Choice in health care

52 Pages·2006·1.02 MB·English

by  Tevec Ibrahim

Eurohealth
RESEARCH (cid:127) DEBATE (cid:127) POLICY (cid:127) NEWS Volume 12 Number 2, 2006
Learning from
the past?
Choice in
health care
Health insurance reform in the Netherlands
Evolution of the Italian health care system
Alcohol in Europe: health, social and economic impact
Water contamination (cid:127) Survey methods (cid:127) Global health policy (cid:127) Fertility in Russia
Protecting trial volunteers in France (cid:127) Children’s lifestyles in Europe
Eurohealth
C
Learning from the past, preparing for
the future
LSE Health, London School of Economics and Political
Science, Houghton Street, London
WC2A 2AE, United Kingdom
There are some who say that there are only seven truly
fax: [phone]
O original storylines. The same might be said of health email: [email protected]
www.lse.ac.uk/LSEHealth
system reforms; most are constantly revamped and
recycled. Here, Walter Holland argues that we forget the Editorial Team
past at our peril. Choice for instance, he contends, was EDITOR:
for many years a major feature of the English NHS. He David McDaid: [phone]
email: [email protected]
questions whether it is cost-effective to invest in a
M FOUNDING EDITOR:
“minor correction to the problems of a health service
Elias Mossialos: [phone]
market, to regain what existed in the past.” Marianna email: [email protected]
Fotaki in her response, agrees that the past is important, DEPUTY EDITOR:
but should not be dwelt upon. Instead, there is a need to Sherry Merkur: [phone]
email: [email protected]
move beyond conventional health policy analysis to
EDITORIAL BOARD:
M enhance understanding of how reform can work.
Reinhard Busse, Josep Figueras, Walter Holland,
Julian Le Grand, Martin McKee, Elias Mossialos
In our health policy section, Bartholomée and Maarse SENIOR EDITORIAL ADVISER:
provide early thoughts on major recent reforms in the Paul Belcher: [phone]
email: [email protected]
Dutch health insurance system. Giannoni meanwhile,
DESIGN EDITOR:
draws on the past to outline challenges in safeguarding
E Sarah Moncrieff: [phone]
the core principles of universality and equity of access email: [email protected]
in the Italian NHS in the face of continuing fiscal and SUBSCRIPTIONS MANAGER:
administrative decentralisation. Champa Heidbrink: [phone]
email: [email protected]
The impact on health across all policies is one theme of Advisory Board
N the current Finnish Presidency. It is nicely Anders Anell; Rita Baeten; Philip Berman; Nick Boyd;
Johan Calltorp; Antonio Correia de Campos; Mia Defever;
illustrated by public health articles here. Anderson
Nick Fahy; Giovanni Fattore; Armin Fidler;
and Baumberg conservatively estimate that the annual Unto Häkkinen; Maria Höfmarcher; David Hunter;
Egon Jonsson; Meri Koivusalo; Allan Krasnik; John Lavis;
health, social and economic costs of alcohol in Europe
Kevin McCarthy; Nata Menabde; Bernard Merkel;
are €125 billion or €650 per household. More than Stipe Oreskovic; Josef Probst; Tessa Richards;
Richard Saltman; Igor Sheiman; Aris Sissouras; Hans Stein;
half these costs occur outside the health system and
Jeffrey L Sturchio; Ken Thorpe; Miriam Wiley
T require multi-sector solutions. Leonardi focuses on the
Article Submission Guidelines
growing threat to the water supply because of
see: www.lse.ac.uk/collections/LSEHealth/documents/
contamination from industrial pollutants. He calls for
eurohealth.htm
solutions that consider both ecosystem protection and
economic growth. Published by LSE Health and the European Observatory
on Health Systems and Policies, with the financial support
of Merck & Co and the European Observatory on Health
‘Snapshots’ written by European journalists are a new Systems and Policies.
feature. Jean-Pierre Langellier, from Le Monde, Eurohealthis a quarterly publication that provides a forum
for researchers, experts and policy makers to express their
highlights developments in clinical trial recruitment views on health policy issues and so contribute to a
in France, while Kirill Anurov from Novosti, reports on constructive debate on health policy in Europe.
measures announced by the Kremlin to address Russia’s The views expressed in Eurohealth are those of the authors
alone and not necessarily those of LSE Health, Merck & Co
dwindling birth rate. We will also cover global health or the European Observatory on Health Systems and Poli-
issues in more depth in a series of articles brought cies.
together by John Wyn Owen. Here he sets the scene The European Observatory on Health Systems and Policies
is a partnership between the WHO Regional Office for Eu-
for this series and calls for a European Global Health rope, the Governments of Belgium, Finland, Greece, Nor-
Strategy. Again this is an area where Europe can have way, Spain and Sweden, the Veneto Region of Italy, the
European Investment Bank, the Open Society Institute, the
much to offer by learning from its past. World Bank, CRP-Santé Luxembourg, the London School
of Economics and Political Science and the London School
of Hygiene & Tropical Medicine.
David McDaid Editor
Sherry Merkur Deputy Editor © LSE Health 2006. No part of this publication may be
copied, reproduced, stored in a retrieval system or transmitted
in any form without prior permission from LSE Health.
Design and Production: Westminster European
email: [email protected]
Printing: Optichrome Ltd
ISSN 1356-1030
Contents
Eurohealth
Volume 12 Number 2
Eurohealth Debate Peter Anderson is an international public
health consultant and is the alcohol policy
1 Choice in health care: old wine in new bottles? advisor to Eurocare, the European Alcohol
Walter Holland v. Marianna Fotaki Policy Alliance.
Kirill Anurov is Deputy Bureau Chief,
European Snapshots Russian News & Information Agency
Novosti (RIA-Novosti), London, UK.
4 A new programme to boost fertility in Russia
Kirill Anurov Yvette Bartholomée is a Researcher at the
Department of Health, Organisation,
5 Protecting trial volunteers: New regulations on biomedical research in France
Policy and Economics, Faculty of Health
Jean-Pierre Langellier Sciences, University of Maastricht, the
Netherlands.
Health Policy
Ben Baumberg is Policy and Research
7 Health insurance reform in the Netherlands Officer, Institute of Alcohol Studies,
London, UK.
Yvette Bartholomée and Hans Maarse
10 Universality and decentralisation: the evolution of the Italian health care system Marianna Fotaki is Lecturer in Health Care
and Public Sector Management, Centre for
Margherita Giannoni
Public Policy and Management,
Manchester Business School, University of
Public Health Perspectives Manchester, UK.
14 Water contamination: a question of sustainability Margherita Giannoniis Senior Researcher
Giovanni Leonardi in Public Economics at the Department of
Economics, Finance and Statistics,
17 Alcohol in Europe: health, social and economic impact
University of Perugia, Perugia, Italy.
Peter Anderson and Ben Baumberg
Walter Holland is Emeritus Professor of
21 Children’s lifestyles in Europe
Public Health Medicine and Visiting
Corinna Sorenson Professor, LSE Health, London School of
Economics and Political Science, UK.
Global Health Policy Jean-Pierre Langellier is UK Correspondent
23 Europe in the world and global health for Le Monde.
John Wyn Owen
Giovanni Leonardiis Honorary Research
Fellow, Public and Environmental Health
Research Unit, London School of Hygiene
Research Methods
and Tropical Medicine, and Consultant in
26 Are non-respondents ill? The relationship between survey participation and Environmental Epidemiology, Health
health Protection Agency, UK.
Ineke Stoop
Hans Maarse is Professor of Political
Science, Department of Health,
Evidence-informed Decision Making Organisation, Policy and Economics,
Faculty of Health Sciences, University of
29 “MythBusters” We can eliminate errors in health care by getting rid of the
Maastricht, the Netherlands.
‘bad apples’
Corinna Sorensonis a Research Associate
31 “Risk in Perspective” Matters of the heart and mind: risk-risk trade-offs in
at LSE Health, London School of Economics
eating fish containing methylmercury and Political Science, UK.
35 “Bandolier” Delivering better health care
Ineke Stoop is a researcher at the Social
and Cultural Planning Office, The Hague,
the Netherlands.
Monitor
John Wyn Owenis a Visiting Fellow, LSE
38 Publications Health, London School of Economics and
Political Science, Adjunct Professor, School
39 Web Watch
of Public Health, University of Sydney,
40 European Union News Australia and Director, Madariaga
European Foundation, Brussels, Belgium.
EUROHEALTH DEBATE
Choice in health care:
Old wine in new bottles?
Walter Marianna Fotaki1 importance of choice by the patient in the of the insured worker, had to pay for GP
discusses and describes treatment undergone or selected. It is care. The insured could choose their
Holland
methods whereby worth understanding how the present Panel Doctor from a list, the others, of
individuals can exercise system, and problems, have arisen. course, could choose freely. Cronin, in
choice in health care provision. She states The Citadel, gives, probably the best
Until about the middle of the 20th centu-
that this is a new measure and that before account of medical care in the 1930s.3
ry physicians had few effective agents
1990, choice of specialist care “was
available that would influence the natural There were two types of hospital at this
needs-based and determined by the
history of most conditions; digitalis and time. About half were Local Authority
patient’s GP, with the exception of pri-
morphia were exceptions to this. The (LA) hospitals (previously the Work
vately purchased services”. The govern-
physician could make a diagnosis, predict Houses) and half Voluntary Hospitals
ment also believes that the introduction
a possible outcome, provide a palliative and charitable foundations. In the middle
of choice polices in the UK is something
medicine, for example, cough suppressant of the 19th century the BMA, (or its
new.2
or advise surgical intervention. The sur- equivalent representing general practice)
These views ignore the past. The mantra geon was able to provide a form of treat- had come to an agreement with the
of ‘choice’ in health services has become Voluntary Hospitals that they would
an icon and suggests that the practice and only see patients in their out-patients
values of the supermarket reign. "The government believes department, if referred by a GP. LA hos-
Although there is an enormous increase pitals rarely had out-patient departments.
in the availability of information on that the introduction of Thus arose the UK practice that a patient
many issues, including medical care, few could only see a specialist if referred by a
commentators, or policy analysts, have choice is something new. GP. There were, of course, casualty
attempted to analyse either the conse- departments in the Voluntary Hospitals
This ignores the past."
quences of choice in heath service treat- (which were mainly in urban areas).
ment, its possibilities or its limits. No one These were used in emergencies and to
questions that, as a general proposition, avoid payment for a GP.
being able to exercise choice is a ‘good ment that would ‘cure’ – for example,
The consultants (specialists) in Voluntary
thing’ – but few really examine the issue appendectomy for acute appendicitis, or
Hospitals, in contrast to those in LA hos-
in depth. In health care nowadays, one ‘cutting for the stone’ to relieve renal
pitals, were not paid a salary. They
mainly considers choice in which hospital colic. The advent of chemo-therapeutic
received a token ‘retainer’ of, at most, £50
or provider should be consulted or pro- and antibiotic agents completely altered
per annum. The consultants in voluntary
vide care. Few really appreciate the the possibilities for the physician as well
hospitals were usually considered (by
as the surgeon; anaesthetic advances
themselves) of a higher grade than those
increased surgical capacity to alleviate
in LA hospitals. All Teaching Hospitals
pain and cure. It is not my intention to
Walter Holland is Emeritus Professor of were Voluntary Hospitals. The
provide a history of advances in medicine
Public Health Medicine and Visiting consultants in the Voluntary Hospitals
– but to consider how choice can, and has
Professor, LSE Health, London School of depended for their income on referrals of
been exercised in medicine.
Economics and Political Science, UK. patients by a GP. Thus they took care to
Email: [email protected] develop friendly relations with their stu-
Choice before the NHS
dents, most of whom would become
Marianna Fotaki is Lecturer in Health Before the NHS was introduced in 1948, GPs, and on whom they would depend
Care and Public Sector Management, the employed population received general for income. Thus a series of friendly
Centre for Public Policy and practitioner (GP) care from their Panel
relationships were established and this is
Management, Manchester Business Doctor, who was paid for this by
what largely influenced the referral
School, University of Manchester, UK. National Insurance. The rest of the popu-
pattern to hospital.
Email: [email protected] lation, including the wives and children
Post 1948
Suggested cite: Holland W, Fotaki M. Choice in health care: old wine in new bottles? In 1948, with the introduction of the
Eurohealth2006;12(2):1–3. NHS, all doctors were paid and thus the
1 Eurohealth Vol 12 No 2
EUROHEALTH DEBATE
dependence of consultants on GPs were far more likely to abide by the GP’s on reducing health inequalities. Lancet
vanished. The habits of old, in the referral advice on which physician to go to. It 2006;367:85.
of patients from general practice to hos- was not until the introduction of the
3. Cronin AJ. The Citadel. London:
pital-based care persisted, to some extent. health service reforms in the 1990s that
Gollancz, 1937.
One of the most important consequences, freedom of choice of specialist became
4. Morell DC, Gage HG, Robinson NA.
following the introduction of the NHS, constrained. Now, with our govern-
Referral to hospital by general
was the spread of specialist services to the ment’s emphasis on choice, this will
practitioners. Journal of Royal College
country as a whole by the creation of continue to be restricted – there may be a
of Practitioners1971;21:77–85.
District General Hospitals. choice between provider institutions but
GPs and patients will not be able to 5. Palmer JW, Kasap HS, Bennett AE,
GPs, in their role as primary contact, not
choose the individual consultant surgeon Holland WW. The use of hospitals by a
only had to diagnose and treat minor ill-
or physician. Although there may be defined population. A community and
nesses, but also refer patients for further
some differences in the cleanliness of hospital study in North Lambeth. British
treatment or diagnosis to specialist care.
institution, or time taken to be seen, the Journal of Preventive Social Medicine
There are many studies of the referral to
variation in the quality of individual 1969;23:91–100.
hospital by GPs, for example, a study by
consultants and their team is likely to be
Morrell and his colleagues.4They had 6. Clarke M, Bennett AE. Problems in
more important in the care that the
complete freedom of choice of hospital the measurement of hospital utilisation.
individual patient receives.
care. In general, most chose a nearby Royal Society of Medicine
institution, but not necessarily. For Patient choice, in England, has only been 1971;64:795–98.
example in a study of the population of considered as a new concept since the 7. Montgomery KM. Outpatients of a
North Lambeth,562% used the local introduction of the ‘market reforms’. It is London Teaching Hospital. British
St. Thomas’ group, while 14% used four not clear that the political emphasis on Journal of Preventive Social Medicine
other local hospitals: Westminster, choice has been examined critically. 1968;22:50–54.
Guy’s, King’s College and the South There is some variation in referral
8. Bennett AE. A case selection in a
London Hospital for Women and patterns between individual GPs and in
London Teaching Hospital. Medical
Children. The remaining 24% used different parts of the country.
Care 1966;4:138–41.
another 93 hospitals. In a study6in a Furthermore, there is some variation in
more rural area, Farnham-Frimley, requests for referral between individuals
66.5% of referrals were to the local coming from different social/ethnic
Farnham group, 14% to other south west groups. Although choice, in abstract, is to Marianna Walter Holland mis-
Metropolitan hospitals, 9% to the be welcomed, exercising choice of place takenly argues that in
Fotaki
Oxford Group and 11% to other hospi- of advice, investigation or intervention is my paper ‘Patient
tals. The major concern, at that time, was often constrained by cultural, social, Choice and
that the Teaching Hospitals were ‘cherry geographic, or quality factors. Empowerment – what does it take to
picking’ the ‘interesting’ patients; this make it real?’1 I present patient choice as
Choice restricted to an institution may
concern was subsequently shown to be a new policy objective. In fact, I discuss
mean that individuals go to modern look-
unwarranted.7,8 the evidence on what, in my view, was an
ing buildings with poor services, or may
unsuccessful attempt at introducing
be constrained by distance, for example,
The recent past greater patient choice as part of the quasi
in a Norfolk village the choice may be
In recent years the relationship between market reforms in the UK in the early
between Norwich (15 kilometres), King’s
a doctor and patient has changed. There 1990s, to demonstrate the exact opposite.
Lynn (65 kilometres) or Bury St.
is now far more communication and One of my key arguments, which Walter
Edmunds (95 kilometres). It is unfortu-
discussion so that a patient has become echoes in his argument, is that these
nate that politicians have seized on this
involved in the choice of treatment. This quasi-market reforms, instead of improv-
issue without adequate consideration of
entails a great deal of effort by both sides. ing actually reduced patient choice. One
what it actually can contribute to the
of a number of reasons for this was the
The relationship is, however, still unbal-
improvement of the quality and quantity
reduction in the number of specialist
anced. The doctor usually has the benefit
of health services. Providing computer
providers that GPs would refer patients
of professional knowledge, crucial in the
programmes for GPs is relatively easy –
on to because of the limiting effect of
provision of advice on treatment and
and it is obviously a relatively cheap
cross-boundary flows via Extra-
referral. The doctor also often has knowl-
trick. But whether it provides a cost-
Contractual Referrals.2
edge of the competence and quality of the
effective solution to health service
specialists to whom referral is made. improvements is doubtful. It is only a I also argued, that by looking at similar
Patients have always been involved in the minor correction to the problems of a experience from quasi-markets in the UK
choice of referral (as well as in the choice health service market, to regain what and various public competition models
of treatment). Observational, qualitative existed in the past. that were phased into several counties in
Sweden in the early 1990s, we realise that
studies in Lambeth of the interaction
REFERENCES the lessons of these reforms have been
between the GP and patient indicated
1. Fotaki M. Patient choice and empow- only superficially, if at all, taken account
that the patient was far more likely to be
erment – what does it take to make it real. of in the current policy approach in
definite about which surgeon they
Eurohealth2005;11(3):3–7. England. Like Walter, I also make the
wished to be operated by; local folklore
case that the present patient choice debate
was a potent source of knowledge. They 2. Editorial. Choice policies must focus
Eurohealth Vol 12 No 2 2
EUROHEALTH DEBATE
is more about rhetorical pronouncements Patient Choice and the Organisation and Marianna It is always a daunting
and presumptions about the needs of Delivery of Health Services: Scoping Fotaki task for an academic
service user rather than about substance. Review. Manchester: Centre for Public who is also a former
This is because the concept of choice is Policy and Management, Manchester practitioner (medical
expected to fulfil several mutually con- Business School, 2005. and senior policy adviser) to demonstrate
flicting policy goals of equity or univer- the fence on which s/he sits. A social
5. Le Grand J. Choice and
sality.3As one recent scoping review psychologist and an influential teacher of
personalisation. Speech given at the
indicated, it is uncertain whether choice management change Kurt Lewin, said
London School of Economics, 21 July
and competition can improve either that there is nothing so challenging as a
2004.
efficiency or quality of service provision practical problem. He also said that there
for the majority of those using the NHS.4 6. Blomqvist P. The choice revolution: is nothing so practical as a good theory.1
privatization of Swedish welfare services The divide in the social sciences between
The real question then is what are the
in the 1990s. Social Policy and theory and practice is in my view artifi-
reasons for this policy recycling and
Administration2004;38(2):139–55. cial. The applicability and capacity of
‘re-invention’, despite its rather limited
both to make the world more compre-
success in the recent past in the UK and 7. Fotaki M, Boyd A. From plan to mar-
hensible and meaningful is their raison
elsewhere? Some analysts have concluded ket: a comparison of health and old age
d’etre. I have argued for this integration
that more market-type reforms are care policies in the UK and Sweden.
of theory and evidence from a wide range
needed for choice to produce its expected Public Money and Management
of social disciplines, not only economics
benefits5while others have proposed that 2005;25(4):237–43.
and political science, but also for exam-
the shift to ‘choice’ reflects the changing
ple, from the perspective of clinical psy-
values of increasingly business minded
chology and management theory. Often
and individualistic constituencies.6,7 Walter There is a difference in
prevailing policy analyses take insuffi-
Regardless of his interesting historical comprehension
Holland cient account of these other factors that
review of the use of patient choice, between Marianna
shape policy, nor do they consider how
Walter in his article here does not, Fotaki and me. In her
they impact on health care organisations
however, offer any plausible answer to original article she states “individual
and users of services alike.
this question by arguing that current patient choice is currently being launched
reforms “are only a minor correction to as a new and ground breaking idea in the My aim was not either, to make a case
the problems of the health service mar- English NHS” – certainly she describes a for, or against, the introduction of
ket, to regain what existed in the past”. number of caveats in the market-oriented individual choice into publicly financed
system of the 1990s but fails to put these and provided health care systems. It was
Neither nostalgic nor euphoric analyses
policies into perspective as to what went rather to offer a critique of the ways that
will enhance our understanding of how
on before. complex and diffuse concepts such as
policy works and what are the drivers
choice are translated into rhetorical poli-
behind policy makers’ decisions. Multi- It is difficult for a practitioner to argue
cy pronouncements, despite the existing
disciplinary theoretical frameworks and with theoreticians, we can only quote
evidence of their limited success as
non-conventional insights from anecdotal evidence or evidence from
demonstrated in the market oriented
disciplines other than political science empirical surveys designed for other pur-
reforms of the 1990s, and without taking
and economics might perhaps be needed poses. It is crucial for academic workers
into account complexities involved in
to illuminate these dynamics. This is a in health policy to have some knowledge
policy implementation. Despite Walter’s
pressing issue, as irrespective of whether of what happens in practice – reality is
arguments to the contrary, I think I have
patient choice policy succeeds or fails, it often far from theory, and most of us
made it clear that current patient choice
will have a lasting impact on how health who have actually delivered a service are
policy is being ‘re-discovered’ and
care will be provided and who will most- aware how centrally imposed policies can
‘invented’ afresh as if it operates in an
ly benefit from the changes still to come. and are subverted.
a-historical vacuum.
REFERENCES As Marianna states far too little research
What I think unites practitioners turned
has been done on how health policies are
1. Fotaki M. Patient choice under market academics like myself, is their desire to
devised, implemented or evaluated. As
reforms in the UK and Sweden: What bring together disparate bodies of litera-
one who, in the past, was involved in the
does it take to make it real? Eurohealth ture to make sense of their experience,
development of some health policies, I
2005;11(3):3 –7. and to improve the understanding of how
am well aware of the possible contribu-
policies operate in reality, rather than
2. Fotaki M. The impact of the market tions of theory, research, practice and
how they should work according to nor-
oriented reforms on information and personal beliefs in policy formulation.
mative assumptions or any preconcep-
choice. Case study of cataract surgery in Thus I do not consider that analysis of
tions.
Outer London and County Council of “frameworks or insights” will be of great
Stockholm.Social Science and Medicine value – nor do I consider offering solu-
1999;48:1415–32. tions – I believe it is far more important
REFERENCES
to state clear objectives for health policy
3. Oliver A, Evans JG. The paradox of
development in terms of desired out- 1. Lewin K. Field theory. In: Cartwright
promoting choice in a collectivist system.
comes and then evaluate what achieve- D (ed). Social Science: Selected
Journal of Medical Ethics2005;31:187.
ments have been made – and modify Theoretical Papers. New York: Harper &
4. Fotaki M, Boyd A, Smith L, et al. them as necessary. Row, 1951.
3 Eurohealth Vol 12 No 2
EUROPEAN SNAPSHOTS
A new programme to boost
fertility in Russia
Kirill Anurov
Russia’s population has been on the that a step-by-step ten year programme January 2007. Payments will be made
decline for over a decade, now decreasing must be drafted and included into the from 2010 onwards. This bond can be
at a rate of 700,000 per annum.1 Having state budget no later than September used towards the costs of mortgage
peaked in 1992, at 148.7 million, it has 2006. Opening the session of the Security payments, tuition fees or invested in
now fallen to just over 142 million.2 If Council, President Putin remarked, “in pension schemes.
the current trend is not successfully fact, we are standing now at a critical
− Increased monthly childcare allowance
reversed, some analysts predict that there point… In the last 13 years the number of
for the first child (up to £30) and the
may be only 1% of the global population deaths has exceeded births by 11.2 mil-
second-born (up to £60)
(100 million people) scattered across the lion. If nothing is done about it, by the
world’s largest country by 2050.3Inward end of the century the population will − Guaranteed 40% of usual salary for a
migration flows have so far helped to have halved”.4 period of up to 18 months if mothers
prevent the figures from plummeting; take time off work
So far, numerous ideas have been floated
however, fertility and mortality are the
along the corridors of the Presidential − Increased cash certificates for pregnant
core issues, as reiterated by the Kremlin’s
and government offices; however, it is women (varying between £40 and
recently announced plan attempting to
not yet what shape the new programme £140)
restore the population to its pre-1990s
will take. The rise of health problems on
level. − Partial subsidy of the cost of school
one hand, including cardiviovascular and
meals: 20% for the first child, 50% for
This decline in the Russian population circulatory diseases, cancer, alcoholism,
the second and 70% for the third.
can be attributed to many factors: a low the epidemic of HIV/AIDS, and TB (still
fertility rate (1.3 per 1,000) where only not fully under control) as well as the In addition, as promised by the First
3% of families have at least three chil- threats to health on the other, such as the Deputy Prime Minister, Dmitry
dren; a reduction in the health of newly prevailing low quality of life and thus Medvedev, other measures include more
born children (in 2004, 40% of newborns fewer incentives to have children, and effective preventive measures against
had health problems);4and the increasing road traffic accidents which claim heart and infectious diseases, better train-
rate of premature mortality. Average life between 35,000–40,000 lives per year, to ing for emergency physicians, and the
expectancy among men is now just 59 name but a few, have been key concerns creation of a working group on migration
years. for society. These will also have some control.
influence on the programme.
The government is aware of the situation,
Potential impact of programme
and has been considering how to address
A national programme for The question remains as to whether this
this challenge for several years. This, in
demographic change policy to increase the birth rate will in
particular, has been in the context of
What is clear however is that this first ten fact be enough to reverse the steady pop-
pension reform, since the Russian popu-
year national programme on demograph- ulation decline. However despite the
lation like that in most other European
ic change, proposed by the Kremlin, is potential benefits that the new policy
countries is ageing. The situation is now
expected to come into operation in 2007. may provide, there are already concerns.
perceived as a national threat. President
While it will probably include more The most pressing issue is how effective
Vladimir Putin in his annual address to
funds to support better health care and the cash incentive will be, and how this
the nation in May 2006 acknowledged in
streamline migration policy, the novelty may affect society.
respect of the declining population that
lies in the direct approach it is likely to
“we have raised this issue on many occa- At present, high prices for oil are provid-
take to boost the‘image of the family’ as
sions but have for the most part done ing an unanticipated windfall for the
very little to address it.”1 well as increasing the fertility rate. The state, but if the oil price falls, the burden
proposed programme will provide direct
of increased expenditure for these cash
Subsequently, at the June session of the economic incentives intended to persuade
payments may be too much for the gov-
National Security Council it was agreed Russians to have more children. These
ernment. If sufficient funds are accumu-
include:
lated by the time the policy takes effect
Kirill Anurov is Deputy Bureau Chief, − Receipt of a maternity bond or ‘basic (as cash payments will only be made
Russian News & Information Agency maternity capital’ of at least £5,000. from 2010), then some increase in the
Novosti (RIA-Novosti), London, UK. The money will be paid to mothers birth rate might be expected. Poorer
Email: [email protected] having a second child, born after 1 families may appreciate the cash benefit
Eurohealth Vol 12 No 2 4
EUROPEAN SNAPSHOTS
at first, but will a focus largely on one-off some parents to become more confident Assembly of the Russian Federation.
payment be sufficient to maintain higher in planning their lives and the future of Moscow: President of Russia, 10 May
fertility rates in the future? their children. Moreover, by knowing 2006. Available in English at www.krem-
that more money will be distributed to lin.ru/eng/speeches/2006/05/10/1823_type
In general, Russians have the same atti-
70029type82912_105566.shtml
each family, producers and the retail
tudes as seen elsewhere in Europe, desir-
industry may raise prices for consumers. 2. Filippov Y.Политический обозреватель
ing no more than one or two children.
РИА «Новости» Юрий Филиппов [Russia's
The new policy may encourage some par- For now, migration might remain the
attraction as an immigration destination].
ents to have a second child earlier than only potentially successful instrument of
RIA Novosti,15 May 2006. Available in
planned, before the period in which the demographic policy, but again, this also
Russian only at www.rian.ru/analytics/
maternity bond can be claimed ends (if deserves a fresh look by the government. 20060516/48208455.html
the government’s promise does indeed It has been observed that migrants do not
3. Becker G. Grappling with Russia’s
last until 2010). It is doubtful however if necessarily assimilate completely into the
Demographic Time Bomb. The Becker-
this incentive scheme will convince them melting pot of society, but rather can
Posner Blog. 5 June 2006. Available at
to have further children. One can hardly evolve into independent communities,
www.becker-posner-blog.com/archives/
expect that within the lifespan of the new which seem reluctant to fully integrate 2006/06/grappling_with.html
programme that the fertility rate would within the country. In any attempt to
4. Putin V. Speech to the Security Council
increase from the current level of 1.3 to change attitudes towards family planning
Meeting devoted to measures to implement
beyond the replacement rate of 2.1. In in Russia, attention will also need to be
the Annual Address to the Federal
practice this is likely to mean a short term placed on providing guarantees to
Assembly. President of Russia, 20 June
surge in births, after which the trend in improve quality of life. These might
2006. Available in English at www.krem-
births may revert back to its current rate.5 include raising the quality of health care lin.ru/eng/text/speeches/2006/06/20/2149_
The other major point to consider is that and ensuring access to affordable housing. type82913type82917_107479.shtml
a one-off financial incentive of £5,000 5. Posner R. Putin’s Population Plan. The
may not be enough to change the quality Becker-Posner Blog. 4 June 2006. Available
of life for a family. This sum may provide REFERENCES at www.becker-posner-blog.com/archives/
an insufficient level of compensation for 1. Putin V. Annual address to the Federal 2006/06/putins_populati.html
Protecting trial volunteers:
New regulations on biomedical research in France
Jean-Pierre Langellier
France has adopted the most protective about any risks involved, and what risation of these bodies. In practice, there
regulations in Europe for volunteers tak- known side-effects might occur. All trials are about 40 ethics committees, known as
ing part in biomedical research, including were required to seek the advice of an Comité de protection des personnes
clinical drugs trials. Strict rules following ethics committee. These strict rules were (CPP). Their members are researchers,
legislation passed in August 2004 will also the inspiration for a European doctors, pharmacists, nurses, psycholo-
come into force before the end of August Directive, adopted in 2001.2 gists, experts in law and bioethics, and
2006. patient association representatives. The
The new law reinforces protection for
number of committees will be reduced
For almost 20 years, France has led the volunteers and improves the organisation
and their role will be more ‘professional’.
way in this field. In 1988, an innovative of clinical trials in two ways. First, ethical
law, loi Huriet, set out procedures committees will now not only have to Even more important is the second inno-
governing biomedical research and the provide advice, but also explicitly vation. The new legislation will not be
protection of volunteers.1 For example, approve trial protocols. Similarly, limited to drug trials. It will be imple-
anyone participating in a clinical trial had approval is also required from health and mented in all fields covered by bio-
to sign a consent form after being told safety agencies. Previously, the absence medical research: physiology, genetics,
of an official response from these bodies psychology, surgery, cosmetic testing and
Jean-Pierre Langellier is UK could be interpreted as an implicit green the storage of biological materials such as
Correspondent for Le Monde. light to go ahead. Now, no research can organs, tissues, labile blood products, and
Email: [email protected] be conducted without the explicit autho- gene and cell therapy products. France is
5 Eurohealth Vol 12 No 2
EUROPEAN SNAPSHOTS
the only country in the EU which has Ray Noble, a UK medical ethicist said, quences. This is why in France, like in the
transposed in an extensive way the “people who are designing these trials UK, such trials are seen as crucial in the
European Directive, in accordance with have to make sure they do not offer so development of new drugs, and merit
its loi Huriet, which was already imple- much money that young people simply taking limited risks for the good of the
mented in all fields of biomedical ignore the boxes about their medical con- wider population.
research. ditions in their consent forms in order to
make sure they get the thousands of
The diversity and the complexity of this
pounds they need to pay off their student REFERENCES
transposition explain why France had
loans”.
1. Republique Francaise. Loi Huriet-
been slow in preparing the new legal sys-
tem texts. “Now, our country is up to It is precisely to prevent this sort of Serusclat. Loi relative à la protection des
personnes qui se prêtent à des recherches
date, with regard to drug trials. And it is behaviour that the new French law has
médicales. (Huriet-Seruscalt Law. Law
still ahead in Europe for biomedical set in place a national computerised data-
governing the protection of individuals
research on the whole”, explains Chantal base which registers all volunteers, the
who participate in medical research). Loi
Belorgey, from the AFSSPS (Agence dates and duration of any trials they par-
n° 88-1138. 20/12/1988. Available at
Française de Sécurité Sanitaire des ticipate in, and the amount of compensa-
www.legifrance.gouv.fr
Produits de Santé), the body ultimately tion received. So it is simple to double
responsible for regulating and authorising check that a potential trial participant has 2. Commission of the European
Communities. Directive 2001/20/EC of the
clinical drug trials.3 not already received the maximum level
European Parliament and of the Council of
of payment from previous trials in any
4 April 2001 on the approximation of the
Payments to volunteers one year. Indeed, any volunteers must
laws, regulations and administrative provi-
The new regulations contain two other wait several months before participating
sions of the Member States relating to the
safeguards concerning another controver- in another study. implementation of good clinical practice in
sial issue: money. The overwhelming Regulating this issue should be relatively the conduct of clinical trials on medicinal
majority of volunteers taking part in the easy as there are approximately only ten products for human use. Luxembourg:
trials enrol because of the fees that they private centres allowed in France to run Commission of the European
can receive. These payments are the Phase 1 drug trials in humans. These tri- Communities, 2001. Available at
norm, but are not a necessity. According als are used to demonstrate safety, and http://europa.eu/eur-lex/pri/en/oj/dat/
to the law, these payments cannot exceed involve a small number of healthy volun- 2001/l_121/l_12120010501en00340044.pdf
a maximum ceiling of €4,500 in any one teers. By contrast, Phase 2 tests can 3. Agence Française de Sécurité Sanitaire
year. The aim is simply to compensate involve several hundred individuals, des Produits de Santé (French Health
volunteers for the time they take out of while the large scale trials run during Products Safety Agency). Available at
their lives to participate in trials, rather Phase 3 of a drug evaluation typically www.sante.gouv.fr or
than being seen to offer any inducement. involve tens of thousands of people. www.agmed.sante.gouv.fr
This concern is shared by some experts in Most trial volunteers in France are stu- RELATEDARTICLES
the UK, where there is no ceiling on dents, with flexible working hours, and in Nau J-Y. Les recherches médicales vont
these payments. This issue has come to need of money. In 2005, around 10,000 être encadrées de manière plus stricte en
prominence following a case in March volunteers took part in 225 Phase 1 drug France. (Medical research rules to be tight-
2006 whensix healthy men suffered mul- trials. 35 side-effects have been officially ened in France) Le Monde20 May 2006.
tiple organ failure during a clinical drug registered, of which only five were Eudes Y. La cage dorée des cobayes. (The
trial run in an independent research unit considered to be serious. None of these guinea pigs gilded cage) Le Monde1 June
at a hospital in north-west London. As incidents has had any long term conse- 2006.
Mark your Calendar!
10th European Health Forum Gastein
3rd–6th October 2007
Bad Hofgastein,
Salzburg, Austria
Eurohealth Vol 12 No 2 6
HEALTH POLICY
Health insurance reform in
the Netherlands
Yvette Bartholomée and Hans Maarse
Intr oduction population. It has been argued that a related contributions to statutory health
On 1 January 2006, a major reform of the mandatory single scheme would not only insurance, the abolition of the obligation
Dutch health insurance system came into resolve various boundary problems for sickness funds to contract with all
effect. The former system, a combination between the statutory health insurance individual providers (collective contract-
of a statutory sickness fund scheme for scheme and private health insurance but ing) and the further development of the
the majority of the population and pri- also, and more importantly, increase soli- risk equalisation scheme. These changes
vate health insurance for the rest, was darity in health insurance. For instance in paved the way for a more radical market-
replaced with a single universal scheme. 1974, the Deputy Minister of Health based reform of statutory health insur-
The aims of the reform were to make the Hendriks argued in favour of a single ance.
health system more efficient, to improve public scheme, but this proposal was
In 2000, the government came up with a
the quality of health care and to make it never translated into a concrete bill. The
new proposal to enact legislation for a
more consumer-driven, while at the same introduction of a single scheme was also a
mandatory single health insurance
time keeping it accessible to everyone. cornerstone of the so-called Dekker
scheme based on the concept of regulated
The ongoing reform is comprehensive report published in 1987.1 However, the
(or managed) competition. After some
because it affects not only health insur- Dekker Committee (named after its
years of political debate, the government
ance but also the purchasing and delivery chairman, a former Chief Executive
that took office in 2003 managed to
of health care; however, it is the new Officer of the Philips Company) devised
mobilise a parliamentary majority for a
health insurance legislation that currently an additional proposal, the introduction
fundamental reconstruction of health
attracts the most attention. This article of regulated market competition. In the
insurance by 2006. In many respects the
presents a brief analysis of the reform’s view of this Committee, market competi-
reform of the present Minister of Health,
historical background and its key tion was necessary to curb the rapid
Hans Hoogervorst, builds on the earlier
elements, goals and preliminary effects. growth of health care expenditure.
proposals of the Dekker Committee,
A subsequent Deputy Minister of Health, combining the idea of a single mandatory
Historical background
Hans Simons, took the Dekker report as scheme and regulated market competi-
The new health insurance system is the
the basis for his plans to re-model health tion. At the same time, the current
most recent stage in a long process of
insurance in the Netherlands. However, reform is more radical than the Dekker
reform. Prior to 2006, 63% of the popu-
his reform proposals did not survive in plan.
lation were covered by the statutory
the political process and a variety of
health insurance scheme operated by Once again the reform was politically
stakeholders expressed concerns.
sickness funds and 37% were covered by contested and dissenting voices (doctors,
Employers were worried about the costs
private health insurance. The latter were patient groups and employers) argued
of a new system, employees feared its
mainly individuals with an income above that health care was not compatible with
effects upon their income, insurers were
a government-set income ceiling.* market competition. However, many
afraid of government intervention in their
health insurers and provider organisa-
There have always been voices calling for field and there were general doubts about
tions developed a pro-market attitude
an end to the dual structure of health whether regulated competition would be
and called for a drastic reform after years
insurance and to replace it with a manda- feasible in health care.2,3
of increasing government interference in
tory single scheme covering the entire
In the 1990s, health insurance reform was health care.
politically taboo, yet many incremental
changes were introduced that, taken Key elements of the new system
Yvette Bartholomée is a Researcher, and together, significantly changed the health The extension of market competition is
Hans Maarse is Professor of Political insurance landscape. Examples include one of the key features of the new health
Science (with special reference to health the introduction of a nominal fee (not insurance system. Health insurers, which
care), Department of Health, income-related) in addition to income- may operate on a for-profit basis, are
Organisation, Policy and Economics
(HOPE), Faculty of Health Sciences, * This dual system of public and private coverage applied to primary and acute care. There
University of Maastricht, the was and still is a separate universal scheme covering long-term care (AWBZ). The AWBZ
Netherlands. scheme has not been significantly affected by the current reforms although there are plans
Email: [email protected] to make changes to it in 2007.
7 Eurohealth Vol 12 No 2