large impact on theirresulting intake fractions while the back-ground ammonia concentration is animportant factor influencing the intakefraction for ammonium nitrate. The back-ground ozone concentration has amoderate impact on the intake fraction forammonium sulphate and nitrate.

Discussion and conclusionsThe intake fraction estimates for China areabout an order of magnitude higher thanthose in similar US analyses. Much of thedifference appears to be explained by thehigher population density in China. Thefindings from our regression analysesgenerally agree with similar analyses ofintake fractions for US power plants. Forexample, population variables alone canexplain the majority of the variability inthe intake fractions. In addition, popu-

lation at medium distance (for example,between 100 and 500 km) significantlyinfluences the intake fraction of primaryfine particles while population at longerdistances (for example, beyond 500 km)significantly influences the secondaryammonium sulphate intake fraction.

Because an individual power plantcontributes a relatively small fraction toambient concentrations, it is difficult to usemonitoring data to “validate” the modeloutputs, an approach that is furtherimpaired by the relative lack of monitoringdata across China. However, we find thatthe relationship between emissions andmodelled concentrations is consistent withaggregate measured PM emissions andconcentrations. The correspondencebetween our results and previous intake

fraction estimates, when accounting forpopulation patterns (at least for primaryPM), provides some assurance that ourestimates are reasonable. The fact that wehave not varied power plant characteristicsmasks some of the true heterogeneity inintake fractions across China, although itallows us to better quantify the influenceof geographic location.

The robustness of our atmosphericmodelling coupled with the strength of theregression equations and the use of stackcharacteristics typical of new power plantssuggest that our model could reasonablypredict the total population exposure topollution from power plants in China. Bycombining our findings on populationexposure with estimates of emissions,human health damages, and the value of

Table 1: Annual average intake fraction estimates and summary statistics across 29 power plant sites in China

Sulphurdioxide

Sulphate NitratePrimary

PM1

PrimaryPM3

PrimaryPM7

PrimaryPM13

Mean 4.8E-06 4.4E-09 3.5E-09 1.0E-05 6.1E-06 3.5E-06 1.8E-06

Standard deviation 1.9E-09 1.5E-06 1.7E-06 3.7E-06 3.0E-06 1.8E-06 1.0E-06

Maximum 1.8E-06 7.3E-07 8.0E-07 2.8E-06 1.7E-06 1.1E-06 6.7E-07

Minimum 8.9E-06 7.3E-06 7.1E-06 1.9E-05 1.2E-05 8.2E-06 5.2E-06

Note: PMx = particulate matter with aerodynamic diameter equal to “x”µm.

Valuing reductions in air pollution-related health risks

Determining the appropriate level of pollution control requires careful balancingof the benefits against the costs. Estimating the value of these benefits is adifficult and controversial task, since it involves ascertaining the monetary worthof effects on human health and the environment.

HCRA Director James K Hammitt and Dr Ying Zhou have been researching thevalue of air pollution-related risk reductions in China. Using a contingent valu-ation survey administered in three diverse locations, they estimate values forthree health endpoints: colds, chronic bronchitis, and premature mortality.Averaged across the locations, they find that (in 1999 US dollars using theofficial exchange rate) median willingness to pay to prevent a cold episoderanges between $3 and $6; to prevent a statistical case of chronic bronchitisranges between $500 and $1,000; and to prevent a statistical case ofpremature mortality ranges between $4,000 and $17,000. The mean values arebetween two and thirteen times larger because some respondents reportedvalues significantly above the median.

The Chinese values are substantially smaller than those for more developedcountries; for example, between about 10 and 1,000 times smaller than similarestimates from the US and Taiwan. These differences are more than proportionalto the differences in income: Chinese per capita income is about 50 timessmaller than in the US and about 20 times smaller than in Taiwan.



these damages, we can estimate the benefitsof increasing pollution controls usingdifferent strategies. Our estimates havebeen incorporated into national-levelmodels in China to determine priorities forpollution control as well as the relativemerits of different control strategies (suchas environmental taxes), as documented ina forthcoming book from MIT Press,Clearing the Air: The Health andEconomic Damages of Air Pollution inChina.

FURTHER READING

Zhou Y, Levy JI, Evans JS, Hammitt JK.Estimating population exposure to powerplant emissions using CALPUFF: a casestudy in Beijing, China. Atmospheric Envi-ronment 2003;37:815–26.

Zhou Y, Levy JI, Evans JS, Hammitt JK. Theinfluence of geographic location on popu-lation exposure to emissions from powerplants throughout China. EnvironmentInternational 2006;32:365-373.

Hammitt JK, Zhou Y. The economic valueof air pollution-related health risks in China:a contingent valuation study. Environmentand Resource Economics 2006;33:399-423.

Ho MS, Nielsen CP (eds). Clearing the Air:The Health and Economic Damages of AirPollution in China. Cambridge, MA: MITPress, 2007.

The project

During the two years of theHPROWOMEN project, an educa-tional and training tool for planning,implementing and evaluating healthpromotion for working women hasbeen developed. The tool is valuablefor all health professionals, particu-larly those specialising in occupa-tional and public health as itconstitutes a manual that presentsoccupational risks and hazards thatare specific to women, or thatwomen are most likely to encounter.The tool can facilitate the planning,implementation and evaluation ofhealth promotion activities targetingwomen at the workplace.

Emphasis has been given to the wayshealthy female employees caninfluence health behaviours in otherenvironments, such as the family andcommunity. Several health topics arecovered such as: needs assessmentand programme planning of worksiteinterventions; mental health andwork-life balance; occupationalhealth; musculoskeletal diseases;work-related violence; bullying andsexual harassment; female repro-ductive health and breast feeding;screening; communicable diseases;smoking; alcohol abuse; nutritionand physical exercise.

Project outcomes

One outcome of the project has beena pilot course, which took place inAthens, Greece in February 2007. Thecourse summarised the expertiseacquired during the implementationof the project and pilot tested thisexpertise with participants involvedin teaching or coordinating work-place health promotion courses orwho are working in the area ofapplied or theoretical workplacehealth promotion.

Because of wide-spread interest, thepartnership is considering repeatingthe pilot course. Those interested inattending a pilot course or obtaininga CD-ROM containing the pilotcourse presentations can contact theproject team by email at:[email protected]

The end product of the project is abook entitled Promoting Health forWorking Women soon to bepublished by Springer Publications.

HPROWOMEN Project Development of an Educational and Training Tool for Workplace Health Promotion focusing on Women

Project website: www.hprowomen.org

Coordination

The HPROWOMEN project is coordi-nated by the University of AthensMedical School. It is a project underthe DG SANCO, 2003–2008 PublicHealth Programme co-funded by theEuropean Commission. The project isalso supported by a generous grantfrom the Stavros Niarchos Foun-dation. The project partnershipconsists of leading European expertsin the field of occupational health,epidemiology, health promotion, andgender issues from the TechnischeUniversität Dresden, the LondonSchool of Economics and PoliticalScience, the Institut Municipal deInvestigacio Medica, Barcelona, theFinnish Institute of OccupationalHealth, the University of ErasmusRotterdam, Prolepsis: Institute ofPreventive Medicine, Environmentaland Occupational Health, Kastri,Greece and the University of SofiaMedical School.

Women currently comprise 42% of the employed population in the EU. Gender issues in the workplace are of utmostimportance, because of major differences in the way work affects the health of men and women. Health promotion atthe workplace has neither addressed women as a separate group, nor taken into consideration factors such as gendersegregation and the increased responsibilities outside the working environment.


NEW PUBLICATIONS

National Strategy for QualityImprovement in Health and SocialServices (2005–2015)

Oslo: National Directorate for Health andSocial Affairs, September 2005

ISBN 978-82-8081-073-0

52 pages

Freely available on line at:http://www.shdir.no/vp/multimedia/archive/00005/IS-1162_E_5484a.pdf

With this strategy, the NorwegianNational Directorate for Health andSocial Affairs has drawn up guidelinesfor work on quality improvement until2015. This is an overall strategy that isexpected to be a common feature formany services, including municipalhealth and social services, countydental services, specialist health servicesand private services.

This strategy aims to ensure that usersand patients of health and socialservices in Norway receive high qualitysupport. The strategy also aims toensure that the authorities’ policy forhigh quality is implemented, and thatquality improvement work initiated indifferent areas within health and socialservices is coordinated and strength-ened.

The report begins by providingexamples of service failure. Then thevision, aim and target groups are iden-tified. Next, six elements in the conceptof quality are described, which include:effective measures, safe and secureservices, involving service users andallowing them to have influence, goodcoordination and continuity in servicesupply, appropriate utilisation ofresources and available services and fairdistribution.

The latter chapters explain qualityimprovement theory, strategic direc-tions, and target areas. There is a relatedweb site, available at www.shdir.no/kvalitetsforbedring/english

Healthcare professionals’ views on clinicianengagement in quality improvement: A literature review

Huw Davies, Alison Powell and RosemaryRushmer

London: The Health Foundation, April 2007

ISBN 0-9548968-6-6

90 pages

Freely available at:http://www.health.org.uk/document.rm?id=135

It is widely accepted that the activeinvolvement of staff is an essentialrequirement for quality improvementin any organisational setting. However,quality improvement initiatives in theNHS have not generally secured thefull engagement of clinicians.

As a result, the Health Foundation isplanning to commission new researchto investigate the opinions of UKhealth care professionals on clinicians’engagement in quality improvement.To inform this research, the authorswere commissioned to conduct a liter-ature review to clarify what is alreadyknown about the views of UK healthcare professionals in this area.

This report is structured through theuse of ten inter-related questions thatemerged during the literature review as

to how health care professionals haveresponded to various quality initiativesin the UK since 1990.

These key questions address thefollowing topics: How is qualitydefined? Does quality of care need tobe improved? What are health careprofessionals’ attitudes towards initia-tives aimed at quality improvement?What are the concepts and methods ofquality improvement? Where shouldresponsibility for quality improvementlie?

Other subjects explored in this reportinclude: clinical guidelines, evidence-based practice, quality measurement,accountability and barriers. The reviewdraws predominantly on studies thatrely on self-reported attitudes.

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.

Contents: Foreword; Who has participated?; Introduction; Two examples ofservice failure; What do we wish to achieve with this strategy?; What is highquality?; What is our theoretical approach?; Where are we heading?; How do weget there?; The way forward; How do we know whether we have reached ourdestination?; To you, the user; References and literature.

Contents: Introduction; Summary of key findings; Literature review; References;Technical appendix: a summary of the main empirical studies used in the review.

www.shdir.no/kvalitetsforbedring/english

http://www.shdir.no/vp/multimedia/archive/00005/IS-1162_E_5484a.pdf


NEW PUBLICATIONS

This is a very interesting historical accountof a large variety of public health activitiesin the United States. Ward is a formereditor of the well-known “Morbidity andMortality Weekly Report Series” publishedby the US Centers for Disease Control andPrevention (CDC) while Warren is ahistorian from the New York Academy ofMedicine. The background of the editorshas obviously been crucial both in thechoice of topics as well as of chapterauthors. The accounts of advances in infec-tious disease are fascinating andoutstanding. Each chapter tackles theproblems from a historical angle and mostare revealing.

The book is divided into ten parts – controlof infectious disease, control of diseasethrough vaccination, maternal and infanthealth, nutrition, occupational health,family planning, oral health and dentalfluoridation, vehicular safety, cardiovas-cular disease, tobacco and diseaseprevention. Each part has two or threechapters which describe the advances andimprovements that have occurred in theirparticular area with the second (or third)chapter giving a fascinating historicalaccount of the background, developmentof methods and campaigns beforeconcluding with a brief note on futureneeds. Each chapter has a voluminousbibliography, including advice on furtherreading materials.

It may be invidious to select individualchapters for their excellence, but several areoutstanding in the analysis of advanceswhich have been made. Of particular noteare the chapters on the contribution ofRené Dubos to the control of infection,

while the two chapters on poliomyelitisgive a vivid account of the dread of thisdisease and the response by thegovernment and public to its prevention, aswell as the lessons that can be learnt fromthis for “biological warfare”. The accountof the background to the First SurgeonGeneral’s report on tobacco is illuminatingand accurate in its conclusions of the effectthat this has had on epidemiologicalthinking and practice.

Reviewing a book of such excellence ischallenging – it is difficult to distinguishbetween different contributions. Howeverit is important to consider whether anyimportant areas have been omitted in orderto put public health problems intoperspective.

The provenance of the book from theCDC may have affected both the choice ofproblem/condition, as well as their descrip-tions. Although many of the chapters,particularly those on infant mortality andmaternal health and nutrition, refer to theassociation with deprivation, none reallydeals in any depth with the recurringproblems of poverty or the influence ofethnicity on health in the US.

It is tempting to identify gaps in any work– and there are some in this book. In theinfectious disease field the omission of thework of Rammelkamp and his group onthe control of streptococcal disease andrheumatic fever is surprising. The lack ofanalysis of influenza can, perhaps, beexcused by the title “victories” since therehas not been a victory, only a debacle withthe mass immunisation against swine flu inthe 1970s. There is also a relatively sparseaccount of environmental improvements inareas such as air pollution, or the aban-donment of lead based paint and its effecton child health. A surprising omission isthe work on tuberculosis in both Alaska(where it was a major scourge) and in thesouthern US. The conquest of syphilis is

also not described, perhaps in deference tothe scandal of Tuskegee County where apopulation was kept in ignorance and nottreated for many years when effectivecontrol measures were available.

An area of public health in which the UShas excelled is in its programmes ofeducation and its Schools of Public Health.It is a shame that the means by which the“victories” have been achieved receive solittle recognition. It is also to be hoped thatthe fear expressed on page 228 that the USwill, in the future, “reject science-basedpolicies”, as is happening with the currentBush administration, will not come to pass.

The title “Silent Victories” has a subtitle –“the history and practice of public healthin twentieth century America”. This workundoubtedly portrays well some of themajor successes. The preface disclaims anysuggestion of comprehensiveness, nonethe-less the choice of subjects and the omissionof such major scourges, as tuberculosis andrheumatic fever, where US public healthhas played an enormous role is unfor-tunate. Although both the swine flu vacci-nation debacle and the Tuskegee episodeare referred to in passing in the intro-duction, the book would have beenimmensely strengthened if it had includedanalysis of these unfortunate events. Ratherthan being only a celebration it would havebeen an important source of reference forpublic health in the United States. Butperhaps the most striking analytic omissionis the difference in infant mortality ratesbetween whites and other ethnic groupswhich has persisted throughout thiscentury. This illustrates the problems ofpoverty in the US more vividly than anyother public health problem. The will-ingness to tolerate Third World conditionsin parts of the country is an unfortunateblot on the US. The neglect of this issue inthe book may be due to its provenancefrom a US government agency.

Silent victories. The history and practice of

public health in twentieth-century America

Review by Walter Holland

Edited by John W Ward and Christian Warren. Oxford University Press, 2006. £29.99 Hardback, 512 Pages ISBN-10: 0-19-515069-4

Walter Holland is Emeritus Professor ofPublic Health Medicine and VisitingProfessor, LSE Health, London School ofEconomics. Email: [email protected]


Please contact Sherry Merkur [email protected] to suggest web sites

for potential inclusion in future issues.

Quest for Quality and ImprovedPerformance (QQUIP)

http://www.health.org.uk/qquip

GTZ-ILO-WHO Consortium onSocial Health Protection inDeveloping Countries

http://www.socialhealthprotection.org

German Institute for Qualityand Efficiency in Health Care(IQWiG)

http://www.iqwig.de

The Consortium is a joint effort to coordinate the work of several organisations working in thefield of social health protection: GTZ - Deutsche Gesellschaft für Technische Zusammenarbeit(German Society for Technical Cooperation), International Labour Organisation (ILO), and theWorld Health Organization (WHO). It collaborates at country, regional and global level andsupports increases in the quality and scope of sustainable and comprehensive health care financingin partner countries, strengthens technical support by joining resources and creates synergies andsavings through complementary activities. The website provides details of the Consortium’s aimsand work, presentations from past conferences, as well as publications for download in variouslanguages including English, French, German and Spanish.

Insight & Action: A new digestfrom the CHSRF

http://www.chsrf.ca/other_docu-ments/insight_action/index_e.php

The Canadian Health Services Research Foundation (CHSRF), which supports the evidence-informed management of Canada’s health care system by facilitating knowledge transfer andexchange, has launched a new weekly digest called Insight & Action. Available in both Englishand French, the digest aims to link those individuals who practice knowledge transfer andexchange with relevant evidence-informed resources. This series provides insights into importantconcepts of knowledge transfer and exchange, including networks, brokering, dissemination andresearch use. It is available for download, or can be received by email following subscription.

Established in June 2004, IQWiG is an independent scientific institute that assesses the qualityand efficiency of health care in Germany. The Institute evaluates pharmaceuticals, surgical proce-dures, diagnostic tests, clinical practice guidelines and aspects of disease management programmes,following the principles of evidence-based medicine. It communicates its findings to the health careprofessions, patients and the general public. The website provides, in both English and German,information on the role and structure of the Institute (including a mandate to assess the cost-effectiveness of drugs), details of commissions undertaken, information on methods and tools,and publications for download, including final reports and other documents produced by theInstitute as well as original articles and reviews produced by scientific staff members.

QQUIP is a five-year research initiative of the Health Foundation in England, which bringstogether data from a wide range of sources to reveal national and international trends on diseaseand quality of care. Its three main aims are: to assess the current state of quality and performanceof health care, to identify what works to improve quality and performance and to measure valuefor money criteria regarding NHS spending. QQUIP also collects, analyses and updates datafrom outside sources, such as OECD Health Data, the Department of Health, the HealthcareCommission, Royal College databases and clinical publications. The website collates evidenceon the impact of various interventions designed to improve the quality of health care interna-tionally, supplies charts that provide at-a-glance data on quality topics (effectiveness, safety,access) and highlight priority areas (cancer, heart disease, diabetes, mental health). Publicationsalso available for download.

Belgian Health Care KnowledgeCentre (KCE)

http://www.kce.fgov.be

Created in December 2002, KCE is in charge of conducting studies that support politicaldecision-making on health care and health insurance in Belgium. It is a public interest organi-sation under the supervision of the Minister of Public Health and Social Affairs. Recent studieshave addressed various topics, including: financing hospital nursing care, chronic care of peoplewith acquired brain injuries, cardiovascular primary prevention, and chronic low back pain. Itswebsite provides details of mission, press releases, outcomes of studies, publications for downloadand useful links to other organisations. The website is in Dutch and French, with some publica-tions also available in English.

WEBwatch

http://www.chsrf.ca/other_documents/insight_action/index_e.php


MONITOR

EUROPEAN MONITOR

60th World Health Assembly The 60th session of the WorldHealth Assembly took place inGeneva between 14 and 23 May.Member States agreed a reso-lution which will help all coun-tries better prepare for the globalpublic health threat which aninfluenza pandemic presents. Theresolution, Sharing of influenzaviruses and access to vaccines andother benefits, restates the generalprinciples of the necessity ofsharing, both in the preparationsfor an influenza pandemic, and inthe benefits that will flow fromimproved international cooper-ation and preparation, such asgreater quantities of and equitable access to H5N1 andpandemic vaccines.

In her closing remarks, theDirector-General Dr MargaretChan told delegates, “all coun-tries need to be aware of theirobligations under the revisedInternational Health Regulations(IHR). When collective securityis at stake, public opinion cancarry great weight. After veryconsiderable discussion, youhave adopted a resolution on thesharing of influenza viruses andaccess to pandemic vaccines andother benefits. I want to under-score the importance of thisdecision. My responsibilities inimplementing the IHR dependon this sharing.”

The resolution requests WHO toestablish an internationalstockpile of vaccines for H5N1 orother influenza viruses ofpandemic potential, and toformulate mechanisms andguidelines aimed at ensuring fairand equitable distribution ofpandemic-influenza vaccines ataffordable prices in the event of apandemic.

It also tasks an interdisciplinaryworking group with drawing upnew Terms of Reference (TORs)for the WHO Influenza Collabo-rating Centre Network, and itsH5 reference laboratories, for thesharing of influenza viruses. Thenew TORs will take into account

the origin of influenza virusesgoing into the WHO GlobalInfluenza Surveillance Network,and will make their use moretransparent. Once finalised, theseTORs will be submitted to aspecial IntergovernmentalMeeting of WHO Member Statesand regional economic organisa-tions.

The Assembly also reached alast-minute agreement on publichealth, innovation and intel-lectual property. The resolutionexpressed appreciation to theDirector-General for hercommitment to the process of theIntergovernmental WorkingGroup on the issue andencouraged her to guide theprocess to draw up a globalstrategy and plan of action. Theresolution also requested theDirector-General to providetechnical and policy support tocountries. Dr Chan said that sheis “fully committed to thisprocess and have noted yourdesire to move forward faster ...We must make a tremendouseffort. We know our incentive:the prevention of large numbersof needless deaths and suffering.”

Norwegian Prime Minister, JensStoltenberg, gave a keynoteaddress to the Assembly,focusing on two of theMillennium Development Goalsthat Norway has paid particularattention to: child mortality andmaternal health. He announcedthat a draft Global Business Planto accelerate progress on thesetwo goals is under preparation,with the intention of beinglaunched in September 2007. Hehoped that the plan “will helpmobilise additional resources thatwill help successfully achieve thegoals on child mortality andmaternal health” and that “it mayprovide the political impetus atthe highest level to facilitatecountry-led action.”

The Health Assembly approvedthe largest-ever budget for theWHO for 2008–2009 of US$4.2billion, an increase of nearly $1billion from the $3.3 billionapproved for 2006–2007. For thefirst time, this budget is part of a

six-year strategic plan for WHO,which Member States alsoadopted at the Assembly.

Among the other issuesdiscussed, Member Statesexpressed their concern thatmalaria continues to cause morethan one million preventabledeaths every year. The Assemblypassed a resolution to intensifyaccess to affordable, safe andeffective antimalarial combi-nation treatments, to intermittentpreventive treatment in preg-nancies, to insecticide treatedmosquito nets, and indoorresidual spraying for malariacontrol with suitable and safeinsecticide. Member Statesrequested that donors adjusttheir policies so as to progres-sively cease to fund the provisionand distribution of oralartemisinin monotherapies, andto join in campaigns to prohibitthe marketing, distribution anduse of counterfeit antimalarialmedicines.

The Assembly also endorsed theGlobal Plan of Action onWorkers’ Health, which aims todevise policy instruments onworkers health; protect andpromote health at the workplace;improve the performance of, andaccess to, occupational healthservices; provide and commu-nicate evidence for preventiveaction; and incorporate workershealth into other policies. TheAssembly adopted a resolutionon emergency trauma caresystems, which draws theattention of governments to theneed to strengthen pre-hospitaland emergency trauma caresystems (including mass casualtymanagement efforts) anddescribes a number of stepsgovernments could take. It alsoinvites WHO to scale up itsefforts to support countries.

Member States approved theresolution on the strengtheningof health information systemsand enhancing WHO’s work onhealth statistics in general. Theyalso called on the DG tostrengthen the information andevidence culture of WHO itself,and ensure the use of accurate

New

s

Press releases andother suggestedinformation forfuture inclusion can be e-mailed tothe editor David [email protected]

and timely health statistics in order togenerate evidence for major policy decisions and recommendations withinWHO. Member States approved a reso-lution and reiterated the importance of acoherent research strategy for WHOwhich will help to disseminate theoutcomes of research and its utilisationin decision- and policy-making for moreeffective health policies.

Other issues discussed includedsmallpox eradication; non-communi-cable diseases; better medicines forchildren; and progress in the rational useof medicines

More information on the World HealthAssembly is available athttp://www.who.int/mediacentre/events/2007/wha60/en/index.html

G8 Summit: Commitments to Africa“will be honoured”The G8 have vowed to deliver on theirexisting pledges to Africa. The discus-sions with African representatives were“very honest, very open” German Chancellor, Angela Merkel, said after thefirst working session on the last day ofthe Summit in Heiligendamm, Germany.The Chancellor’s message to the coun-tries of Africa was this: “We are aware ofour responsibility and we will honourour commitments.” The G8 needed to“fulfil the promises we made,” she said.

US$60 billion has been pledged over thecoming years to combat HIV/AIDS,malaria and tuberculosis. This is to beused to safeguard universal access tocomprehensive HIV/AIDS preventionprogrammes, treatment and care, and todevelop health systems at local level.Particular attention in the fight againstinfectious diseases is to be paid to theneeds of adolescent girls, women andchildren. G8 hosts, Germany, will beproviding €4 billion to support effortsto combat these illnesses, while overallhalf of the budget will come from theUnited States.

The vow for action, comes after theacknowledgement that the G8 membershad not met their 2005 commitments.Anti-poverty campaigners weredecidedly unimpressed. “This wasn’tserious, this was a total farce... I won’thave it spun as anything else except afarce”, said Bob Geldof. He added thatinstead of re-committing to the promisesmade two years ago, the G8 leaders hadto get “serious and deliver”. However he

singled out, UK Prime Minister TonyBlair for pursuing the anti-povertycampaign “to the point of exhaustion”.

A policy advisor from the UK NGO,Oxfam, said only $3bn of the moneywas new, “We must not be distracted bybig numbers. What the $60 billionheadline means at best is just $3 billionextra in aid by 2010”. “Before thissummit, Oxfam showed the G8 were setto miss their 2010 target by a massive$30 billion. Today’s announcement mayonly close that gap to $27 billion” headded. Steve Cockburn of the StopAIDS Campaign said the pledge fellshort of UN targets obliging G8 nationsto spend $15 billion per year to combatAIDS alone through to 2010.

This is not to say that no progress hashowever been made since the 2005summit in Gleneagles, Scotland. This hasincluded the write off of the debt ofeighteen African nations. In the case ofZambia, free health care in rural areashas been expanded as a result.

In their final declaration, the G8affirmed their commitment in Africa to“focus on promoting growth and invest-ments in order to combat poverty andhunger, to foster peace and security,good governance and the strengtheningof health systems, and to assist the fightagainst infectious diseases.”

The G8 countries also pledged tosupport their African partners inmeeting the challenges they face when itcomes to climate policy. They also wantto contribute to strengthening politicalstructures, to promote investments andto development the local economy. TheSummit Declaration “Growth andResponsibility in Africa” lists the 63commitments which cover a widevariety of issues.

More information on the G8 summit isavailable at http://www.g-8.de/Webs/G8/EN/G8Summit/g8-summit.html

Global health: launch of the firstadvance market commitment for newvaccinesIn Rome on 9 February, at a ceremonyattended by Her Majesty Queen RaniaAl-Abdullah of Jordan, then Presidentof the World Bank, Paul Wolfowitz, andMinisters from Italy, Canada, Russia,Norway, the UK, Malawi and Ghana,the first step was taken to accelerate thedevelopment of new vaccines for

diseases that afflict the poorest countrieswith the launch of the Advanced MarketCommitment (AMC).

The AMC is an innovative, market-based mechanism with the potential tosave millions of lives by acceleratingaccess to vaccines in the world’s poorestcountries; vaccines that would nototherwise be available for many years.The first AMC will target pneumococcaldisease, bringing potentially life-savingvaccines more quickly to one hundredmillion children and preventing over fivemillion deaths by 2030.

Speaking at the launch of the AMC, thenUK Finance Minister, Gordon Brown,said, “we have come together in a uniqueand historic global alliance to put inno-vative finance fully at the service ofinnovative medicine and to save millionsof lives. The advanced market mech-anism we launch today means that –instead of high costs, low volume drugproduction as in the past – we can havehigh volume, low cost production ofdrugs in the future and ensure that themany will not be denied the medicaladvances available to the few.” He addedthat “we call on other countries to joinus to put finance fully at the service ofinnovative medicine.”

The AMC concept was developed inresponse to a tragic dilemma, notedItalian Finance Minister TommasoPadoa-Schioppa, whose ministry led thedrive to adopt the AMC pilot. “TheAMCs are an absolutely innovativeapproach which combines market-basedfinancing tools with public intervention.This innovative instrument opens a newfrontier in the financing of the fightagainst poverty and endemic diseases.”He went on to add that “internationalprojects such as this one will make itpossible to save millions of human livesand demonstrate that development canand must go together with the need toensure equality and guarantees of abetter future for the poorest and theweakest.”

The AMC for pneumococcal disease willprovide $1.5 billion in future financialcommitments to the poorest countries,giving them the purchasing power tobuy a suitable vaccine at discountedprices when one becomes available. Bycreating a market for vaccines in thepoorest countries, the AMC createsincentives for the pharmaceuticalcompanies to invest in research,


NEWS

http://www.who.int/mediacentre/events/2007/wha60/en/index.html

http://www.g-8.de/Webs/G8/EN/G8Summit/g8-summit.html

development and production capacityfor new vaccines that serve the poor.Commitments to the pneumococcalAMC have so far been made by Italy$635m, UK $485m, Canada $200m,Russia $80m, Norway $50m and theGates Foundation $50 m.

Julian Lob-Levyt, executive secretary ofthe Global Alliance for Vaccines andImmunisations (GAVI), said new pneu-mococcal vaccines would reach devel-oping countries by 2010 thanks to theproject, at least ten years earlier thanthey would have done otherwise.However, he added, manufacturers lackthe capacity to provide a vaccine well-suited to the developing world on a largescale, and extended protection vaccinesare needed to bring pneumococcaldisease under control in developingcountries. The then World Bank Pres-ident, Wolfowitz, also noted that “onaverage vaccines take fifteen to twentyyears to get to the poor, AMC breaksthat vicious circle.”

Her Majesty Queen Rania pointed outthat in the poorest regions of the world,two to three million children die ofpreventable diseases every year. HerMajesty took particular note of thedonor nations that are helping to meetthe goal of reducing by two-thirds thenumber of deaths among the world’smost vulnerable children. “You aregiving the gift of health, and, more thanthat, the gift of hope” said the Queen.“Thanks to you, more families will havea fighting chance to see their babiessurvive, to see their boys and girls growup, their sons and daughters liveproductive lives. Thanks to you, entirecommunities may find the strength topush back against poverty and entirecountries may take a step up the ladderof human development.” Pope Benedicthas also given his support to the projectfollowing a meeting at the Vatican.

An independent expert committee, withrepresentation from developing andindustrialised countries, was instru-mental in recommending that pneumo-coccal disease be the target of the initialAMC pilot. Pneumonia is the leadinginfectious cause of child mortalityworldwide, causing an estimated 1.9million child deaths each year, almost20% of all child deaths. Pneumococcaldisease is also the second leading causeof childhood meningitis deaths. Thiskills more than 1.6 million peopleincluding nearly one million children

under age five every year. HIV/AIDS isincreasing the rate of infections, withHIV-infected children twenty to fortytimes more likely to get pneumococcaldiseases.

Going forward, the AMC will beoverseen by an independent assessmentcommittee, which will set and monitorstandards for the vaccines. The WorldHealth Organization will facilitate theestablishment of the target productprofile and assess the quality, safety andimmunogenicity of AMC vaccines. TheGAVI Alliance and the World Bank willbe responsible for supporting theprogrammatic and financial functions ofthe AMC.

Ulla Schmidt: Good progress on healthpolicy under German PresidencyThe EU Council of Health Ministersmet in Brussels on 31 May. GermanMinister of Health, Mrs Ulla Schmidt,appreciated the agreement reached bythe EU Health Ministers concerning theregulation of medicinal products for so-called advanced therapies. Mrs Schmidtsaid that “the regulation decisivelycontributes to the competitiveness of theEU in key areas of biotechnology andsupports the growth of this upcomingsector of industry. At the same timeappropriate attention is paid to ethicalissues.”

The revision of the Medical DevicesDirectives was also completed. MrsSchmidt emphasised that “the public isright to expect that these products meetthe highest safety standards and complywith the relevant standards through outthe European Union. This is guaranteeddue to the amendments of the MedicalDevices Directives.”

After five months of the GermanCouncil Presidency, Mrs Schmidt, alsoreflected more generally on progressachieved so far. “For the GermanCouncil Presidency, ‘innovation,prevention and access to health careservices’ have been our priorities inhealth policy. We achieved decisiveprogress in all of these areas and they arefollowed up within the scope of theTriple Presidency with Portugal andSlovenia.”

She added that “the permanent andserious threat to public health byHIV/AIDS in Europe is the reason whyHealth Ministers committed themselvesin the Council Conclusions adopted

today to new initiatives to combatHIV/AIDS in the European Union andin the neighbouring countries”. Thus theCouncil endorsed the results of theministerial conference held under theGerman Council Presidency in March,in which Federal Chancellor, AngelaMerkel, had also participated. In thiscontext Minister Schmidt confirmed thatshe had intensive conversations withpharmaceutical industry and theEuropean Commission with the aim ofenabling patients to have access toexpensive antiretroviral drugs in allEuropean states by an appropriatecountry-specific pricing.

She also warmly welcomed the conclu-sions which had been adopted regardingthe planned Community framework onhealth services. During an informalmeeting in April, the European HealthMinisters expressed their support for acomprehensive legal framework guaran-teeing access to health services for allpatients throughout the whole EuropeanUnion. Together with Federal MinisterHorst Seehofer, Ulla Schmidt alsowelcomed the “Council conclusions onhealth promotion by means of nutritionand physical activity”. They are basedon the key results of an expertconference in Badenweiler, which hadbeen jointly organised by the FederalMinistry of Health and the FederalMinistry of Food, Agriculture andConsumer Protection under the GermanPresidency.

Further information on health policyunder the German Presidency can befound at www.eu2007-bmg.de

Commission proposes EU-wide efforts totackle the obesity epidemicOn 30 May, the European Commissionadopted a White Paper setting out awide range of proposals on how the EUcan tackle nutrition, overweight andobesity related health issues.

The prevalence of obesity has more thantrebled in many European countriessince the 1980s, according to the WorldHealth Organization. In the majority ofMember States more than 50% of theadult population is overweight or obese.Child obesity is of particular concern.An estimated three million Europeanschool children are now obese, and some85,000 more children become obese eachyear. Young people tend to retain excessweight throughout their adult lives andare more likely to become obese.


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The White Paper stresses the importanceof enabling consumers to make informedchoices, ensuring that healthy optionsare available, and calls upon the foodindustry to work on reformulatingrecipes, in particular to reduce levels ofsalt and fats. Stressing the benefit ofphysical activity and encouraging Europeans to exercise more is anotherarea to develop.

The need for EU action in the area ofnutrition and physical activity stemsfrom the fact that poor diets and lowlevels of physical activity in Europeaccount for six of the seven leading riskfactors for ill health in Europe.

Stronger partnerships

The White Paper calls for more actionorientated partnerships across the EUinvolving inter alia private actors andpublic health and consumer organisa-tions. This builds on existing mecha-nisms such as the EU Platform forAction on Diet, Physical Activity andHealth and calls on the range of stake-holders across the EU to work togetherto establish fora at national and locallevel within Member States. It aims tostrengthen links with Member States, theWorld Health Organization and otherimportant stakeholders. To ensure highlevel political support, and cross sectoralcooperation within Member States, theWhite Paper proposes the creation of anew High Level Group focused onnutrition, overweight and obesity relatedhealth issues, comprising a represen-tative from every Member State.

The Commission also calls for strongeraction on the part of private actorsacross the EU in a number of areas.These include the development ofstronger advertising codes, greaterefforts by the food and retailingindustry, and initiatives by sportingbodies to develop advertising andmarketing campaigns to encouragephysical activity and focusing on targetgroups such as children

Commission action

The White Paper clarifies the range ofCommission policies that can bemarshalled towards these objectives,such as health and food safety policies,regional policy in the form of structuralfunds, transport and urban policies,sport policy and research programmes.Areas where the Commission proposesnew actions include a revision of

nutrition labelling, programmes topromote the consumption of fruit andvegetables, a White Paper on Sport and astudy to explore the potential of foodreformulation to improved diet.

The Commission will monitor theprogress and performance of all actorswith a first report due in 2010 and willcollaborate with the World HealthOrganization to improve surveillance ofnutrition and physical activity actionsand health status in the EU.

Reaction

There has been a mixed reaction to theWhite Paper. Director of the EuropeanConsumers’ Organisation (BEUC) JimMurray, stated that it contained a “disappointing, unambitious and minimalist response to the problems ofobesity and diet related diseases.” Hewent on to say that “reading the WhitePaper it seems that Mr Kyprianou andthe Barroso Commission have alreadydecided to leave much of the work totheir successors – who will no doubtthemselves wish to ‘review the situation’before deciding what to do,” urging theCommission to do “much more beforethey go” and to at least to bring forwarda “robust proposal for simplified nutritional labelling”. In contrast boththe Confederation of the Food andDrink Industries of the EU (CIAA) andthe Association of the Chocolate, Biscuitand Confectionery Industries(CAOBISCO) welcomed theCommission’s strategy.

The trade association of Television andRadio adverting sales across Europe,egta, also welcomed the White Paper.Michel Grégoire, Secretary General ofegta stated that “the EuropeanCommission offers a comprehensive andbalanced approach to the fight againstobesity in this Strategy. The marketingof food products is part of the politicaldebate but the Commission acknowl-edges that it must be treated in a propor-tionate way”. He went on adding “withthe European Commission’s support ofself-regulation, all stakeholders withinthe advertising industry must nowamplify their efforts to make sure thatself-regulation is really made effectiveacross Europe; that it properly addressesthe issue of healthy lifestyles and, notleast, that it deals with new marketingcommunications and not only thealready-regulated television and radioadvertising.”

The White Paper on Nutrition andPhysical Activity can be found at:http://ec.europa.eu/dgs/health_consumer/index_en.htm

Renewed commitment for cooperationon cross-border electronic healthservicesOn 19 April, at the 2007 eHealthConference, representatives of EuropeanUnion Member States and Members ofthe European Economic Area adopted acommon Declaration. They agreed topursue close interaction and collabo-ration in the area of cross-border electronic health services throughoutEurope.

This conference had From Strategies toApplications as its guiding theme,focusing on the implementation of electronic health-service applicationsand infrastructures such as electronicprescriptions, electronic patient files andother services made possible with anelectronic health card.

Dr Klaus Theo Schröder, State Secretaryat the German Federal Ministry ofHealth declared, “by adopting today’sDeclaration, we seek to ensure that, inthe future, electronic health services forEurope’s citizens do not stop at nationalborders. We want to give patients accessto their medication records and patientsummaries from everywhere within theEuropean Union. This not only servesthe continuity of care but also affordssafety in an emergency.”

The declaration included an under-standing that national well-organisedeHealth infrastructures are a pre-requisite to cross-border solutions, butthat European standardisation will openup market opportunities. Implemen-tation of eHealth services will howeverrequire greater synergies betweenresearch and education, and agreementon common standards by all EUMember States is essential. The Decla-ration identifies the next steps requiredfor European cooperation, in the shapeof large scale pilots to test the appli-cation of improved patient summaries indifferent health contexts such as medicalemergencies or prescription dispensing.

Frans de Bruïne, Director, EuropeanCommission, Directorate-General Infor-mation Society and Media, remarkedthat “the 2007 eHealth Conference hasdeepened the cooperation among theMember States and all stakeholders. The


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Commission welcomes the Declarationon European cooperation in the field ofEurope-wide electronic health services.The European Commission issupporting the first steps towards theirconcrete implementation by means ofLarge Scale Pilots.”

Dorjan Marušic, State Secretary at theMinistry of Health of the Republic ofSlovenia added, “we now have theopportunity to further the main themeof the German EU Presidency Europe –succeeding together and make it tangibleon the ground in our citizens’ everydaylife. We intend to continue the initiativeof Germany’s Council Presidency. Ournational activities provide a sound basisfor achieving this aim.”

The full declaration can be accessed athttp://ec.europa.eu/information_society/activities/health/docs/events/ehealth2007/eh_declaration20070417

Commission proposes actions toincrease organ donations and transplantsOn 30 May, the European Commissionadopted a Communication proposingactions for closer cooperation betweenMember States in the field of organdonation and transplantation, andannouncing plans for a EuropeanDirective on the quality and safety oforgan donation. The Communicationincludes ideas to raise public awarenessso as to increase organ donation, such asthe creation of a European organ donorcard.

Every day ten people die in Europewhile waiting for an organ. Themortality rate of patients waiting for aheart, liver or lung transplant is between15% and 30%. Currently, there arearound 40,000 patients in Europe onwaiting lists. Across Europe, there arehuge disparities in the number of organdonors, ranging from 34.6 donors permillion people in Spain to 13.8 in theUK, 6 in Greece and 0.5 in Romania.

A new Eurobarometer survey showsthat while 81% of European citizenssupport the use of an organ donor card,only 12% of Europeans currently haveone. The shortage of legally-donatedorgans can, unfortunately, encourageillegal trafficking in human organs,which creates both serious ethicalproblems and health dangers.

The Communication sets out ideas toincrease organ availability, such as

creating organ transplant coordinators inhospitals and expanding the use of livingdonors. The Commission will alsopromote the exchange of best practicesbetween Member States to make organtransplant systems more efficient andaccessible. EU Health CommissionerMarkos Kyprianou said that “thousandsof lives are saved every year in Europeby organ transplants. Yet many morelives could be saved if we could reducethe current shortage of organs in manyEuropean countries. A European organdonor card, and common EU standardson the quality and safety of organ dona-tions and transplants, could add value tonational efforts to secure a sufficient andsafe supply or organs.”

Increasing organ availability

Public awareness and opinion has animportant role to play in increasingorgan donation. In 2006, 56% of Europeans declared themselves ready todonate their organs after death, but thisreadiness varies considerably fromcountry to country. The Communi-cation argues that creating a Europeanorgan donor card which indicates thewillingness of the holder to donateorgans will contribute to increasingpublic awareness. The Commission willpromote cooperation between MemberStates to increase public awareness, andthe creation of such a donor card, or itsincorporation into the existing Europeanhealth insurance card, should beconsidered in this context.

In order to increase organ donation,learning from the best models usingliving donors or the so called expandeddonors (donors that can be used only forspecific recipients) will be promoted.Cooperation between countries will bethe best way of defining practice guidelines for those cases.

Directive on quality and safety Every year, a number of organs areexchanged between hospitals in differentEU Member States, carried out byhospitals or professionals falling underdifferent national requirements withregard to safety and quality. Thesequality and safety measures currentlyvary widely.

A European Directive on quality andsafety of organ donation, based onArticle 152 of the EC Treaty, wouldcreate common standards for quality andsafety at every stage of the transplant

process across the Community, withoutaffecting organ donation rates in the EU.

The Directive, expected to be proposedin 2008, would establish oversightauthorities in Member States, a commonset of quality and safety standards, and asystem to ensure the traceability andreporting of serious adverse events andreactions. It would also establishinspection and control measures, andincorporate a mechanism to characteriseorgans, so that the transplant teams canundertake the appropriate riskassessment.

The Communication on organ donationand transplantation can be found at:http://ec.europa.eu/health/ph_threats/human_substance/oc_organs/oc_organs_en.htm

The Eurobarometer survey on attitudestowards organ donation is available athttp://europa.eu.int/comm/health/ph_publication/eurobarometers_en.htm

NEWS FROM THE ECJ

ECJ rules against a priori exclusion ofreimbursement of treatment receivedabroadOn 19 April, in case C444/05, AikateriniStamatelaki versus NPDD OrganismosAsfaliseos Eleftheron Epangelmation(OAEE – Insurance Institution for theLiberal Professions), the EuropeanCourt of Justice ruled that excluding apriori reimbursement of treatmentsabroad is contrary to Community law.

The case concerned Dimitrios Stamate-lakis, a Greek national, who had paid£13,600 to obtain health care from aprivate hospital in London between Mayand June 1998. The OAEE refused toreimburse him, as under Greek lawreimbursement of treatment in privatehospitals abroad is not permitted forthose over fourteen years of age. MrStamatelakis’ widow argued that this lawwas not consistent with the principle offreedom of services within the EU(article 49 of the EU Treaty).

The ECJ, in its judgement, stated thatArticle 49 was applicable to Mr Stamate-lakis, regardless of whether thetreatment received was provided in thepublic or private sectors. Referring toprevious judgements (Case C-157/99Smits and Peerbooms [2001] and Watts,


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http://ec.europa.eu/health/ph_threats/human_substance/oc_organs/oc_organs_en.htm

http://europa.eu.int/comm/health/ph_publication/eurobarometers_en.htm

(Case C-372/04 Watts [2006]), the Courtnoted that national legislation mustcomply with Community law, inparticular the provisions on the freedomto provide services. Those provisionsprohibit the Member States from introducing or maintaining unjustifiedrestrictions on the exercise of thatfreedom in the health care sector.

The ECJ argued that the Greek legis-lation was not proportionate, as lessrestrictive protections against any threatof seriously undermining the financialbalance of the Greek social securitysystem, such as a prior authorisationscheme could have been put in place.

The Court also dismissed the Greekgovernment’s argument relating to thefact that Greek social security institu-tions do not check the quality oftreatment provided in private hospitalsin another Member State, and to the lackof verification as to whether hospitalswith which an agreement has beenentered into are able to provide appro-priate, identical or equivalent, medicaltreatment. Private hospitals in allMember States, the Court deemed, aresubject to quality controls. Doctors whooperate in those establishments provideprofessional guarantees equivalent tothose of doctors established in Greece,in particular since the adoption andimplementation of Council Directive93/16/EEC of 5 April 1993 to facilitatethe free movement of doctors and themutual recognition of their diplomas,certificates and other evidence of formalqualifications.

More information athttp://curia.europa.eu/en/actu/commu-niques/cp07/aff/cp070031en.pdf

ECJ rules against Swedish alcoholrestrictionsUnder Swedish law beverages thatcontain more than 3.5% volume ofalcohol can only be bought in Systembo-laget, a government owned retailmonopoly. Only Systembolaget andwholesalers authorised by the State mayimport alcoholic beverages. Private indi-viduals are prohibited from importingalcoholic beverages. That prohibitionmeans that an individual wishing toimport alcohol from other MemberStates must do so exclusively throughSystembolaget. Systembolaget isrequired to obtain any alcoholicbeverage on request at the consumer’sexpense, provided that it sees no

objection to doing so.

Klas Rosengren and several otherSwedish nationals ordered, via a Danishwebsite, a number of cases of Spanishwine. The wine was imported intoSweden, without being declared tocustoms, by a private transporter. Thewine was then confiscated by thecustoms authorities at Göteborg.Criminal proceedings were broughtagainst Mr Rosengren and other indi-viduals for unlawful importation of alco-holic beverages.

The Högsta Domstolen (SwedishSupreme Court), dealing with the case atfinal instance, asked the Court of Justiceof the European Communities whetherthe provisions of the Swedish legislationare compatible with Community law, inparticular with the principle of freemovement of goods guaranteed by theTreaty.

In a preliminary ruling, on 6 June, theCourt stated that the rules at issue mustbe assessed in the light of theCommunity provisions relating to thefree movement of goods and not in thelight of the specific provisions relating toState monopolies; the latter apply onlyto rules relating to the existence or oper-ation of monopolies. The importation ofalcoholic beverages is not the specificfunction assigned to the monopoly bythe law on alcohol, which rather conferson the monopoly the exclusive right toretail sales of alcoholic beverages inSweden.

Accordingly, the Court took the viewthat the fact that Systembolaget mayrefuse an order from a consumer toimport alcoholic beverages amounts to aquantitative restriction on imports.Furthermore, the Court noted thatconsumers, when making use of theservices of Systembolaget to secure theimportation of alcoholic beverages, findthat they face a variety of inconvenienceswith which they would not be faced ifthey imported the beverages themselves.These include additional administrativecosts and a profit margin which might beavoided if the individual imported thosegoods himself. This also in the Court’sview amounts to a quantitativerestriction on the free movement ofgoods.

The Swedish government argued thatthis restriction was justified on thegrounds of public health. In its ruling,the Court recognised that measures

which amount to quantitative restric-tions on imports can be justified on thegrounds of protection of the health andlife of humans. Rules which seek toprevent the harmful effects of alcoholand to combat alcohol abuse maytherefore be justified in that regard.These rules however must be propor-tionate.

Even though it is indeed possible forSystembolaget to refuse an order, it wasnot apparent from the informationavailable to the Court that Systembo-laget has, in practice, refused an order byreference to maximum quantities ofalcohol. In those circumstances, theprohibition of importation is less amethod of limiting alcohol consumptiongenerally, than a means of favouringSystembolaget as a channel for the distri-bution of alcoholic beverages. Thus, theprohibition of importation must beconsidered unsuitable for attaining theobjective of protecting the health and lifeof individuals.

With regard to the claim that the prohi-bition is justified on the ground that itachieves the objective of protectingyoung persons from the harmful effectsof alcohol, the Court notes that theprohibition applies to all persons, irre-spective of age. Accordingly, it mani-festly goes beyond what is necessarywith regard to the objective pursued ofprotecting young people from theharmful effects of alcohol.

Finally, taking into account the methodsof distribution of the goods and thechecks on the age of purchasers, theCourt took the view that, in all thecircumstances, an effective check on theage of people to whom alcoholicbeverages are supplied is not fully guar-anteed. Furthermore, it is not establishedthat age checks could not be carried outusing methods which are at least equallyeffective and less restrictive. Forexample, the Commission submitted,without being contradicted, that a decla-ration system by which the recipientcertifies, on a form accompanying thegoods, that he is over 20 years of agewould achieve the same objective. Thus,the prohibition is not proportionate forachieving the objective of protectingyoung persons against the harmfuleffects of alcohol.

In those circumstances, the Court ruledthat the prohibition of importation ofalcoholic beverages cannot be justified


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on grounds of protection of the life andhealth of humans.

The issue will now return to the SwedishSupreme Court for further consider-ation. Commenting on the judgementPublic Health Minister, Maria Larssontold that press that “Sweden’s alcoholpolicies stay firm, with our goals toreach decreased alcohol consumption.”

According to the English languageSwedish on-line newspaper The Local,Public Health Minister, Maria Larsson,said a ruling by the EU court inNovember stating that goods importedto Sweden are to be taxed according toSwedish regulations was of greaterimportance in maintaining the country’srestrictive alcohol policy. “As taxes arejust as high when making purchases overthe internet the interest (in importingprivately) will be moderate,” Larssonsaid. Swedish Customs were reported tohave temporarily stopped confiscatingalcohol imported via the internet,according to Lennart Nilsson, the headof the customs agency’s crime unitspeaking to Swedish radio. The SwedishTax Board’s position remains thatcustoms have the right to confiscatealcohol purchased on line.

More information on the ECJ judgementis available athttp://curia.europa.eu/en/actu/commu-niques/cp07/aff/cp070038en.pdf

Advocate General Opinion on Germanadvertising rulesOn 13 February, in case C374/05, GintecInternational Import-Export GmbH vVerband Sozialer Wettbewerb e.V., theAdvocate General of the EuropeanCourt of Justice gave an opinion on theconsistency of the German Act ofAdvertising within the area of healthcare with that of EC Directive 2001/83(Medicinal Products Directive).

Directive 2001/83 prohibits the adver-tising of unauthorised medicinalproducts. The advertising ofprescription-only medicines is permittedwhen directed to professionals.Medicinal products which are intendedto be used without a prescription may beadvertised, subject to various conditions.These include the prohibition of thedirect distribution of medicines forpromotional purposes. They also stip-ulate that advertising should not refer inimproper, alarming or misleading terms,to claims of recovery of health status.

The specifics of the case concerned aGerman company, Gintec InternationalImport-Export, that marketed severalmedicinal products containing ginseng.In May 2005, it undertook a mailingcampaign including promotionalmaterial containing positive results froma public opinion poll regarding itsproducts. Moreover, the company on itsweb page also offered readers the oppor-tunity to win boxes of Gintec productsin monthly draws.

The German Association for thePrevention of Unfair Competition(Verband Sozialer Wettbewerb)embarked on a course of legal actionagainst the company. They claimed thatthis advertising campaign violatedsections of the German Act on Adver-tising within the area of health care.Under this law, the use of testimonyfrom third parties or prize draws areprohibited from advertising campaigns.

As these rules are more restrictive thanthose of the EU Directive, on 12October 2005, the Bundesgerichtshof(German Federal Court of Justice)sought a preliminary ruling from theEuropean Court of Justice as to whetherthe standards set under EC Directive2001/83 should prevent a Member Statefrom adopting stricter legislation. If theanswer to this question was yes, theBundesgerichtshof wanted the Court toconsider two further questions. First,whether public opinions polls onmedicinal products should be banned asabusive “patient claims of recovery”; andsecondly whether the placing of suchprize draws on the internet is prohibitedby EC Directive 2001/83.

The Advocate General gave the Opinionthat the Medicinal Products Directivedoes indeed set a maximum standard,and thus no Member State is allowed tomake any additional prohibitions orrestrictions. Directive 2001/83 isintended to safeguard public health bymeans which will not interfere with freetrade to harmonise national laws. Thesegoals would not be met if discrepanciesbetween the laws of Member States wereallowed. Thus national laws, such asthose that impose a general prohibitionon adverts containing third party state-ments or prize draws, are inconsistentwith the provisions of the Directive.

Second, the advertising of medicinalproducts by the use of generally positivepublic opinion polls findings, without

indicating precisely the medicinalproducts’ therapeutic properties, doesnot operate as improper, alarming ormisleading claims of recovery in terms ofArticle 90. Thus, such advertising shouldnot be prohibited.

However, an internet advertisement bymeans of a monthly draw where theprize is the advertised product itself,violates Article 87 paragraph 3 of theDirective because it encourages thepublic to use the medicine in an unrea-sonable way. Moreover, such advertisingis prohibited under Article 88 paragraph6, because it qualifies as a direct promo-tional distribution of a medicinalproduct to the public.

The Opinion can be accessed in severallanguages via http://curia.europa.eu

COUNTRY NEWS

Russia: Putin cites progress on health inannual address to Federal AssemblyOn 26 April, President Vladimir Putinmade his annual address to the FederalAssembly in Moscow. In his address,President Putin gave an assessment ofthe situation in the country and set outpolicy priorities for the economy, socialsphere, science, defence and security, andfor domestic and foreign policy. Inreference to health, he spoke of achieve-ments made so far in the prioritynational health project established in2005 stating that “it had brought resultsin the form of victories, small victories,yes, but victories nonetheless, repre-sented by the lives of thousands of ourfellow citizens. The reduction in thedeath rate and rise in the birth rate thatwe achieved in 2006 and that hascontinued in the first months of this yearare clear evidence that we are working inthe right direction.”

He also pointed to investment inproviding health care establishmentswith state-of-the-art equipment, andproviding financial support to univer-sities using new teaching methods andconcepts. He went on to declare hissupport for 2008 to be the Year of theFamily in Russia saying that he hopedthat “this decision will consolidate theefforts of the state and the businesscommunity to help strengthen andsupport the institution of the family andbasic family values.”


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The full text of the President’s speech isavailable athttp://www.kremlin.ru/eng/speeches/2007/04/26/1209_type70029_125494.shtml

Moldova: World Bank Health Servicesand Social Assistance ProjectIn Washington, on 7 June 2007, theWorld Bank approved a US$17 millioninterest free loan for a Health Servicesand Social Assistance Project forMoldova. The project will assist thegovernment in reducing prematuremortality and disability, and inimproving the targeting of socialtransfers and services to the poor.

Moldova has made notable progress inreforming its health sector, including theintroduction of mandatory healthinsurance and the consolidation of thehealth infrastructure, while extendingthe primary care network and decentral-ising its management to local govern-ments. However, important challengesremain and the authorities need tofurther the reform process if thecountry’s health and social assistancesystems are to offer effective andsustainable care, particularly to thecountry’s poor.

Health sector reforms undertaken inrecent years by the government riskbeing undermined as the populationcontinues to face low average lifeexpectancy, high mortality rates, and there-emergence of tuberculosis and otherillnesses. Access to quality health careservices remains skewed in favour of thelargely better-off urban population. Thecountry still lacks universal healthinsurance coverage, and informalpayments to obtain medical treatmentare commonplace. In addition, poorconditions in many hospitals and polyclinics, and the widespread lack ofnurses and doctors lead to inadequatehealth care.

In the area of social protection, theGovernment has established a NationalSocial Insurance House to improve theadministration of pension and socialinsurance, and to eliminate arrears in thepayment of pensions. However,Moldova currently has fifteen socialassistance benefits with a range of eligi-bility criteria and processing procedures,which are not applied using poverty-related instruments. This fragmentationof social assistance transfers limits theirability to reach the poor and much ofsocial assistance ends up benefiting the

middle and upper-income groups.

Rekha Menon, World Bank Task TeamLeader for the project, said that it“builds on the ongoing reform processoutlined in the government’s MediumTerm Expenditure Framework and willbe implemented in close coordinationwith other donors. It aims at addressingthe most prevalent health concerns,including reducing the high rates ofpremature mortality, modernising thehospital sector, and improved targetingof social services for Moldova’s poorestpeople.”

The project has three main components.The first component, Health SystemModernisation, builds on on-goingreforms in the health sector that formpart of the National Health Strategy2007–2017. The second component,Social Assistance and Welfare, supportsgovernment plans to improve the effectiveness of cash benefits and socialwelfare services in combating poverty.The third component, institutionalsupport, relates to the provision of insti-tutional support for the implementationof the reform strategies.

The project is an integral part of a largerand longer-term programme of thegovernment to improve the efficiencyand effectiveness of social spending inMoldova. It is jointly supported byother donors, including the EuropeanUnion, the Swedish International Development Cooperation Agency, theUnited Kingdom’s Department forInternational Development, the Councilof Europe Development Bank, andrelevant UN agencies. The project willbe run over a four-year period, fromSeptember 2007 to February 2011, andwill be implemented by the Ministry ofHealth as well as that of SocialProtection, Family and Child.

More information on the World Bank’swork in Moldova is available athttp://www.worldbank.org.md

UK: Branded medicines regulationsenter into force New legislation requiring pharmaceu-tical companies to provide the UKDepartment of Health (DoH) withinformation on income from the sales ofeach branded medicine supplied to theNHS, has taken effect.

On 25 May, the Health Service Medi-cines (Information Relating to Sales ofBranded Medicines Etc.) Regulations

2007 came into force in the UK. Theyplace additional requirements uponmembers of the voluntary Pharmaceu-tical Price Regulation Scheme (PPRS),which was negotiated by the DoH andthe Association of the British Pharma-ceutical Industry to control NHS expen-diture on branded medicines. Under theRegulations, PPRS members must nowsupply information on the sales of eachpack size and strength of branded medi-cines to the DoH on a quarterly basis, inorder that the data be analysed for theNHS.

The PPRS regulates the prices ofbranded prescription medicines and theprofits that manufacturers are allowed tomake on the sales of these medicines tothe NHS, and covers approximately £8billion of the value of medicines used inthe NHS in both primary and secondarycare. A new five year scheme started on1 January 2005, providing for a 7%reduction in price for brandedprescription medicines to the NHS,which is thought to be saving the NHSan estimated £1.8 billion over the fiveyears. The new Regulations, byrequiring PPRS members to give infor-mation on the discounts they give forbranded medicines, will make it possiblefor the DoH to assess whether it is in theNHS’s best interests to continue the 7%reduction. This is particularly importantin light of revisions by several largepharmaceutical companies to distri-bution arrangements for their brandedmedicines, changes which could poten-tially affect the NHS’s discount savings.

The Statutory Instrument can be viewedat http://www.opsi.gov.uk/si/si2007/20071320.htm

England: vote of confidence by patientsin care provided by NHS hospitals Patients have given a vote of confidenceto the overall care provided by NHShospitals with nine out of ten peoplesurveyed by the Healthcare Commissionrating it as “excellent”, “very good” or“good”. The Commission is the healthwatchdog in England. It keeps check onhealth services to ensure that they aremeeting standards in a range of areas.The Commission also promotesimprovements in the quality of healthcare and public health in Englandthrough independent, authoritative,patient-centred assessments of thosewho provide services.

The findings are from the Commission’s


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http://www.opsi.gov.uk/si/si2007/20071320.htm

inpatient survey, the biggest test of theexperiences of patients in NHS hospitalsin England. In autumn 2006, 80,000patients at 167 acute and specialist trustsresponded to the survey, coordinated onbehalf of the Commission by the independent Picker Institute.

Just 2% of patients said the overall carethey received in hospital was “poor”.More patients said they waited sixmonths or less for planned admissions,84% in this survey compared with 78%in 2005. Compared with the previousinpatient survey, more people alsoresponded positively to questions aboutcleanliness and efforts to controlinfection through handwashing.

The results also highlighted considerablevariation in the performance of acutetrusts on a range of issues relating todignity in care. Of patients who indi-cated that they needed help eating, 20%said they did not get enough. There were30 trusts where one in five, or more,patients rated the food as “poor”. But inmost other trusts, few patients rated thefood as “poor”, just 2% in one trust.Looking at planned admissions only andexcluding those who stayed in criticalcare units, 11% of patients nationallysaid they shared a room or bay with apatient of the opposite sex. Almost onein three said they had to share abathroom or shower area with membersof the opposite sex.

Commenting on the publication of thesurvey, British Medical Associationconsultants’ committee chairman, DrJonathan Fielden, said that “it is grati-fying that this survey reflects theimmense efforts from doctors toimprove the quality and experience ofcare for their patients despite thefinancial pressures placed upon thehealth service.”

Anna Walker, Chief Executive of theHealthcare Commission, said “we allhear a lot of negative comment about theNHS, but we must never forget thatmost patients have consistently rated theoverall quality of their care as good orexcellent. Staff should remember this asit shows that patients value the goodwork they do. The results also suggestthat we need a fresh drive to tackle a setof issues related to treating patients withdignity. But, where there are problems itseems as if there are a minority of truststhat are letting the rest down.”

She also commented that “patients have

the right to expect all hospitals to get thebasics right, like offering help witheating and answering calls for assistance.It is also clear that for a significantminority of patients, the NHS isperforming below standards on segre-gated accommodation.”

The Commission will feed the results ofthe inpatient survey into its annualassessment of NHS trusts, which usesinformation to target inspections andultimately leads to an annualperformance rating.

Further information on the survey can befound at http://www.healthcarecom-mission.org.uk/nationalfindings/surveys/patientsurveys/nhspatientsurvey2006/inpatients.cfm

Northern Ireland: Survey on satisfactionwith health and social care servicesEight out of ten people in NorthernIreland are happy with the health andsocial care services they received lastyear. The latest public attitudes surveywas carried out in 2006 and involvedinterviews with around 1,500 people.Newly appointed Health Minister,Michael McGimpsey, welcomed thegenerally positive findings but said thatthe survey also highlights scope forimprovement.

He said that the survey “shows thatprogress has been made and that stan-dards are high across many aspects ofhealth and social care provision inNorthern Ireland. Health and social carestaff are to be commended for theirdedication in achieving these standards,particularly during a time of change andupheaval in the health service.”However, he cautioned that “there is stillmuch to be done, both in making furtherprogress in areas showing a high level ofsatisfaction and in tackling the issueswhich the public have clearly said are ofconcern to them”

For the first time, the survey soughtpublic views on tackling health care-associated infections, such as MRSA. MrMcGimpsey said that the “findings high-light the public’s concern and a sensethat not enough is being done. This isanother important area in whichprogress must be made”

The survey also indicated that the publichad been responding to healthpromotion messages, with 65% indi-cating some positive changes to theirbehaviour in the last twelve months,

such as eating more fruit and vegetables,other improvements to diet, taking moreexercise, reducing alcohol consumptionand stopping smoking. The Ministerrecognised the importance of the cross-departmental ‘Investing for Health’strategy in this achievement, given itsemphasis on preventing illness throughhealthier lifestyles.

More information at http://www.north-ernireland.gov.uk/news/news-dhssps/news-dhssps-010607-survey-reveals-high.htm

Ireland: Health Information & QualityAuthority established The Health Information and QualityAuthority, Ireland’s first independentAuthority to drive continuous improve-ments in Ireland’s health and social careservices was formally established on 15May.

Speaking on the establishment of thenew Authority, Mary Harney, Ministerfor Health and Children said “this is amajor step forward in ensuring safetyand standards for patients and a verysignificant day in the development of thereform programme in the HealthServices. I am certain that the work ofthe Authority will yield real and tangiblebenefits. It will help to ensure that allpersons receiving health services willhave them delivered in accordance withthe highest quality and safety standards.

The establishment of the Authority willhave a positive impact on public confi-dence generally by enabling people tohave confidence in the safety and qualityof the health care they and their familiesreceive, including the safety and qualityof the residential services being providedto older people, persons with disabilitiesand children in need of care andprotection.”

Mr Pat McGrath, Chairman of theHealth Information and QualityAuthority, said that “Ireland is unique inthe world in establishing an independentAuthority with the powers to set,monitor and investigate health care stan-dards, to evaluate the effectiveness of themedications and treatments being usedand to advise on the collection andsharing of information across the entirehealth and social care services.

The key drivers of quality are allcontained within the functions of theAuthority, which reflects thegovernment’s ongoing commitment to


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http://www.northernireland.gov.uk/news/news-dhssps/news-dhssps-010607-survey-reveals-high.htm

continuous improvement in our healthsystem. The Health Information andQuality Authority will be a powerfuldriver of reliable, safe and qualityservices. It will take time but all of us inthe Authority are determined to playour part in helping Ireland achieve thehealth and social services it deserves”.

Dr Tracey Cooper, Chief Executive ofthe new Authority, said that “the HealthInformation and Quality Authority willsupport the further development of aculture in our health and social serviceswhere learning takes place when thingsgo wrong; where staff are developed,supported and feel comfortable to shareconcerns; where people using theservices are involved in their own careand the planning of their services; whereservices are quality assured to providehigh quality, safe care and where bestpractice is shared and celebrated.”

As an independent Authority, we arecommitted to an open and transparentrelationship with those working inhealth and social services and withpeople using these services so thatpeople can, and will, have confidence inthe quality and safety of care beingdelivered and received. Our inde-pendence within the health system willbe key as we grow the organisation andbegin our work over the comingmonths”.

The Social Services Inspectorate and theIrish Health Services AccreditationBoard have been incorporated into thenew Authority. The functions of theSocial Services Inspectorate have beenexpanded to include the inspection ofresidential homes for older people andpeople with disabilities. The HealthInformation and Quality Authority iscurrently developing the National Stan-dards for Residential Care Settings forOlder People.

More information on HIQA is availableat http://www.hiqa.ie

Austria: INCB warning on counterfeitmedicinesOn 1 March 2007, the Vienna-basedInternational Narcotics Control Board(INCB) warned that the flood of coun-terfeit medicines now available in manycountries could have fatal consequencesfor consumers. In its Annual Report, theBoard also called on Member States toenforce legislation to ensure thatnarcotic drugs and psychotropic

substances are not illegally manufacturedor diverted from illicit manufacture anddistribution channels to unregulatedmarkets.

The danger of unregulated markets is thetheme of chapter one of the AnnualReport. The Board is calling for it to beaddressed on a priority basis. The exis-tence of unregulated markets means thatsubstandard, and sometimes even lethalmedication is sold to the unsuspectingconsumer. Unregulated markets areoften supplied with stolen and diverteddrugs, illicitly manufactured pharmaceu-ticals or through illegal sales on theinternet and distributed through the mailand courier services.

Apart from consumers who purchasepharmaceuticals containing controlledsubstances on the unregulated marketbecause of limited access to health carefacilities or lower prices, personsdependent on and abusing such medica-tions make use of unregulated marketsto obtain them without prescription.“Besides the fact that the existence ofunregulated markets, the sale of divertedand counterfeit drugs and the purchaseof drugs containing controlledsubstances without prescription contravenes international treaties ondrug control, it is important forconsumers to realise that what theythink is a cut-price medication boughton an unregulated market may howeverhave potentially lethal effects wheneverthe consumed drugs are not the genuineproduct or are taken without medicaladvice. Instead of healing, they can takelives,” said Dr Philip O Emafo, Pres-ident of the INCB.

This danger is real and sizeable. TheWorld Health Organization estimatesthat 25–50% of medicines consumed indeveloping countries are believed to becounterfeit. The problem is furthercompounded by the fact that counterfeitdrugs are easy to manufacture – they canresemble genuine drugs in packaging,and labelling. Unknowing clients haveexperienced serious health or even lethalconsequences; for instance, in Africa, theuse of counterfeit vaccines in 1995resulted in 2,500 deaths.

Narcotics, benzodiazepines, ampheta-mines and other internationallycontrolled drugs are easily available instreet markets in several developingcountries. In developed countries, thesedrugs are sold via illegal internet

pharmacies, without the mandatoryprescriptions.

“The problem of counterfeit medicationand abuse of pharmaceuticals containingcontrolled substances bought withoutprescriptions, has been in existence forsome time. However, the rapidexpansion of unregulated markets hasdramatically worsened the situation,”said Dr Emafo.

The unregulated market broadly coverstwo scenarios: unlicensed individualsand/or entities conducting illegal tradeof pharmaceutical products containingcontrolled substances – for instance, astreet vendor selling a controlled drug,such as a narcotic drug, a stimulant or asedative in a village fair; and, licensedindividuals and/or entities contraveninglaws to sell controlled drugs, such as apharmacist who sells controlled drugswithout asking for a prescription.

The Board has called on Member Statesto enforce existing legislation, to impedethis menace, and also take appropriatemeasures to increase the availability ofmedicinal drugs through legitimatechannels, particularly in areas wherethere is lack of access.

The report is available athttp://www.incb.org/incb/en/annual_report_2006.html

Netherlands: Cabinet approvescompulsory health insurance excessOn 23 May, the government of theNetherlands announced plans to abolishthe no-claims scheme under the HealthInsurance Act from 1 January 2008. Thiswill be replaced by a compulsory excessof €150 a year, which will be collectedby the health insurer. People withunavoidable long-term health expenses,for example due to chronic illness ordisability, will be compensated finan-cially. The Cabinet agreed to HealthMinister, Ab Klink’s, proposal toapprove the bill.

Like the no-claims bonus, thecompulsory excess will only apply topeople aged 18 and over, and the sameforms of health care will also beexcluded. The no-claims scheme will stillcover bills for 2007, which means thebonus for 2007 will be paid out in March2008. Health care insurers will still beentitled to reclaim incorrectly madepayments until 1 April 2009. TheCabinet has agreed to pass on the bill tothe advisory Council of State. The text


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and the Council of State’s recommen-dation will only be made public whenthey are submitted to the House ofRepresentatives. This is expected to takeplace in June.

Poland: government fails to tightenabortion lawsOn 13 April, Poland’s parliamentrejected constitutional amendments thatwould have strengthened the country’santi-abortion laws. Poland’s current1993 abortion law is already one ofEurope’s strictest, allowing abortionsonly when the woman’s health isthreatened by pregnancy, the baby islikely to have severe disabilities, or thepregnancy is the result of rape.

The conservative ruling League of PolishFamilies and Law and Justice partiesproposed these amendments, whichwould have either banned abortionsaltogether or made it harder to weakenexisting anti-abortion legislation. Theamendments failed to achieve the two-thirds majority required by the Polishconstitution.

The vote also exposed divisions betweenthe coalition partners, with the Leagueof Polish Families voting for a total ban,while most members of Law and Justicesought just to bolster the existing legis-lation. The centrist and leftist oppositionvoted against the proposed changes.Piotr Gadzinowski of the DemocraticLeft Alliance told Polish television thevote was a “victory of reason over back-wardness.”

The issue of abortion is highly charged,in this very conservative Catholiccountry. In March, protesters ralliedacross Poland in support of a completeban on abortion. The European Court ofHuman Rights (ECHR) awardeddamages of €25,000 in the same monthto a Polish woman who had beenrefused an abortion despite fears that shemight loose her sight as a result of child-birth.

When Alicja Tysiac became pregnant inFebruary 2000, three eye specialists toldher having another baby could put hereyesight at serious risk. But neither thespecialists nor her GP would authorisean abortion. After giving birth, MsTysiac suffered a retinal haemorrhageand now wears glasses with thickpowerful lenses and cannot see objectsmore than a metre and a half away. TheECHR ruling will not however affect the

current abortion laws. Polish women’srights groups estimate there are just 200legal abortions performed every year.

Norway: National strategy to reducesocial inequalities in healthSocial inequalities in health are a publichealth concern and an expression ofunacceptable systematic injustices, saysSylvia Brustad, Norwegian Minister ofHealth and Social Affairs. The Ministryof Health and Care Services has in areport to the Storting (Parliament) maderecommendations for a national strategyto reduce social inequalities in health.

The Norwegian population enjoys goodhealth. However, averages conceal major,systematic inequalities. Minister Brustadsaid that “we have to acknowledge thatwe live in a stratified society, where themost privileged people, in economicterms, have the best health. Theseinequalities in health are socially deter-mined, unfair and modifiable. Thegovernment has therefore decided toinitiate a broad, long-term strategy toreduce social inequalities in health. Afair distribution is good public healthpolicy.”

The Norwegian policy will continue tobuild on the Nordic tradition of generalwelfare schemes and at the same timeimplement special measures to help thepeople with the most problems. Inkeeping with the identified need for abroad approach, the strategy operateswith four priority areas for the next tenyears. First, to reduce social inequalitiesthat contribute to inequalities in healthand second, those social inequalities inhealth-related behaviour and use of thehealth services. Social inclusion will bepromoted through targeted initiativeswhile another objective will be toenhance knowledge and develop cross-sectoral tools.

The report is available in English athttp://www.regjeringen.no/en/dep/hod/Documents/regpubl/stmeld/2006-2007/Report-No-20-2006-2007-to-the-Storting.html?id=466505&epslanguage=EN-GB

Hungary’s health fund in surplus afterreforms On 12 April, health officials reportedthat Hungary’s national health insurancefund had a surplus in the first quarter ofthe year after reforms which curtailedthe rise in spending on drug subsidiesand health care provision. The insurance

fund recorded a Ft 17 billion ($93.13million) surplus in the first threemonths, said Zoltán Major, generaldirector of the National HealthInsurance Fund. “This is negligiblecompared to the total 1,600 billion forinthealth budget, but it gives reason fordefinite optimism,” Major told theHungarian newspaper Napi Gazdaság.The number of hospital outpatient visitshas dropped by 60% since the 15February introduction of physicianvisiting fees and hospital fees, anotherdaily, Magyar Hirlap, reported.

Health reform is one of the key planksof the Hungarian government’s plans toreduce its budget deficit, which in 2006hit almost 10% of GDP. Further cost-cutting measures have been announced,with the closure of almost 9,000 of80,000 hospital beds. Other measures areplanned, although some have met withfierce opposition in the Socialist Party,the main partner in the governingcoalition.

Health Minister, Lajos Molnár, resignedin early April saying he could not acceptany further delay in the decision abouttransforming the insurance system.Molnár’s party, the liberal Alliance ofFree Democrats are in favour of amultiple insurer model so as to reducethe costs for the state, but PrimeMinister Ferenc Gyurcsány’s SocialistParty wants to slow changes, fearing amarket-based model would hurt theirolder, poorer voters.

As Health Minister, Molnár, drasticallycut subsidies on medicines, closedhospitals, raised pharmaceutical manu-facturers contributions to the healthbudget and imposed fees for visits todoctors. Commenting on the event,János Kóka, Minister of Economy andTransport, as well as chair of the left-wing SZDSZ party and junior coalitionpartner entitled to nominate the healthminister under the coalition agreement,said that continuation of the health carereform and introduction of a multiplepayer insurance regime were his party’sprerequisites for remaining within thegovernment coalition. Kóka said Molnárresigned because he felt that professionalconflicts had become personal and wereslowing the coalition’s decision makingon the insurance system. He stated thathis party would retain the healthministry and would choose a newminister committed to the proposedsystem.


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EU signs new treaty on disabilityrights On 30 March, in New York, the EUsigned up to a new UN treaty ondisability rights. The Convention aims toensure that people with disabilities enjoyhuman rights and fundamental freedomson an equal basis with everyone else. Itwill provide protection for 50 millionEU citizens and 650 million people withdisabilities worldwide. The Conventionwill enter into force when ratified by 20countries.

More information on the EU’s DisabilityStrategy is available athttp://ec.europa.eu/employment_social/disability/index_en.html

International conference on mentalhealth promotion The IMHPA (Implementing MentalHealth Promotion Action) network, incooperation with the Catalan Ministry ofHealth and with the support of theEuropean Commission, is hosting aconference in Barcelona from 13–15September. This is in support of theforthcoming European CommissionStrategy on Mental Health and will alsobuild on mental health promotion andmental disorder prevention componentsof the WHO Declaration and ActionPlan for Mental Health. The conferenceaims to share examples, barriers andopportunities encountered throughoutEurope in implementing prevention andpromotion actions for mental health.Outcomes will include a set of recom-mendations and suggested proposals tosupport implementation of actions formental health promotion and mentaldisorder prevention across Europe.

Registration details and further infor-mation are available atwww.imhpa.net/conference

Report on euthanasia in the Netherlands According to a new report, published bythe Ministry of Health, Welfare andSport in the Netherlands, there has beena considerable fall in the number of casesof euthanasia between 2001 and 2005. In2005 there were more than 2,300 cases ofeuthanasia and 100 cases of assistedsuicide, compared with 3,500 and 300

cases respectively in 2001. Doctors arenow reporting cases of euthanasia moreoften, with the proportion of casesreported rising from 54% to 80%.Thenumber of express requests foreuthanasia or assisted suicide fell from9,700 in 2001 to 8,400 in 2005, but thenumber of cases of palliative sedationrose from 8,500 to 9,600. The increase inthe use of palliative sedation probablyexplains, in part, the decrease in thenumber of cases of euthanasia andassisted suicide. One recommendation ofthe report is that better informationshould be provided on the possibilitiesand limitations of euthanasia declara-tions. It appears that there are stillmisunderstandings about this amongboth doctors and the general public.

An English language summary isavailable athttp://www.minvws.nl/images/ eval-uatie-euthanasiewet-engels_tcm20-147320.pdf

Disability trends among older populations A new working paper, written for theOrganisation of Economic Cooperationand Development by Gaétan Lafortune,Gaëlle Balestat and Disability StudyExpert Group Members, assesses themost recent evidence on trends indisability among the over 65s in twelveOECD countries: Australia, Belgium,Canada, Denmark, Finland, France,Italy, Japan, the Netherlands, Sweden,the United Kingdom and the UnitedStates. The focus is on reviewing trendsin severe disability (or dependency),defined where possible as one or morelimitations in basic activities of dailyliving.

The report is available athttp://www.oecd.org/dataoecd/13/8/38343783.pdf

Comparison of US and internationalhealth care systems A new report, from the New Yorkbased, independent foundation, theCommonwealth Fund, reports thatdespite having the most costly healthsystem in the world, the United Statesconsistently under performs on mostdimensions of performance, relative toother countries. This report, an update to

two earlier editions, includes data fromsurveys of patients, as well as infor-mation from primary care physiciansabout their medical practices and viewsof their countries' health systems.Compared with five other nations,Australia, Canada, Germany, NewZealand and the United Kingdom, theUS health care system ranks last or next-to-last on five dimensions of a highperformance health system: quality,access, efficiency, equity, and healthylives. The US is the only country in thestudy without universal health insurancecoverage, partly accounting for its poorperformance on access, equity, andhealth outcomes. The inclusion ofphysician survey data also shows the USlagging in adoption of information tech-nology and use of nurses to improve carecoordination for the chronically ill.

The report is available viahttp://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

UK survey on public expectations oflong-term care funding A new survey reveals that there are threetimes more people who think that indi-vidual need should determine how careservices are funded than those (23%)who think it should be based on theirincome or assets, as is currently the casein the UK. The YouGov survey wascommissioned by a partnership of fifteenhealth and care organisations to generatea national debate on the future of long-term care funding. The partnership,called Caring Choices, aims to consultolder people, carers, professionals, careproviders and commissioners of careservices on options for reforming thecurrent system of paying for long-termcare in old age.

More information on the survey and theCaring Choices partnership athttp://www.caringchoices.org.uk

News in Brief

Additional materials supplied by

EuroHealthNet

6 Philippe Le Bon, Brussels.Tel: + 32 2 235 03 20Fax: + 32 2 235 03 39Email: [email protected]

http://ec.europa.eu/employment_social/disability/index_en.html

http://www.minvws.nl/images/evaluatie-euthanasiewet-engels_tcm20-147320.pdf

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

http://www.oecd.org/dataoecd/13/8/38343783.pdf

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 to aca-demics, policy makers and health care managersand 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, review arti-cles 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

South-eastern European countries, and the European Union as a whole, arepresented with a very particular set of challenges in the domain of health caredelivery.

This three-day conference will address recent medical advances in areas ofhigh public health significance in South-eastern Europe, and the implicationsof these in local and Europe-wide health policy development.

Speakers will include international authorities in relevant medical fields, public health and health policy, representatives from the WHO, EuropeanCommission, medical press, local governments, medical associations and theglobal pharmaceutical sector.

This is the first time that a meeting attempts to address this combination of themes, from clinical medicine through public health to health policy,which, though intimately linked, are rarely addressed together in an inter-professional fashion.

The conference will be of interest to a wide audience, from clinicians to public health physicians, health managers, policy researchers, civil servantsand politicians.

INTERNATIONAL HEALTH CONFERENCE:

RECENT ADVANCES IN CLINICAL MEDICINE, PUBLICHEALTH AND HEALTH POLICY

Further information is available on the website: www.internationalhealth2007.com

Conference Office, Royal College of Physicians, 11 St Andrews Place, Regent’s Park, London NW1 4LE

Tel: 020 7935 1174 ext 251 Fax: 020 7224 0719 Email: [email protected]

20–22 SEPTEMBER 2007

THE ATHENS HILTON

ATHENS

GREECE

Eurohealth is a quarterlypublication that provides a forum for researchers, experts and policy makers to express their views onhealth policy issues and socontribute to a constructivedebate on health policy inEurope

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